1. HCBS Quarterly Training January 10, 2008 HCBS Regional Changes CCO/ISB Update Proposed Rule Changes/Additions: –Supported Employment –Incident Reporting –Restraints, Restrictions, Beh Interventions –Documentation/Records/Audits/Reviews Leap Year and Service Plans New Quality Assurance Process

2. HCBS NEWS Effective 2/1/2008, the Specialist regions will be restructured. The specialist assigned to your region will provide TA/QA for the following programs: –HCBS Waivers –Habilitation –Remedial Services A list/map of the specialists regions are available at: www.ime.state.ia.us/HCBS/help_ownhome.html

3. Independent Support Broker Update Brooke Lovelace Consumer Choices Option (515) 725-1154 blovela@dhs.state.ia.us

4. Proposed Supported Employment Rule Changes MR – IAC 44178.41(7) BI – IAC 44178.43(4) Habilitation – IAC 44178.27(10)

5. Activities to Obtain a Job Definition changed to include …on behalf of individual for whom competitive employment is reasonably expected within less than one year. Services must focus on job placement, not on teaching generalized employment skills or habilitative goals. Prior to provision of Activities to Obtain a Job services, the consumer and the IDT must complete the Iowa Vocational Rehabilitation Services supported employment (IVRS SE) form

6. Activities to Obtain a Job Service components: –Consumer Job Development Job Procurement training – including hygiene and grooming, application, resume development, interviewing skills, follow-up letters and job search activities. Job retention training - including promptness, co-worker relations, transportation, disability related supports, job benefits, understanding employee rights and self-advocacy Customized job development specific to the consumer A unit of service is a job placement that holds for 30 or more consecutive calendar days. A consumer may receive 2 units during a 12 month period. Payment can be made once the IDT determines the service is as necessary and (the service is) approved by the CM

7. Employer Development Services These are services designed to: – to support employers in hiring and retaining consumers in their workforce –To communicate expectations of the business with the IDT These services may only be provided to consumers reasonably expected to work no more than 10 hours per week Prior to using this service, the consumer and IDT must complete the IVRS SE form

8. Employer Development Services Components: –Developing relationships with employers and providing leads for individual consumers when appropriate –Job analysis for a specific job –Development of a customized training plan –Identifying and arranging reasonable accommodations –Providing disability awareness/training to employer –Providing TA to employer regarding training progress on customized plan A unit of service is one job placement, that the consumer holds for 30 or more consecutive calendar days – may use 2 units in 12 mo period Payment is made once the consumer holds a job for 30 days.

9. Enhanced Consumer Job Search Activities associated with obtaining initial employment after Consumer Job Development services have been provided for at least 30 days or to assist a consumer change jobs due to lay-off, termination, or consumer choice Services provided: –Job opening identification with the consumer –Assistance with applying for a job – apps/interview –Worksite assessment and job accommodation evaluation A unit of service is one hour. A maximum of 26 units may be provided in a 12 month period

10. Proposed Reimbursement for SE Activities to Obtain a Job $900 per unit* Consumer Job Development Activities to Obtain a Job $900 per unit* Employer Development Activities to Obtain a Job Max of $34.63 Enhanced Consumer Job Search per hr. Max of units per 12 mos *Unit equals a job placement

11. Proposed Rules for Incident Management/Reporting Impacts E, I&H, PD, A/H, MR, BI, CMHW, Habilitation providers excluding these services: –Assistive devices –Chore –CCO goods and services –Environmental modifications and adaptive devices –HVM –Specialized medical equipment –HDMs –PERS –Transportation Anticipated effective date: April 1, 2008

12. Major Incident Definitions 1.Results in physical injury to or by the individual that requires a physicians treatment or admission to a hospital 2.Results in the death of any person 3.Requires emergency mental health treatment for the individual 4.Requires the intervention of law enforcement 5.Requires a report of child abuse or dependent adult abuse 6.Constitutes a med error or pattern of med errors that lead to 1, 2, or 3 above

13. Major Incident Reporting Report form approved by the department Major incidents requires: –When incident occurs or when staff become aware of an incident, provider staff shall notify the consumer or legal guardian within 72 hrs of the incident –The completed incident form shall be distributed: Provider staff supervisor within 24 hrs of incident Consumers CM and BLTC within 72 hours of incident Centralized file (provider) with a notation in the consumers file

14. Minor Incidents Definition Occurs during service provision and is not a major incident. 1.Results in the application of first aid; 2.Results in bruising; 3.Results in seizure activity; 4.Results in injury to self, others, or to property; 5.Constitutes a prescription medication error

15. Minor Incident Reporting Recorded on an incident reporting form approved by the department Provider staff shall distribute the completed incident report as follows*: –To the supervisor of the provider staff within 24 hours of the incident –To a centralized file location with a notation in the consumers file * This is the HCBS/Habilitation guidelines for service providers. Providers working with CM must also follow guidelines for Chapter 24 regarding reporting of incidents; ie., notifying CM of minor incidents

16. Proposed Rules – Restraints, Restrictions, and Behavioral Interventions(R,R, and BhI) Impacts all waiver service providers (E, I&H, PD, BI, MR, A/H, CMHW, Habilitation) using restraints, restrictions, or behavioral interventions Rules require policies and procedures on R, R, and BhI Rules require these provider to comply with the content of the rules

17. Restraints Definition: …use of any chemical, physical or manual intervention used to restrict the movement of the consumer, including, but not limited to: –Holding consumers body or limb(s) contingent of behavior –Using an approved manual restraint procedure so that movement is restricted or prevented for any amount of time

18. Restrictions Definition – …any activity that limits the consumers access to home or community daily living activities

19. Behavior Interventions Definition – …activities related to regulating the consumers behavior including coping with demands from others, making choices, controlling impulses, conforming conduct to laws, and displaying appropriate sociosexual behavior.

20. Provider Requirements for R, R, and BhI Provider must inform consumers and legal guardians of the providers R, R, and BI policies and procedures at the time of service initiation and as changes occur R, R, and BhI may only be imposed pursuant to written R, R, and BI program developed for the individual – time limited and reviewed at least quarterly R, R, and BhI must be designed and implemented for the individual and not used as punishment, staff convenience, or as a substitute for a nonaversive program R, R, and BhI may only be used for reducing or eliminating maladaptive target behaviors identified in the R, R, and BhI intervention program Corporal punishment and verbal or physical abuse are prohibited

21. Proposed 4/1/08 Rule Changes on Documentation Documentation requirements SURS review information Correcting records Record submission deadlines Sampling techniques for audits/reviews Process for submissions on preliminary overpayment findings

22. Accessing the Proposed Rules www.dhs.state.ia.us/policyanalysis/RulesPages/dockets.htm

23. Accessing the Proposed Rules Once you have accessed the rules docket, scroll down to the rule changes listed as ARC 6391B(11/7/07) and click on this information. Click on this information Clicking on the information will take you to the proposed rule changes.

24. Leap Year and Service Plans 2008 is a leap year (29 days in February) Service plans in ISIS ending 2/28/08 need to be changed to 2/29/08 It is not necessary to do this on a QA form if done before 3/1/08.

25. Provider Oversight Process

26. Current Quality Assurance Requirements IAC 441-- 77.37(1)f – MR SCL, SE, and Respite services IAC 441 -- 77.39(1)f – BI SCL, SE, Behavioral Programming and Respite services The organization has a systematic, organization wide, planned approach to designing, measuring, evaluating, and improving the level of its performance. The organization: 1)Measures and assesses organizational activities and services annually 2)Gathers information from consumers, family members, and staff 3)Conducts an internal review of consumer service records, including all major and minor incident reports according to subrule 77.37(8) MR or 77.39(6) BI 4)Tracks incident data and analyzes trends annually to assess the health and safety of consumers served by the organization 5)Identifies areas in need of improvement 6)Develops a plan to address the areas in need of improvement 7)Implements the plan and documents the results

27. Current QA Target Areas for HCBS 77.37(1)f(2) MR and 77.39(1)f(2) BI – Gathers information from consumers, family members, and staff. –Service satisfaction surveys, staff evaluations 77.37(1)f(3) MR and 77.39(1)f(3) BI – Conducts an internal review of consumer service records, including all major and minor incidents… –Reviews consumer files for releases of information, guardianship papers, consumer contracts, incident reports, staff narrative, etc… 77.37(1)f(4) MR and 77.39(1)f(4) BI – Tracks incident data and analyzes trends annually to assess the health and safety of consumers served by the organization –Reviews incident report data on an aggregate level, identifies trends (accidents, injuries, etc.) and addresses the trends through environmental changes, staff training, consumer satisfaction with services, etc….

28. Why a New Process? The need for a Quality Improvement (QI) system that will gather input from all people receiving Waiver, Remedial and Habilitation services Expanding the Quality Improvement (QI) system to provide enhanced oversight for these services and providers Expanding and enhancing quality improvement activities Current process does not allow for maximum efficiency of resources CMS expectations

29. Provider Oversight Process The Provider Oversight Process will be comprehensive and utilize standardized forms. The process will be based upon expected standards of practice for provision of services. Refer to the Provider Requirements handout

30. Four Methods of Provider Oversight Provider annual Self-Assessment Focused desk review Targeted provider review On-site review

31. The First Method – Self-Assessment The first method of oversight requires providers to complete an annual self-assessment. This assessment will be submitted to the DHS Bureau of Long Term Care. The assessment serves as the provider's assurance that their policies, procedures, and quality improvement activities are in compliance with Iowa Administrative Code standards. Providers who identify deficiencies are required to submit a plan to come into compliance with IAC.

32. The Second Method – Focused Desk Review The second method of oversight will consist of a desk review. This review will relate to randomly selected focus areas or when issues are identified through the self- assessment. The purpose of these reviews is to verify the accuracy of the provider's self-assessment. Providers will be randomly selected by service, provider type, and geographical area. Focus areas will be identified and reviewed by the HCBS Quality Assurance Specialist. Based on an examination of the providers policies, procedures and evidence of implementation of such, the outcome may result in corrective actions or an on-site review.

33. The Third Method – Targeted Provider Review The third method of oversight will be targeted on-site reviews. These reviews will be initiated as a result of concerns arising from a desk review, incident reports, consumer interviews, or as the result of a filed complaint regarding a specific provider's service delivery. The outcome of this review could result in recommendations, corrective actions or sanctions.

34. The Fourth Method – Periodic On-Site Review In addition to the first three methods, providers will receive a full on-site review on a periodic basis. The review will evaluate the accuracy of the self- assessment as well as the providers compliance with IAC standards.

35. Results of Reviews The aggregate data gathered from the four methods will be used to identify any concerns with service delivery, and to evaluate the overall statewide system, which could result in remediation and improvement.

36. Self-Assessment Checklist Verification that the provider has met the following requirements for: –Mission statement –Fiscal accountability –Staff training –Governing body –Policies and Procedures –Mandatory Quality Improvement activities

37. Mandatory Areas for QI Incident Reports Service Documentation Behavioral Plans Personnel Records Appeals and Grievances Identification of Rights Restrictions Consumer risk assessment/health and safety plans Achievement of person- centered planning and service delivery Achievement of the outcomes for rights and dignity Stakeholder input Medication management Compliance with IAC standards for services

38. Waiver, Habilitation, and Remedial Services Requiring Self-Assessments and Periodic On-site Reviews: Behavior Programming CDAC - Agency Day Habilitation IMMT Pre-Voc RB/SCL Respite SCL Family & Community Support Services Supported Employment In-home Family Therapy Adult Day Care EW Case Management (if not Chapter 24 accredited) Home Based Habilitation Community Psychiatric Supportive Treatment Crisis Intervention Health or behavior intervention Rehabilitation program Skills training and development

39. Services Requiring an Annual Self-Assessment but Not a Periodic On-site Review Counseling Home Health Aide Nursing Mental Health Outreach

40. Self-Assessments and Periodic On-site Reviews will not be Required for: –Assistive Devices –Environmental Modifications and Adaptive Devices –Homemaker –Nutritional Counseling –Senior Companion –Specialized Medical Equipment –Individual CDAC –Home and Vehicle Modification –Home Delivered Meals –Transportation –Chore –PERS –Consumer Choices Option - Financial Management

41. Implementation of the New Provider Oversight Process January ICN announcement of the process February 2008 - IME mailing to announce dates, times, locations of regional trainings March 2008 - regional training regarding process and expectations –Ongoing regional training throughout 2008 April 2008 - Provider Services send out Self-Assessment Self-Assessment sent to IME in June 2008 Early 2009 - (next) Annual self-assessment will be due and onsite reviews to verify implementation of policies to begin

42. Concurrent Process Participant Experience Survey (PES) interviews to be completed statewide based on a random sample of consumers 2008 - HCBS staff continue to develop: –Rules –Provider Manual RULES PROVIDER

43. Please submit questions to: HCBSWaiver@dhs.state.ia.us