Individual and Family Developmental Disabilities Support DD Waiver

1
Individual and FamilyDevelopmental Disabilities
Support (DD) Waiver

• Department of Medical Assistance Services
• Division of Long-Term Care
• November 2008

2
Workshop Goals

• Standards of Learning
•  
• Team approach
•  
• Case Management
•  
• Trends seen by analysts
•  

• Face to face and Quarterlies
• Abuse and Neglect
• Quality Management Reviews
• Billing

3
Standards of Learning 

• Activity for the Case Managers

4
The Team Approach to the Plan of Care Meeting

• Participant, Family, and Providers

5
What does the Team approach ensure?

• Satisfaction with services
• Health and safety
• Coordination
• Organized

• Unduplicated
• No breaks in service
• Optimal service delivery
• (DD Waiver Manual, Chapter IV)

6
Who does the case manager contact for a Plan of
Care Meeting?

• Participant and/or his/her family,
• All current service providers and
• Friend, Legal Guardian, significant other
• Date/Time/Meeting location/advance notice
• (DD Waiver Manual, Chapter IV)

7
What is the goal of the Plan of Care Meeting?

• Person Centered
• Decision-Making
• Discuss concerns
• Satisfaction with Services/Meeting needs
• (DD Waiver Manual, Chapter IV)

8
What is the goal of the Plan of Care Meeting?

• Short and Long-term goals
• Focus of meeting
• Target date
• Effective and Consistent
• (DD Waiver Manual, Chapter IV)

9
Case Management

• What is Case Management?
• Case Management activities include
• Assessing and planning
• Linking
• Coordinating
• Monitoring/Follow up
• Making Collateral Contacts
• Advocating
• Education and Counseling
• Enhancing community integration (12 VAC
  30.50.490)

10
What are other important topics?

• Freedom of Choice
• Future planning
• Aging
• Graduation/Transition Planning
• Aging Caregiver
• Behavioral/Crisis Planning
• Contingency plans

11
Choice of Services

• Why is choice important?
• Empowering
• In control of their lives
• Helps CM to develop the POC
• Who makes the choice?
• Is the participant over 18?
• Does he/she have the ability to make their own
  choices?
• Does he/she direct his own care?
• Does he/she have a legal guardian?

12
Resources to help with Choices

• Network with other Case Managers
• DMAS website
• Develop your own provider list for your families

13
Trends Seen By Analysts

• Level of Functioning Assessments
• DMAS 456
• Social Assessment
• DMAS 457
• DMAS 97 A/B
• DMAS 99
• Environmental Modifications

14
Trends Seen by Analysts

• Assistive Technology
• Consumer Directed and Agency Directed Companion
• In-Home Residential
• Therapeutic Consultation
• Denial of Services

15
How to reduce Trends

• The key to successful plan submissions is error
  free work
• Double check that no spaces are left blank and
  that the documentation matches the requested
  hours of service
• Complete justification is required for requests
  for services including adding new services,
  increases or decreases in services and/or service
  hours

16
How to reduce Trends

• Use the DD Waiver Fax Sheet
• Please use the new fax cover sheet included in
  your packets
• Identify the type of plan and include any special
  instructions you may have for DMAS
• Resubmissions/Pend responses
• Identify on the new fax sheet what your
  resubmission is addressing
• Note when submitting a response to a pend you do
  not need to resubmit the entire packet. You only
  need to submit the information that is being
  requested on the 454.

17
Face to Face Visits
18
Face to Face Meetings

• A face to face (FF) visit is defined as
• the case manager or service provider must meet
  with the individual in person and that the
  individual should be engaged in the visit to the
  maximum extent possible. (12VAC30-120-700)
• A face to face contact is required at a minimum
  of every 90 days. (Chapter IV, 12 VAC 30-50-490)

19
Face to Face Meetings

• Documentation Requirements
• FF with individual
• Assessment of service satisfaction
• Any unmet needs
• Individuals status
• Service modification
• (DD Waiver Manual, Chapter IV)

20
TIPS for FF

• Case notes may be in the form of
  contact-by-contact entries or a monthly summary
  as long as they correspond with a contact log.
  These notes must include the date, type, and
  reason for each contact.
• All entries must be signed (first initial and
  last name minimum) and dated.
• Face to face visit notes are not quarterly
  reports and need to be documented separately.

21
Case Management Review process
22
Case Management Review

• At a minimum, every three months review
• Plan of care equals a FF with the individual
• Quarterly goals and objectives to ensure they are
  being met, and
• Any necessary modifications to the plan of care

23
Case Management Review

• At least once per plan of care year this review
  must occur in the individuals home environment.
• (12VAC30-120-720.E.b.1-3c.)

24
Why is this process separate from the face to
face contact meetings?

• Comprehensive evaluation must include the
  following
• The DMAS 457 support documentation which includes
  all of the individuals goals and objectives as
  agreed upon in the team meeting.
• The plan of care which includes all DD waiver
  services including case management.
• The service providers quarterly reports submitted
  to the case manager. (12VAC30.120.720.E.1.b)

25
These are the required components for your
Quarterly Report

• Revisions to the Plan Of Care
• General status
• Significant events
• Progress or lack of progress in goals
• Satisfaction with Services and Case Management
  (DD Waiver Manual, Chapter IV)

26
Quarterly Review

• All service providers must complete a written
  quarterly report and forward to the case manager.
  
• Exception! When any sporadic and temporary
  services such as Respite, Assistive Technology,
  Environmental Modification, PERS and Crisis
  Stabilization are provided during the quarter,
  the case manager must obtain details of the
  services from those providers and include this
  information in the Quarterly report. (DD Waiver
  manual, Chapter IV)

27
Goal and Objective Review (Quarterly Review)

• The Quarterly Review schedule is based on the
  start date of the POC.
• Initial plan year view
• POC Start Date Quarterly
  Due Semi Annual Due
  Quarterly Due
  
  Jan 1, 2008 April 1, 2008
  July 1, 2008
  October 1, 2008
  
  
• Months 1 2 3 4
  5 6 7
  8 9 10 11
  12

28
Goal and Objective Review (Quarterly Review)

• Quarterly Reviews are planned around the POC
  start date.
• Renewal Plan Year View
• Annual Plan Due
  Quarterly Review Semiannual Due
  Quarterly Due
• January 1, 2009
  April 1, 2009 July 1, 2009
  October 1,2009
  
  
• Months 13 14 15 16
  17 18 19
  20 21 22 23
  24

29
Emergency Plans of Care (POC)
30
Processing Plans of Care (POC)

• Emergency plans
• What is considered an emergency?
• It is at the discretion of DMAS staff whether a
  plan falls into the emergency criteria for a plan
  to be worked out of the normal work flow
• When a Case Manager requests emergency
  consideration, a team review will take place
  prior to the deciding to work the plan

31
Emergency (POC)

• Most emergency plans are medical in nature
• Poor planning on your part does not constitute an
  emergency

32
Emergency (POC)

• Examples of emergency plans
• A participant has broken her hip and needs
  additional hours of service
• A participant is experiencing skin breakdown and
  needs additional hours
• How do you define an emergency?

33
Processing Emergency (POC)

• Crisis vs. Emergency
• Crisis is defined as a mental health emergency
• DMAS is required to review crisis plans as they
  are received so authorization can be obtained
  within 72 hours

34
Interruptions and Extensions
35
The difference between Extension Letters and
Interruptions

• Extensions are requested prior to beginning
  services
• Interruptions are requested after the participant
  has started service and has not received services
  in thirty days

36
What are the extension letter requirements?

• Requests must be in writing
• Letters must be received by DMAS within the 30
  day period the extension is requested
• No more than 4 extensions may be approved
• Extension letters must contain the specific start
  and end dates for the requested time period
• Extension letters must contain information why
  more time is needed to initiate waiver services
• (12VAC30-120-720.9.)

37
When is an Extension letter needed?

• When a participant is unable to initiate services
  within 60 calendar days of becoming Medicaid
  eligible an extension letter is required (DD
  Waiver Manual, Chapter IV)

38
When are plan interruptions needed?

• When a participant has not received DD Waiver
  services for more than 30 days
• It is the Case Managers responsibility to submit
  an Interruption POC to DMAS

39
How do you interrupt a POC?

• If possible, the Case Manager should meet with
  the participant and/or family member to obtain
  their signature on the Plan of Care
• (Note participants should be notified that
  services can only be interrupted for 90 days and
  then the withdrawal process will begin)
• At the top of the Plan of Care, the Case Manager
  should check the box for Interruption and
  update the DMAS 457 to explain why services are
  being interrupted then submit the documents to
  DMAS

40
How do you restart a POC?

• Meet with the participant and/or family and
  providers to discuss the POC
• Resubmit the updated POC marked Revision with
  an updated 457
• The supporting documentation for the services
  being requested
• Note DMAS has the same work time for restarting
  a POC as regular plans that are submitted daily.
  (DD waiver manual, Chapter 4)

41
Transferring Case Management Services
42
Transfer of Case Management

• If a participant wishes to switch to another
  case manager, the current CM is responsible for
• Send a Case Management list
• Informing the participant that the Case Manager
  needs written permission to exchange information
  (a copy of your agencys Consent Form) with the
  new case manager they have selected

43
Transfer of Case Manager

• When a participant has selected another case
  manager and provided consent to exchange
  information,
• The existing case manager copies the complete
  record and forwards it to new case manager

44
Transfer of Case Manager

• Current case manager needs to follow-up with a
  phone call and document that they updated the new
  case manager on the case
• The case manager must inform DMAS and individual
  in writing of the change (fax is fine) and submit
  a copy of the consent form to DMAS

45
Housekeeping Tips
46
Housekeeping Tips

• Verify that all paperwork submitted by providers
  is correct prior to submitting it to DMAS
• Ensure that plans and supporting documentation
  are submitted to DMAS in a timely manner
• Submit renewal plans no earlier than 60 days
  prior to plan start date

47
Housekeeping

• Required Documentation
• POC can only be worked with submission of
  complete documentation. Please refer to your
  Provider Manual for required documentation,
  service limits, and exclusions.

48
Housekeeping

• Participants should be notified that services can
  only be interrupted for 90 days and then the
  withdrawal process will begin.
• DMAS has the same work time for restarting a POC
  as regular plans that are submitted daily.

49
Housekeeping Tips

• Case Management and Service Facilitation
  documentation should be separate
• Legible writing
• Objective written documentation notes as to why
  there are no other providers available to provide
  care this includes advertisements and number of
  attempts.
• Document, Document, Document

50

• Abuse, Neglect and Exploitation

51
We Need Your Help!

• Children's Stats
• In FY 2007 CPS received
• 46,000 reported cases of abuse or neglect
• 6,400 were founded cases
• 29 died 27 under the age of 4

• In FY 2007, Virginia APS received over 13,000
  reports of adult abuse, neglect and/or
  exploitation.
• 65 of the reports were substantiated
• About 70 of report subjects were 60 years or
  older

52
For this purpose . . .

• Adults are
• Persons 18 years old or older who are
  incapacitated
• Persons age 60 and older

• Children Are
• - Persons under the age of 18 years

53
Types of Abuse

• Adults
• Physical
• Verbal
• Emotional
• Sexual
• Neglect
• Self Neglect
• Exploitation

• Children
• Physical
• Sexual
• Neglect
• Home Alone
• Emotional
• Medical

Financial Exploitation is a growing trend in Abuse
54
What is a Mandated Reporter?

• A mandated reporter is an individual who is
  required by Virginia law to report situations
  immediately in which
• they suspect anyone that
• may have been abused,
• neglected or exploited,
• or is at risk of being abused,
• neglected or exploited

55
Who must report?

• Medical professionals 54.1-2503 of the Code of
  Virginia,
• Persons licensed to practice medicine or any
  healing arts
• Hospital residents, interns, and nurses
• Any emergency medical services personnel
  certified by the Board of Health 32.1-111.5
• Social workers and Probation officers
• 54.1-2400.1
• Teachers and school personnel
• Public, private, kindergarten or nursery school
• Child care providers

56
Who must report?

• Accredited Christian Science practitioners
• Mental health professionals
• Law enforcement officers
• Professional staff
• Mediators certified to receive court referrals
• Designated court appointed special advocates

57
Employers of Mandated Reporters

• Must notify mandated reporters of their
  obligation to report
• May establish in-house procedures for reporting
• Cannot prohibit employees from reporting directly
  to APS

58
WHEN do I report?

• Report situations they encounter while performing
  their official job duties
• The report must be made immediately upon becoming
  aware of the situation of abuse, neglect and/or
  exploitation

59
Making a Report

• When to report
• Immediately
• How to report
• Call local department of social services
• Or call Hotline 24 hrs a day, 7 days a week
• WHAT do I report?
• The identity, age, and location of the alleged
  abused individual
• Any information about the suspected abuse,
  neglect or exploitation

For Children 1-800-552-7096
For Adults 1 [phone])
60
Questions

• If you have questions about reporting suspected
  adult abuse, neglect and/or exploitation, or
  other questions regarding your status as a
  mandated reporter, call an APS regional
  specialist
• Eastern Region (vacant) [phone]
• Barbara Jenkins [phone]
• Carol McCray [phone]
• Bill Parcell [phone]
• David Stasko [phone]

61
You are Key!

• Report suspected Abuse, Neglect and Exploitation!
• You can help vulnerable children and adults
  suffering in silence have safer, happier and more
  productive lives!

62
Questions and Answers

• For questions, please contact the Division of
  Long-Term Care at 804-225-4222, press option 1
  or by fax at 804-371-4986.
• Please visit the DMAS website at
• www.dmas.virginia.gov
• Thank You!!!!!!

63
Look Ahead

• TO INFINITY AND BEYOND

64
What to Expect During a Quality Management
Review(QMR)

• Department of Medical Assistance Services

65
What Generates a Review?

• Statewide Sample
• A computer generated list is created and reviews
  are scheduled randomly.
• Complaints
• DMAS receives a concern regarding services from a
  constituent.

66
Quality Management Review

• Unannounced
• May be on-site or desk review
• May include
• observation of service delivery,
• face to face or telephone interviews with the
  consumer and caregivers.
• Usually 2 5 days in length

67
QMR (contd)

• Upon arrival, Analyst will
• Request charts be gathered together in a central
  location.
• Secure a workplace to conduct the review.

68
QMR (contd)

• During the review
• Analyst may ask questions regarding your
  documentation.
• Analyst may request additional documentation.
• Analyst will let you know how long the review
  will last and time of the Exit Conference.

???
69
Quality Management Review (contd)

• Exit Conference will usually occur on the last
  day of the review and may be via telephone or
  alternate media.
• You may have any of your staff attend.

70
Items to be Reviewed

• Assessments
• Plan Of Care (CSP)
• Supporting Documentation (457)
• Quarterly/Semiannual Reports (of other providers)
• CM documents and documentation

71
(more) Items to be Reviewed

• Individual records
• Appropriate data, contact notes, or progress
  notes
• Reports
• Documentation

72
(more) Items to be Reviewed

• Personnel records (qualifications, background
  check, references)

73
QMR Findings Letter Contents

• Summary
• Technical Assistance
• Issues not in compliance with Medicaid policy
  that should be addressed by the provider.
• Corrective Action Plan (CAP)
• Situations in which the provider has failed to
  comply with federal and state regulations or
  policy guidelines and procedural changes are
  required.

74
Provider Options

• Reconsideration
• Request will be reviewed and response letter sent
  to provider.
• If denial is upheld, provider has the right to
  appeal.

75
Provider Options (contd)

• Appeals
• Informal Fact Finding Conference (IFFC)
• Provider may request within 30 days of receipt of
  reconsideration decision.
• Formal Evidentiary Hearing
• Request must be made within 30 days of receipt of
  IFFC decision.

76
Recent Findings Trends

•  
• Documentation demonstrates consumers is receiving
  any necessary medical care.
• Documentation of side effects of medication and
  all health, safety and welfare incidents or
  concerns.

77
Recent Findings Trends(contd)

• Documentation of progress towards CSP goals and
  or changes.
• Annual documentation includes summary of each
  quarter, satisfaction with each service and
  justification for continuation or discontinuance
  of services/waiver.

78
Recent Findings Trendscontd

• Quarterly review of status of each service
  participant is receiving or service authorized on
  CSP.
• Quarterly review accurately reflects the
  individuals responses to services for the
  quarter.
• Quarterly review documents participants choices
  and involvement with development of plan.

79
Recent Findings Trendscontd

• The Case Managers quarterly review includes a
  summary of each providers quarterly or
  semi-annual review.
• The Case Managers quarterly review is completed
  within the required timeframe.
• CM job responsibilities are completed regardless
  of billing status.

80
Recent Findings Trends(contd)

• FacetoFace contact occurs at least every 90
  days.
• Documentation of Faceto-Face contact include
  components required per manual and VAC
  regulations.
• All CM and SF documentation maintained
  separately.

81
Recent Findings Trends(contd)

• Billable and legible monthly CM contact notes.
• Contact notes signed and dated.
• Participants full name or Medicaid number on
  each page.
• Health and safety needs documented in plan and
  reflected in services.