016.05.17 Ark. Code R. 001

Current through Register Vol. 49, No. 9, September, 2024

Rule 016.05.17-001 - DDS Alternative Community Services Waiver (DDS ACS) Update #1-17 and Developmental Disabilities Services ACS Waiver

Application for a §1915(c) Home and Community-Based Services Waiver

PURPOSE OF THE HCBS WAIVER PROGRAM

The Medicaid Home and Community-Based Services (HCBS) waiver program is authorized in §1915(c) of the Social Security Act. The program permits a State to furnish an array of home and community-based services that assist Medicaid beneficiaries to live in the community and avoid institutionalization. The State has broad discretion to design its waiver program to address the needs of the waiver's target population. Waiver services complement and/or supplement the services that are available to participants through the Medicaid State plan and other federal, state and local public programs as well as the supports that families and communities provide.

The Centers for Medicare & Medicaid Services (CMS) recognizes that the design and operational features of a waiver program will vary depending on the specific needs of the target population, the resources available to the State, service delivery system structure, State goals and objectives, and other factors. A State has the latitude to design a waiver program that is cost-effective and employs a variety of service delivery approaches, including participant direction of services.

Request for a Renewal to a §1915(c) Home and Community-Based Services

Waiver

1. Major Changes

Describe any significant changes to the approved waiver that are being made in this renewal application:

Appendix B - Increased by 100 the unduplicated and the point-in-time number of slots reserved for DCFS. Total reserved for

DCFS (for children in foster care) is 200.

Appendix C - Supportive Living - added retainer payments to providers for the lesser of 14 consecutive days or the number of days during which an individual is in an ineligible setting. Removed restriction on paying overtime and family working over 40

hours a week.

Appendix C - Case Management - added requirements regarding conflict of interest, including a stipulation that prohibits an

Organization from providing case management and any direct service to the same person.

Appendix C-1 added provision for case management through contracted provider

Appendix C5 - Added the Home and Community-Based Settings Transition Plan

Appendix D1 - added requirements regarding conflict of interest during the person-centered planning meeting, added a prohibition that individuals developing the PCSP are not related by blood or marriage to the individual or to any paid caregiver,

are not financially responsible for the individual, empowered to make financial or health-related decision for the individual or are individuals who would benefit financially from the provision of services

Appendix D - rewrote to include all requirements stated in the Final Rule

Appendix D1 - changed the effective term of the Interim Service Plan from 90 days to 60, according to guidelines in the

Technical Guide

Appendix G1 - Identified critical events as distinguished from reportable events

Appendix G2 - Clarified and defined each type of restraint and restrictive intervention, and specified when behavior plans are required

Appendix G3 - Clarified when a medication management plan must be in place and specified the components of the plan

Rewrote all Performance Measures to address required assurances and sub assurances so that they are measurable and have a direct impact on quality.

Application for a §1915(c) Home and Community-Based Services Waiver 1. Request Information (1 of 3)

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2. Brief Waiver Description

Brief Waiver Description. In one page or less, briefly describe the purpose of the waiver, including its goals, objectives, organizational structure (e.g., the roles of state, local and other entities), and service delivery methods. The purpose of the ACS Waiver is to support individuals of all ages who have a developmental disability, meet ICF level of care and require waiver support services to live in the community and prevent institutionalization.

The goals of HCBS Waiver are to:

1) Support the person in all major life activities,

2) Promote community inclusion through integrated employment options and community experiences.

Support of the person includes:

1) Developing a relationship with the person and maintaining direct contact,

2) Determining the person's choices about their life,

3) Locating, coordinating and monitoring needed developmental, medical, behavioral, social, educational and other services,

4) Accessing informal community supports needed by the person,

5) Development and implementation of a Person Centered Service plan in coordination with an interdisciplinary team,

6) Accessing employment services and support individuals in seeking and maintaining competitive employment, and

7) Integration into the life and activities of the person's community.

The objectives are as follows:

1) To enhance and maintain community living for all persons participating in the HCBS Waiver program,

2) To transition eligible persons who choose the HCBS Waiver option from residential facilities to the community.

Under the organizational structure of the Department of Human Services (DHS), the Division of Medical Services (DMS) is the state Medicaid agency. DMS has administrative authority for the HCBS Waiver including the items as outlined in the Interagency Agreement (See Appendix A-2-b). The Division of Developmental Disabilities Services (DDS), also within DHS, is responsible for operation of the ACS Waiver, including the items as outlined in the Interagency Agreement. ACS Waiver services are delivered through private providers who are certified by the DDS Quality Assurance Section. The providers must first meet DDS certification requirements and then enroll with Medicaid as HCBS Waiver providers before the provider can deliver services.

ACS Waiver services are accessed through DDS Intake and Referral units, which include DDS Adult Intake and Referral, DDS Children's Services Intake and Referral, and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) intake and referral staff. The intake and referral staff distribute the initial application, assist with completion, explain program options and offer choice of waiver services or ICF/IID services. The completed application packet is transmitted either directly or via the Waiver Application Unit (WAU) to the DDS Psychology Team for a determination of eligibility for institutional level of care services. The Waiver Application Unit (WAU) tracks applications once eligibility has been determined. The DDS

Waiver Application Unit is also responsible for assuring a person meets ICF/IID level of care and Medicaid income eligibility criteria prior to the person receiving waiver services. DDS Specialists offer choice of waiver providers.

Waiver services are delivered by DDS certified providers who have enrolled with DMS. During the DDS certification process, the providers identify the services they will provide, the counties they will serve and, if desired, the maximum number of people they will serve. Providers are permitted to change these criteria and may do so by contacting the DDS Certification Unit. However, change cannot be made if the change will adversely impact any persons receiving services from that provider at the time the change is desired.

Providers must request in writing and receive written permission from DDS before reducing the number of person they serve. Providers may reduce numbers by ceasing provision of services in a designated county or counties, freezing the number of persons they serve at the current number and reducing the number through attrition or ceasing provision of services to those persons they have most recently begun serving. Providers are responsible for continuing to provide services until transition of persons to another provider is complete.

All services must be delivered based on an individual person-centered service plan (PCSP), which is based on service needs assessments, has measurable goals, specific objectives, measures progress through data collection, and is overseen and updated by the person's case manager though consultation with the team, which includes the person receiving services.

The provider assures that the person being served and the team has input into the development of the PCSP, including services needed and desired outcomes for the person, and decisions on hiring direct care professionals.

3. Components of the Waiver Request

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4. Waiver(s) Requested

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5. Assurances

In accordance with 42 CFR § 441.302, the State provides the following assurances to CMS:

A. Health & Welfare: The State assures that necessary safeguards have been taken to protect the health and welfare of persons receiving services under this waiver. These safeguards include:

1. As specified in Appendix C, adequate standards for all types of providers that provide services under this waiver;

2. Assurance that the standards of any State licensure or certification requirements specified in Appendix C are met for services or for individuals furnishing services that are provided under the waiver. The State assures that these requirements are met on the date that the services are furnished; and,

3. Assurance that all facilities subject to §1616(e) of the Act where home and community-based waiver services are provided comply with the applicable State standards for board and care facilities as specified in Appendix C.

B. Financial Accountability. The State assures financial accountability for funds expended for home and community-based services and maintains and makes available to the Department of Health and Human Services (including the Office of the Inspector General), the Comptroller General, or other designees, appropriate financial records documenting the cost of services provided under the waiver. Methods of financial accountability are specified in Appendix I.

C. Evaluation of Need: The State assures that it provides for an initial evaluation (and periodic reevaluations, at least annually) of the need for a level of care specified for this waiver, when there is a reasonable indication that an individual might need such services in the near future (one month or less) but for the receipt of home and community-based services under this waiver. The procedures for evaluation and reevaluation of level of care are specified in Appendix B.

D. Choice of Alternatives: The State assures that when an individual is determined to be likely to require the level of care specified for this waiver and is in a target group specified in Appendix B, the individual (or, legal representative, if applicable) is:

1. Informed of any feasible alternatives under the waiver; and,

2. Given the choice of either institutional or home and community-based waiver services. Appendix B specifies the procedures that the State employs to ensure that individuals are informed of feasible alternatives under the waiver and given the choice of institutional or home and community-based waiver services.

E. Average Per Capita Expenditures: The State assures that, for any year that the waiver is in effect, the average per capita expenditures under the waiver will not exceed 100 percent of the average per capita expenditures that would have been made under the Medicaid State plan for the level(s) of care specified for this waiver had the waiver not been granted. Cost-neutrality is demonstrated in Appendix J.

F. Actual Total Expenditures: The State assures that the actual total expenditures for home and community-based waiver and other Medicaid services and its claim for FFP in expenditures for the services provided to individuals under the waiver will not, in any year of the waiver period, exceed 100 percent of the amount that would be incurred in the absence of the waiver by the State's Medicaid program for these individuals in the institutional setting(s) specified for this waiver.

G. Institutionalization Absent Waiver: The State assures that, absent the waiver, individuals served in the waiver would receive the appropriate type of Medicaid-funded institutional care for the level of care specified for this waiver.

H. Reporting: The State assures that annually it will provide CMS with information concerning the impact of the waiver on the type, amount and cost of services provided under the Medicaid State plan and on the health and welfare of waiver participants. This information will be consistent with a data collection plan designed by CMS.

I. Habilitation Services. The State assures that prevocational, educational, or supported employment services, or a combination of these services, if provided as habilitation services under the waiver are:

(1) not otherwise available to the individual through a local educational agency under the Individuals with Disabilities Education Act (IDEA) or the Rehabilitation Act of 1973; and,

(2) furnished as part of expanded habilitation services.

J. Services for Individuals with Chronic Mental Illness. The State assures that federal financial participation (FFP) will not be claimed in expenditures for waiver services including, but not limited to, day treatment or partial hospitalization, psychosocial rehabilitation services, and clinic services provided as home and community-based services to individuals with chronic mental illnesses if these individuals, in the absence of a waiver, would be placed in an IMD and are:

(1) age 22 to 64;

(2) age 65 and older and the State has not included the optional Medicaid benefit cited in 42 CFR § 440.140; or (3) age 21 and under and the State has not included the optional Medicaid benefit cited in 42 CFR § 440.160.

6. Additional Requirements

Note: Item 6-I must be completed.

A. Service Plan. In accordance with 42 CFR § 441.301(b)(1)(i), a participant-centered service plan (of care) is developed for each participant employing the procedures specified in Appendix D. All waiver services are furnished pursuant to the service plan. The service plan describes:

(a) the waiver services that are furnished to the participant, their projected frequency and the type of provider that furnishes each service and (b) the other services (regardless of funding source, including State plan services) and informal supports that complement waiver services in meeting the needs of the participant. The service plan is subject to the approval of the Medicaid agency. Federal financial participation (FFP) is not claimed for waiver services furnished prior to the development of the service plan or for services that are not included in the service plan.

B. Inpatients. In accordance with 42 CFR § 441.301(b)(1)(ii), waiver services are not furnished to individuals who are in-patients of a hospital, nursing facility or ICF/IID.

C. Room and Board. In accordance with 42 CFR § 441.310(a)(2), FFP is not claimed for the cost of room and board except when:

(a) provided as part of respite services in a facility approved by the State that is not a private residence or (b) claimed as a portion of the rent and food that may be reasonably attributed to an unrelated caregiver who resides in the same household as the participant, as provided in Appendix I.

D. Access to Services. The State does not limit or restrict participant access to waiver services except as provided in Appendix C.

E. Free Choice of Provider. In accordance with 42 CFR § 431.151, a participant may select any willing and qualified provider to furnish waiver services included in the service plan unless the State has received approval to limit the number of providers under the provisions of §1915(b) or another provision of the Act.

F. FFP Limitation. In accordance with 42 CFR § 433 Subpart D, FFP is not claimed for services when another third-party (e.g., another third party health insurer or other federal or state program) is legally liable and responsible for the provision and payment of the service. FFP also may not be claimed for services that are available without charge, or as free care to the community. Services will not be considered to be without charge, or free care, when (1) the provider establishes a fee schedule for each service available and (2) collects insurance information from all those served (Medicaid, and non-Medicaid), and bills other legally liable third party insurers. Alternatively, if a provider certifies that a particular legally liable third party insurer does not pay for the service(s), the provider may not generate further bills for that insurer for that annual period.

G. Fair Hearing: The State provides the opportunity to request a Fair Hearing under 42 CFR § 431 Subpart E, to individuals:

(a) who are not given the choice of home and community-based waiver services as an alternative to institutional level of care specified for this waiver; (b) who are denied the service(s) of their choice or the provider(s) of their choice; or (c) whose services are denied, suspended, reduced or terminated. Appendix F specifies the State's procedures to provide individuals the opportunity to request a Fair Hearing, including providing notice of action as required in 42 CFR § 431.210.

H. Quality Improvement. The State operates a formal, comprehensive system to ensure that the waiver meets the assurances and other requirements contained in this application. Through an ongoing process of discovery, remediation and improvement, the State assures the health and welfare of participants by monitoring:

(a) level of care determinations;

(b) individual plans and services delivery; (c) provider qualifications; (d) participant health and welfare; (e) financial oversight and (f) administrative oversight of the waiver. The State further assures that all problems identified through its discovery processes are addressed in an appropriate and timely manner, consistent with the severity and nature of the problem. During the period that the waiver is in effect, the State will implement the Quality Improvement Strategy specified in Appendix H.

I. Public Input. Describe how the State secures public input into the development of the waiver:

DDS secured public input into the renewal of the HCBS Alternative Community Services (ACS) Waiver through the use of various workgroups, committees, and both informal and formal public notice. The DDS Quality Assurance Committee, which includes representatives of providers and people served, has been in existence since 2011. This Committee reviews policies and other documents that impact people served by DDS, including pertinent portions of the ACS Waiver. A workgroup that reviewed and revised existing Standards for HCBS providers has been expanded and was utilized for the in-depth review of the ACS Waiver. DDS sent copies of draft documents and notice of public comment periods or public hearings that impact the ACS Waiver to all providers and interested parties. This included the Arkansas HCBS Statewide Settings Transition Plan, http://dds-hcbs.herokuapp.com/, the HCBS ACS Waiver renewal application, HCBS Standards, and the Medicaid HCBS Provider Manual. DDS held a stakeholder meeting for consumers, families and providers to address conflict-free case management requirements. The complete ACS Waiver Renewal application was posted on the DDS Website for informal comment/question period following the meeting. Comments/questions received were reviewed and changes incorporated in the application. Comments were received in the areas of choice, conflict-free case management, needs assessment, PCSP process and assurance of a conflict-free planning process. Due to space limitations, actual comments and responses have been added to this document and can be located in the section titled Optional.

Websites for the Arkansas Waiver Association, the Developmental Disabilities Provider Association and DDS contain information about the ACS Waiver. DDS staff participate at provider conferences and take comments by phone and email from providers and people receiving or applying for services.

After input was obtained, DDS considered the recommendations and incorporated changes that improved the ACS Waiver services and its processes. DDS emailed a final draft to providers and interested parties prior to the formal public comment period. The draft was posted on the DDS website and the DMS website for review and comment by the public.

After any changes were made during the public comment period, DMS submitted the renewal application to CMS. Upon approval by CMS, DMS and DDS will implement the regulations, policies, rules and procedures that are promulgated in accordance with the Arkansas Administrative Procedure Act. This process allows for another opportunity for public comment and changes prior to the final rule submission. After review and approval from Arkansas Legislative Committees, the implementing regulations, policies, rules and procedures are incorporated into the DMS Medical Services Manual. This manual is available to all providers and the general public on the DMS website.

J. Notice to Tribal Governments. The State assures that it has notified in writing all federally-recognized Tribal

Governments that maintain a primary office and/or majority population within the State of the State's intent to submit a Medicaid waiver request or renewal request to CMS at least 60 days before the anticipated submission date is provided by Presidential Executive Order 13175 of November 6, 2000. Evidence of the applicable notice is available through the Medicaid Agency.

K. Limited English Proficient Persons. The State assures that it provides meaningful access to waiver services by Limited English Proficient persons in accordance with:

(a) Presidential Executive Order 13166 of August 11, 2000 (65 FR 50121) and (b) Department of Health and Human Services "Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons" (68 FR 47311 -August 8, 2003). Appendix B describes how the State assures meaningful access to waiver services by Limited English Proficient persons.

7. Contact Person(s)

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8. Authorizing Signature

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Attachment #2: Home and Community-Based Settings Waiver Transition Plan

Specify the state's process to bring this waiver into compliance with federal home and community-based (HCB) settings requirements at 42 CFR 441.301(c)(4)-(5), and associated CMS guidance.

Consult with CMS for instructions before completing this item. This field describes the status of a transition process at the point

in time of submission. Relevant information in the planning phase will differ from information required to describe attainment of

milestones.

To the extent that the state has submitted a statewide HCB settings transition plan to CMS, the description in this field may

reference that statewide plan. The narrative in this field must include enough information to demonstrate that this waiver

complies with federal HCB settings requirements, including the compliance and transition requirements at 42 CFR 441.301(c)

(6) , and that this submission is consistent with the portions of the statewide HCB settings transition plan that are germane to this

waiver. Quote or summarize germane portions of the statewide HCB settings transition plan as required.

Note that Appendix C-5 HCB Settings describes settings that do not require transition; the settings listed there meet federal HCB

setting requirements as of the date of submission. Do not duplicate that information here.

Update this field and Appendix C-5 when submitting a renewal or amendment to this waiver for other purposes. It is not

necessary for the state to amend the waiver solely for the purpose of updating this field and Appendix C-5. At the end of the

state's HCB settings transition process for this waiver, when all waiver settings meet federal HCB setting requirements, enter

"Completed" in this field, and include in Section C-5 the information on all HCB settings in the waiver.

The Division of Developmental Disabilities Services (DDS) is the operating agency for one 1915(c) waiver impacted by the HCBS Settings Rule: AR.0188 DDS - Alternative Community Services (ACS) Waiver. The purpose of this waiver is to support individuals of all ages who have a developmental disability and choose to receive services within their community. The person-centered service plan offers an array of services that allow flexibility and choice for the participant. Services are provided in the person's home and community.

Individuals served by the ACS Waiver can choose to reside in a private home in the community and receive HCBS services in their home. The home may be the person's home, or the home of a family member or friend. The remainder live in either a group home, a provider owned or controlled apartment, or in the home of a staff person who is employed by the HCBS provider. It is expected that people who live in their own home or the home of a family member or friend who is not paid staff receive services in a setting that complies with requirements found at 42 CFR 441.301(c)(4).

DDS staff offers each person a choice of both case management and direct service providers. The chosen case management provider assesses the person's needs and wants and facilitates the development of the person-centered plan, which is approved by DDS staff. DDS ACS Waiver staff will monitor services through random home visits (minimum 10% per staff caseload). In addition, as part of the DDS certification process, DDS Licensure and Certification staff monitors services in the person's home. DDS ACS Waiver staff and DDS Licensure and Certification staff have been trained on the CMS Final Rule.

DDS is proposing to achieve and maintain full compliance with HCBS requirements, as indicated by this statewide transition plan. A transition plan chart is attached which outlines the processes and timeline which DDS and stakeholders will follow to identify and assess at-risk providers, remediate any areas of non-compliance, and conduct outreach to engage providers and other stakeholders [see AR HCBS STP-Timeline Chart( 12-15-2015)].

Description of State Assessment of Current Level of Compliance

Review of State Policies and Procedures

DDS has revised its HCBS Standards to include the characteristics of Settings which will guide DDS providers as they transition provider settings to those which fully include all the necessary characteristics and traits of a fully compliant HCBS setting. New providers are expected to be compliant with the Final Rule at the time of application.

Assessment of Provider Compliance with Residential and Non-Residential Settings Requirements

As part of the Statewide Transition Plan, the state of Arkansas has developed an inter-agency HCBS Settings working group. The group discusses assessment activities, including provider self-assessment surveys, site visits, and ongoing compliance with the HCBS Settings rule. An inter-agency site review Team is being developed that will review the provider self-assessment surveys, conduct an on-site assessment tool to validate provider self-assessments, and analyze compliance over the coming months.

Provider self-assessment.

DDS is conducting the assessment process outlined in CMS guidance. DDS is analyzing both its residential and day service systems. Residential providers include Group Homes, Apartments, and provider staff homes in which consumers live. Each residential provider has completed and returned a self-study to DDS. The self-study is based on the "Exploratory Questions" document included in the toolkit developed by CMS. It will serve as a baseline "snapshot" of the residential provider's existing self-assessed compliance with the HCBS Settings rule. All DDS providers participated in the self-assessment process. Survey responses are being validated through on-site visits.

Validation of self-assessment (site visits).

As stated in a previous section, an inter-agency team composed of staff employed by the Division of Aging and Adult Services, Division of Developmental Disabilities Services, and the Division of Medical Services will be identified and assigned to an inter-agency site visit team. This team will conduct the initial review of settings for compliance with CMS setting regulations. . DDS Certification staff have conducted an on-site technical support visit to each group home and provider owned or controlled apartment and are in the process of conducting technical support site visits to each provider who uses staff homes as settings. Of the 151 Residential Settings, 123 settings received an on-site technical support visit. An analysis of the information is being provided to the inter-agency site review team as part of the state provider assessment process.

Ongoing Assessment of Settings

Licensed and certified settings are subject to periodic compliance site-visits by DDS. HCBS settings requirements will be enforced during those visits. Settings found to have deficiencies are required to implement corrective actions and can lose their license or certification when noncompliance continues or is egregious. New providers will also be subject to an assessment of compliance with the HCBS settings requirements prior to licensure and certification.

Remediation

DDS has developed and will promulgate standards that support and promote the belief that individuals must have full access to the benefits of community living and have the opportunity to receive services in the most integrated setting appropriate. The standards specify how services must be offered in settings that are designed specifically for people with disabilities when the individuals in the setting are primarily people with disabilities and on-site staff provide services to them and the setting may have the effect of isolating the individuals who live there from the broader community of individuals not receiving Medicaid-funded HCBS.

The standards require that organizations that own or operate a residential service setting or a day service setting which may be presumed to have institutional qualities to offer services in such a way as to ensure that the characteristics required of an HCBS setting are present. The standards:

1) require assurance of specific individual rights; 2) prescribe certain characteristics of the physical plant; and 3) specify steps which must be taken if any of the required conditions must be modified based on a specific assessed need of an individual.

DDS issues a report to each Organization that owns, operates, or otherwise controls a residential setting of any characteristics at each location that does not appear to be in compliance with the current HCBS settings rule. Each Organization that receives a report identifying practices that require improvement from DDS, responds with an improvement plan and submits relevant policies to assure best practice.

DDS will issue a recommendation of approval to the site development review subcommittee for each residential setting that is in compliance with the HCBS Settings requirements. If a residential setting is not recommended for approval as complying with HCBS Settings requirements, DDS will defer to site subcommittee for final determination. If the HCBS site review subcommittee and the HCBS Settings working group do not feel that a provider is progressing towards compliance, the state will need to implement relocation strategies. The HCBS Settings working group will be developing a relocation plan in the coming months as we work through the on-site assessment process. The relocation remediation strategy will include a detailed relocation plan that provides reasonable notice and due process for residents. The relocation plan will also include a timeframe, a description of the state's process to ensure sufficient services and supports are in place prior to the transition, and assurances that affected residents will receive sufficient information, opportunity, and supports to make an informed choice regarding transition to a new compliant setting.

Heightened Scrutiny

DDS recognizes that certain settings are presumed non-compliant with the HCBS Settings requirements. Specifically, some home and community based settings have institutional qualities - those settings that are publicly or privately owned facilities that provide inpatient treatment, those settings that are located on the grounds of, or immediately adjacent to, a public institution, or those settings that have the effect of isolating individuals from the broader community. These settings include those that are located on or near the grounds of an institution and settings which may isolate individuals from the community. These settings include group homes located on the grounds of or adjacent to a public institution, numerous group homes co-located on a single site, a disability-specific farm-like service setting and apartments located in apartment complexes also occupied by persons who do not receive HCBS services. DDS will request heightened scrutiny for those settings presumed not to be home and community based.

Following the provider self-assessment and on-site assessment(s), settings that meet any of the above criteria will be published in a public notice in the statewide newspaper, Arkansas Democrat-Gazette, to allow for public comment. The public notice will list the affected settings by name and location, and will identify the number of individuals served at each setting. The public notice will include all justifications as to how and why the setting meets HCBS requirements and will specifically note that the public has an opportunity to comment on the state's evidence. The state will provide responses to these public comments in a subsequent version of the STP.

In cases where DDS asks for heightened scrutiny by CMS for certain settings, the same process as described in the DAAS section will be utilized by DDS.

Additional Needed Information (Optional)

Provide additional needed information for the waiver (optional):

The following comments were received during the public comment period.

Comment: Please clarify which services are deemed direct and which are deemed indirect. Of those deemed indirect will case management companies be allowed to provide those supports? Will case management companies be allowed to provide direct services under another division or funding source such as Aging or DDTCS?

Response: The Department will take these in consideration as we move forward in designing systems in accordance with CMS regulation in regard to conflict free case management.

Comment: Of those developing the PCSP where the Guardian is related to staff there is a direct interest in financial determinations. How will DDS handle this in the future to assure service planning is not driven by staff hours/pay rather than service need? Response: DMS/DDS is currently exploring conflict free case management options inclusive of PCSP development.

Comment: As a matter of principle we submit that the waiting list for waiver of 3000 people clearly violates an individual's opportunity for choice. It is not a choice to ask families, individuals, guardians to select an option that is unavailable. Response: Thank you for your comment.

Comment: At this time one of three main actions occur when an individual with no other support is hospitalized. One, we request GR funding for this support which is fiscally undesirable and often unavailable; two, people go without support which is unsafe and leads to longer hospitalization and often higher reoccurrence of illness; three, the provider eats the cost of staff support which is unsustainable long-term. There needs to be a systemic response to this problem.

Response: The Department will take this under advisement and consult with CMS as this is a statutory requirement under 42 CFR § 441.301(b)(1)(ii).

Comment: While we understand the need for DHS to utilize waiver slots to prevent individuals from remaining in more restrictive placements when less restrictive are requested, there is no legitimate basis for this delineation. The state's lack of funding or fear of a Waitlist or Olmstead lawsuit is not sufficient justification to engage in adverse action against community families, let alone adverse action without due process. Response: Thank you for your comment.

Comment: One commenter noted that the individuals preparing the PCSP cannot be related by blood or marriage, yet the relative box within the waiver is checked on who can provide service. Further the requirement of being conflict free should be added to provider qualifications on the same page within the waiver. Response: Thank you for your suggestion. Changes will be made within the document.

Comment: Please define clinic, does this refer to doctor's office or is clinic utilization specifying another location? Response: Clinic is being removed to comply with settings requirements per CMS regulations.

Comment: Under the service of supported employment there are many people who want to work, but need less than 15 hours per week, or need to share a job with another. There is no definition that DDS only provide supported employment under the definition used by ARS and there was a previous agreement to remove the minimum number of hours worked requirement under waiver. By deleting the minimum requirement someone who can only work a few would still be able to work those hours. Response: The supported employment definition will be revised and an amendment submitted.

Comment: The need for agencies to determine how direct care supervisors will supervise staff is at the agency's discretion and in line with agency personnel policies. The DDS agency should not prescribe how supervision will occur or the timeframe of that supervision. Please remove "maintained weekly." Some agencies review notes daily, others per-pay-period and others on a monthly basis. Response: Thank you for your comment. Change has been made in document.

Comment: Please change QMRP to QDDP as noted in the rest of the document. Thank you for changing this language. Response: Thank you for bringing this to our attention. We will make this change.

Comment: Activity fees are limited to individuals who have anger or weight issues. Why?

Response: Supplemental support by definition is used as a response to crisis, emergency or life threatening situations.

Comment: Please clarify who provides choice once the conflict free company is in place, and who is to perform the annual needs assessments. How will Arkansas DDS review those assessments prior to approving an individual's plan of care? Will this slow the plan of care application and approval process? Response: Thank you for your comment. It will be used in the development of the conflict free process.

Comment: Please remove the line from page 82 that requires approval from DDS authority on hiring eligible relatives. Response: Thank you for your comment. This has been removed from the document.

Comment:DDS has previously denoted that the level of care is functional qualification, not a funding level. However, the funding is reviewed annually and listed in the waiver itself on page 90. The previous correction to this was announced a year ago at AWA where the DDS representative announced that the levels of care in the waiver were agreed to be arbitrary and would be removed. Response: Thank you for your comment.

Comment: In the last waiver renewal, the agency agreed to a 10% cost of living adjustment per year, as it was agreed that rates were far removed from the cost necessary to provide quality supports. This occurred once. Response: Thank you for your comment.

Comment: The risk assessment area of the plan of care should rest with the case management entity. If a number of providers are eligible to be selected, the coordination of assessing risk will need to cross agency lines.

Response: Thank you for your comment. We will utilize your comment as we move forward on developing conflict free case management.

Comment: Most long term care programs have absentee rates. Keeping beds/slots full spreads the overhead costs of the program and keeps from continual staff turnover. Further, absentee rates help retain employees who might need leave, and lowers the cost of replacement and retraining. In our current workforce crisis, any mechanism to staff, and retain staff are necessary. An absentee rate under waiver could assist the staffing of these programs. Response: Thank you for your comment.

Comment: One commenter noted that DDS policy does not include spina bifida and Down Syndrome as a qualifying diagnosis.

Both diagnoses were added to the Statute by Act 68 of 2011.

Response: Thank you for your comment. Revision is forthcoming to align with DDS policy.

Comment: One commenter wrote in great detail their concerns about participant access and eligibility, level of care criteria, procedure for offering opportunity to request a fair hearing and the availability of additional dispute resolution process. Response: Thank you for your comment. This information will be considered in future amendments.

Comment: One commenter recommended that the State accept the Community First Choice Option and additional federal funds to increase the number of HCBS Waiver slots available to persons with development disabilities in Arkansas who desire to live in the community. In the alternative, the state should immediately increase the number of HCBS Waiver slots to cover all of those who have been on the waiver waiting list for more than 5 years and increase the number of slots available annually by at least 200 slots for the next five years. Response: Thank you for your comment. This information will be considered in future amendments.

Comment: One commenter recommended that the State address the need for conflict free case management by increasing rates available for providers of case management services.

Response: Thank you for your comment. This information will be considered in future amendments.

Comment: One commenter wrote in great detail their multiple concerns with what they considered as inadequacies of the

Transition Plan.

Response: Thank you for your comment. This information will be considered in future amendments.

Comment: The State should revise the list of incidents that are designated as critical and require follow-up by DDS. Response: Thank you for your comment. This information will be considered in future amendments.

Comment: The State should revise the Participant Rights section of the Request to align it with federal law regarding a beneficiary's access to services during the pendency of the appeal. The State should also make changes to either the request or the State policy regarding appeals to ensure that both are consistent with each other and should implement a mechanism to ensure that both are carried out with fidelity. In addition, DDS should consider providing simple, plain language guidance to explain the appeals process to an ordinary consumer. Response: Thank you for your comment. This information will be considered in future amendments.

Appendix A: Waiver Administration and Operation

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Quality Improvement: Administrative Authority of the Single State Medicaid Agency

As a distinct component of the State's quality improvement strategy, provide information in the following fields to detail the State's methods for discovery and remediation.

a. Methods for Discovery: Administrative Authority

The Medicaid Agency retains ultimate administrative authority and responsibility for the operation of the waiver program by exercising oversight of the performance of waiver functions by other state and local/regional non-state agencies (if appropriate) and contracted entities.

i. Performance Measures

For each performance measure the State will use to assess compliance with the statutory assurance, complete the following. Performance measures for administrative authority should not duplicate measures found in other appendices of the waiver application. As necessary and applicable, performance measures should focus on:

* Uniformity of development/execution of provider agreements throughout all geographic areas covered by the waiver

* Equitable distribution of waiver openings in all geographic areas covered by the waiver

* Compliance with HCB settings requirements and other new regulatory components (for waiver actions submitted on or after March 17, 2014)

Where possible, include numerator/denominator.

For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

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b. Methods for Remediation/Fixing Individual Problems

i. Describe the State's method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.

The Division of Developmental Disabilities Services (the operating agency) and the Division of Medical Services (Medicaid agency) participate in quarterly team meetings to discuss and address individual problems associated with administrative authority, as well as problem correction and remediation. DDS and DMS have an Interagency Agreement for measures related to administrative authority of the HCBS Waiver.

In cases where the numbers of unduplicated participants served in the HCBS Waiver are not within approved limits, remediation includes HCBS Waiver amendments and implementing a waiting list. DMS reviews and approves all policy and procedures, including HCBS Waiver amendments, developed by DDS prior to implementation, as part of the Interagency Agreement. In cases where policy or procedures were not reviewed and approved by DMS, remediation includes DMS reviewing the policy upon discovery, and approving or removing the policy.

In cases where there are problems with level of care determinations completed by a qualified evaluator, where instruments and processes were not followed as described in the waiver, or were not completed within specified time frames, additional staff training, staff counseling or disciplinary action may be part of remediation. Similarly, remediation for PCSPs not completed in specified time frames includes completing the PCSP upon discovery, additional training for staff, and staff counseling or disciplinary action. DDS conducts all remediation efforts in these areas.

Remediation to address participants not receiving at least one waiver service a month in accordance with the PCSP and the agreement with DMS includes closing a case, conducting monitoring visits, revising a PCSP to add a service, checking on provider billing, and providing training. DDS conducts remediation efforts in these areas, and the tool used for case record review documents and tracks remediation.

Remediation associated with provider certifications that are not current according to the DDS/DMS agreement may include recertifying providers upon discovery if appropriate, requesting termination of the provider's Arkansas Medicaid enrollment, referral to the Office of Medicaid Inspector General for possible recoupment for services provided after certification expired, and allowing the participant to choose another provider. DDS conducts remediation in these areas.

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Appendix B: Participant Access and Eligibility

B-1: Specification of the Waiver Target Group(s)

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b. Additional Criteria. The State further specifies its target group(s) as follows:

Both persons with intellectual disability and persons with developmental disability are recognized as target groups. Developmental disability diagnoses include Cerebral Palsy, Epilepsy, Autism, Down Syndrome, and Spina Bifida as categorically qualified diagnoses. Onset must occur before the person is 22 years old and must be expected to continue indefinitely. Other diagnoses will be considered if the condition causes the person to function as though they have an intellectual disability.

DDS eligibility is established by Arkansas Code Annotated, Section 20-48-101. The statute applies to Intermediate Care Facilities for individuals with Intellectual Disability (ICF/IID) and the HCBS Waiver. DDS interprets a developmental disability to be (1) a categorically qualifying diagnosis and (2) significant adaptive behavior deficits related to this diagnosis. Following are the categorically qualifying diagnoses:

Cerebral Palsy as established by the results of a medical examination provided by a licensed physician. Epilepsy as established by the results of a neurological examination provided by a licensed physician.

Autism as established as a result of a team evaluation by at a minimum a licensed physician, a psychologist or psychological examiner, and speech pathologist.

Down syndrome as established by the results of a medical examination provided by a licensed physician. Spina Bifida as established by the results of a medical examination provided by a licensed physician.

Intellectual Disability as established by significant intellectual limitations that exist concurrently with deficits in adaptive behavior that are manifested before the age of 22. "Significant intellectual limitations" are defined as a full scale intelligence score of approximately 70 or below as measured by a standard test designed for individual administration. Group methods of testing are unacceptable.

The qualifying disability must constitute a substantial handicap to the person's ability to function without appropriate support services including, but not limited to, daily living and social activities, medical services, physical therapy, speech therapy, occupational therapy, job training and employment. When the age of onset of the qualifying disability is indeterminate, the Assistant Director or the Director for Developmental Disabilities Services will review evidence and determine if the disability was present before age 22.

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B-2: Individual Cost Limit (1 of 2)

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B-3: Number of Individuals Served (1 of 4)

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B-4: Eligibility Groups Served in the Waiver

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B-5: Post-Eligibility Treatment of Income (1 of 7)

In accordance with 42 CFR § 441.303(e), Appendix B-5 must be completed when the State furnishes waiver services to individuals in the special home and community-based waiver group under 42 CFR § 435.217, as indicated in Appendix B-4. Post-eligibility applies only to the 42 CFR § 435.217 group.

a. Use of Spousal Impoverishment Rules. Indicate whether spousal impoverishment rules are used to determine eligibility for the special home and community-based waiver group under 42 CFR § 435.217:

Note: For the five-year period beginning January 1, 2014, the following instructions are mandatory. The following box should be checked for all waivers that furnish waiver services to the 42 CFR § 435.217 group effective at any point during this time period.

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Note: The following selections apply for the time periods before January 1, 2014 or after December 31, 2018.

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Note: The following selections apply for the time periods before January 1, 2014 or after December 31, 2018.

c. Regular Post-Eligibility Treatment of Income: 209(B) State.

Answers provided in Appendix B-4 indicate that you do not need to complete this section and therefore this section is not visible.

Note: The following selections apply for the time periods before January 1, 2014 or after December 31, 2018.

d. Post-Eligibility Treatment of Income Using Spousal Impoverishment Rules

The State uses the post-eligibility rules of §1924(d) of the Act (spousal impoverishment protection) to determine the contribution of a participant with a community spouse toward the cost of home and community-based care if it determines the individual's eligibility under §1924 of the Act. There is deducted from the participant's monthly income a personal needs allowance (as specified below), a community spouse's allowance and a family allowance as specified in the State Medicaid Plan. The State must also protect amounts for incurred expenses for medical or remedial care (as specified below).

Answers provided in Appendix B-5-a indicate that you do not need to complete this section and therefore this section is not visible.

Note: The following selections apply for the five-year period beginning January 1, 2014.

e. Regular Post-Eligibility Treatment of Income: §1634 State - 2014 through 2018.

The State uses the post-eligibility rules at 42 CFR § 435.726 for individuals who do not have a spouse or have a spouse who is not a community spouse as specified in §1924 of the Act. Payment for home and community-based waiver services is reduced by the amount remaining after deducting the following allowances and expenses from the waiver participant's income:

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f. Regular Post-Eligibility Treatment of Income: 209(B) State - 2014 through 2018.

Answers provided in Appendix B-4 indicate that you do not need to complete this section and therefore this section is not visible.

Note: The following selections apply for the five-year period beginning January 1, 2014.

g. Post-Eligibility Treatment of Income Using Spousal Impoverishment Rules - 2014 through 2018.

The State uses the post-eligibility rules of §1924(d) of the Act (spousal impoverishment protection) to determine the contribution of a participant with a community spouse toward the cost of home and community-based care. There is deducted from the participant's monthly income a personal needs allowance (as specified below), a community spouse's allowance and a family allowance as specified in the State Medicaid Plan. The State must also protect amounts for incurred expenses for medical or remedial care (as specified below).

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B-6: Evaluation/Reevaluation of Level of Care

As specified in 42 CFR § 441.302(c), the State provides for an evaluation (and periodic reevaluations) of the need for the level(s) of care specified for this waiver, when there is a reasonable indication that an individual may need such services in the near future (one month or less), but for the availability of home and community-based waiver services.

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Quality Improvement: Level of Care

As a distinct component of the State's quality improvement strategy, provide information in the following fields to detail the State's methods for discovery and remediation.

a. Methods for Discovery: Level of Care Assurance/Sub-assurances

The state demonstrates that it implements the processes and instrument(s) specified in its approved waiver for evaluating/reevaluating an applicant's/waiver participant's level of care consistent with level of care provided in a hospital, NF or ICF/IID.

i. Sub-Assurances:

a.Sub-assurance: An evaluation for LOC is provided to all applicants for whom there is reasonable indication that services may be needed in the future.

Performance Measures

For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

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b.Sub-assurance: The levels of care of enrolled participants are reevaluated at least annually or as specified in the approved waiver.

Performance Measures

For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

c.Sub-assurance: The processes and instruments described in the approved waiver are applied appropriately and according to the approved description to determine participant level of care.

Performance Measures

For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

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b. Methods for Remediation/Fixing Individual Problems

(LOC A1) The Intake and Referral (I&R) Application Tracking system tracks all applications on an ongoing basis. At 45 days, the Intake Specialist sends a notice to families to notify them that the information is due. For applications over 90 days old, the Intake Manager reviews overdue applications for cause and then contacts Intake staff to develop a corrective action plan, which will be implemented within 10 days. The Intake Manager will submit an I&R Report of Timely Application submissions to the I&R administrator monthly for review to identify any systemic issues and to determine if there is a need for corrective action. The I&R administrator will submit a quarterly report to the QA Assistant Director and describes any corrective actions.

(LOC A2) The system in place for new applicants to enter the HCBS waiver program does not allow for services to be delivered prior to an initial determination of Level of Care.

(LOC C1) The DDS Psychology Team manager reviews 100% of all initial waiver application determinations submitted within the previous month for process and instrumentation review. A Requirement checklist form for each application in the sample is completed for procedural accuracy and appropriateness of testing instruments utilized in adjudications. Results are tracked. The Psychology Supervisor contacts Psychology staff to develop corrective action plan, which will be implemented within 10 days. The Psychology supervisor submits a quarterly report to the QA Assistant director and outlines corrective actions.

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B-7: Freedom of Choice

Freedom of Choice. As provided in 42 CFR § 441.302(d), when an individual is determined to be likely to require a level of care for this waiver, the individual or his or her legal representative is:

i. informed of any feasible alternatives under the waiver; and ii. given the choice of either institutional or home and community-based services.

a. Procedures. Specify the State's procedures for informing eligible individuals (or their legal representatives) of the feasible alternatives available under the waiver and allowing these individuals to choose either institutional or waiver services. Identify the form(s) that are employed to document freedom of choice. The form or forms are available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Intake and referral for the HCBS Waiver is the responsibility of intake and referral staff with the DDS Children's Services Section for persons birth to 21 if still in high school or of DDS Adult Services Section for persons age 18 and over if the person has completed high school. The DDS staff person explains the service options of HCBS Waiver or ICF/IID to each person or their legal guardian by phone, personal visit, email, or mail. The individual or legal guardian completes the HCBS Choice Form and selects either the HCBS Waiver program or ICF/IID placement. For persons residing in an ICF/IID, choice between the programs is offered annually at the time of their annual PCSP review. Anyone residing in an ICF/IID can request HCBS Waiver services at any time by contacting the transition coordinator. The transition coordinator works with the HCBS Waiver Applications Unit Administrator and assigned DDS HCBS Waiver Specialist. Annual choice is offered by the assigned DDS Specialist prior to the individual's annual review. The choice form provides a means to track whether choice was offered. It also provides supporting evidence that the options elicit an informed choice as attested to by the signature of the DDS representative.

b. Maintenance of Forms. Per 45 CFR § 92.42, written copies or electronically retrievable facsimiles of Freedom of Choice forms are maintained for a minimum of three years. Specify the locations where copies of these forms are maintained.

Individual HCBS Waiver application packets including the choice form are maintained in an electronic format during the application process. Person's electronic case file is maintained by the assigned DDS Specialists who are located in designated DHS county offices. Documentation of annual choice following initial HCBS Waiver program participation is maintained in the electronic case file.

Appendix B: Participant Access and Eligibility

B-8: Access to Services by Limited English Proficiency Persons

Access to Services by Limited English Proficient Persons. Specify the methods that the State uses to provide meaningful access to the waiver by Limited English Proficient persons in accordance with the Department of Health and Human Services "Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons" (68 FR 47311 - August 8, 2003):

DDS provides information in an alternate format once the need for accommodation is identified. Identification for need is obtained through observation, document review for diagnosis and other case related information, and self or third party notification. Awareness is provided through training, employee technical assistance, communications with provider organizations and consumer advocates, and Department of Human Services (DHS) electronic medias. A HCBS Waiver handbook is available in Spanish, hardcopy and online. In addition, the handbook will be made available in any other language, large print or any other medium to reasonably accommodate needs as identified by the individual. DHS contracts for interpreter services when needed.

Appendix C: Participant Services

C-1: Summary of Services Covered (1 of 2)

a. Waiver Services Summary. List the services that are furnished under the waiver in the following table. If case management is not a service under the waiver, complete items C-1-b and C-1-c:

Service Type	Service
Statutory Service	Case Management
Statutory Service	Respite
Statutory Service	Supported Employment
Statutory Service	Supportive Living
Extended State Plan Service	Specialized Medical Supplies
Other Service	Adaptive Equipment
Other Service	Community Transition Services
Other Service	Consultation
Other Service	Crisis Intervention
Other Service	Environmental Modifications
Other Service	Supplemental Support

C-1/C-3: Service Specification

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Service Definition (Scope):

Services that assist participants in gaining access to needed waiver and other state plan services; as well as, medical, social, educational and other generic services, regardless of the funding source for the services to which access is available.

Case Management services include responsibility for guidance and support in all life activities including locating, coordinating and monitoring of the following:

1) All proposed waiver services;

2) Other state plan services;

3) Needed medical, social, educational and other publicly funded services (regardless of funding source);

4) Informal community supports needed by eligible persons and their families. Case Management services include the following activities:

1) Arranging for the provision of services and additional supports;

2) Monitoring and review of services included in the individual's service plan;

3) Monitoring and review of services to assure health and safety of the participant;

4) Facilitating crisis intervention;

5) Guidance and support to obtain generic needs;

6) Case planning;

7) Needs assessment and referral for resources;

8) Monitoring to assure quality of care and case reviews which focus on the person's progress in meeting goals and objectives established through the case plan;

9) Providing assistance relative to the obtaining of waiver Medicaid eligibility and ICF/IID level of care eligibility determinations;

10) Assuring the integrity of all case management Medicaid waiver billing in that the service delivered must have DDS prior authorization, must meet required waiver service definitions, and must be delivered before billing can occur;

11) Assuring submission of timely (advance) and comprehensive behavior and assessment reports, continued plans of care, revisions as needs change and information and documents required for ICF/IID level of care and waiver Medicaid eligibility determinations;

12) Arranging for access to advocacy services as requested by consumers.

13) Upon receipt of DDS approvals and denials, ensures that a copy is provided to the individual or their legal representative;

14) Provides assistance with appeals when appeal is chosen.

The State of Arkansas adheres to CMS regulations as it relates to conflict free case management. Case Management Services may not include the provision to the individual of direct services that are typically or otherwise covered as a service under HCBS Waiver or State Plan. The organization may not provide case management services to any person to whom they provide any direct services.

Case Management services may be available during the last 180 consecutive days of a Medicaid eligible person's institutional stay to allow case management activities to be performed related to transitioning the person to the community. The person must be approved and in the waiver program for case management to be billed.

Case Management will be provided up to a maximum of a 90 day transition period for all persons who seek to voluntarily withdraw from waiver services. The transition period will allow for follow up to assure that the person is referred to other available services and to assure that the person's needs can be met through optional services. It also serves to assure that the person understands the effects and outcomes of withdrawal and to ascertain if the person was coerced or otherwise was unduly influenced to withdraw. During this 90 day timeframe, the person remains enrolled and the case remains open. During the transition period, the individual remains enrolled in the waiver program and waiver services will continue to be available up and until such time as the individual finalizes their intent to withdraw.

Case management waiver services will be furnished when payment to the hospital, NF or ICF/IID is being made through private pay or private insurance and Medicaid is not reimbursing for this care. While the waiver participant is in a hospital, nursing facility or institution (ICF) receiving treatment, they are not residing in the treatment facility. Rather, just like any non-institutionalized person or person without a developmental disability, their community residence (home in which they reside) is maintained. When Medicaid is not the payer for the treatment, the waiver individual can remain enrolled in the Waiver without harm to the payments for the treatment. When this provision applies, approval is in 3 month increments with no approval beyond 1 year.

Given the nature of the population of the ACS waiver, it is sometimes necessary to place cases in abeyance to allow the case to remain open while the participant is temporarily placed in a licensed or certified treatment program for the purposes of behavior, physical or health treatment or stabilization. On a monthly basis, the case management provider must conduct a monitoring contact and report the status to the applicable DDS Specialist. If the case management provider does not conduct the monitoring contact for the month, the DDS Specialist is responsible for the monitoring contact.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

There is a maximum reimbursement limit of $117.70 per month and $1,412.40 annually for each person served.

Service contacts have minimum requirements depending on the person's service level. They are:

1) Pervasive - minimum of one face-to-face visit and one other contact with the individual or legal representative monthly. At least one visit must be made annually at the individual's place of residence.

2) Extensive - minimum of one face-to-face visit with the individual or legal representative each month. At least one visit must be made annually at the individual's place of residence.

3) Limited - minimum of one face-to-face visit with the individual or legal representative each quarter and a minimum of one contact monthly for months when a face-to-face visit is not made. At least one visit must be made annually at the individual's place of residence.

These service levels are defined in Supportive Living, C-1.

4) Abeyance - minimum of one visit or contact a month by the Case Manager or the DDS Specialist (When the DDS Specialist performs the monitoring functions, no waiver fee is charged or reimbursed - the cost is absorbed in the DDS Waiver Administrative budget). Abeyance is used when a person is temporarily ( must be out of service at least one month with abeyance approved in 3 month increments, not to exceed one year) placed in a licensed or certified treatment program for purposes of behavior, physical or health treatment or stabilization.

This waiver service is only provided to individuals age 21 and over. All medically necessary case management services for children under the age of 21 are covered in the state plan pursuant to the EPSDT benefit.

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Service Definition (Scope):

Respite services are provided on a short term basis to participants unable to care for themselves due to the absence of or need for relief to the non-paid primary caregiver. Federal Financial Participation (FFP) may not be claimed for the cost of room & board, except when provided as part of the respite care furnished in a facility approved by the state; FFP may not be claimed for room and board when Respite is provided in the participant's home or private place of residence.

Receipt of respite does not necessarily preclude a participant from receiving other services on the same day. For example, a participant may receive day services, such as, supported employment on the same day as respite services.

When respite is furnished for the relief of a foster care provider, foster care services may not be billed during the period that respite is furnished. Respite may not be furnished for the purpose of compensating relief or substitute staff for supportive living services. Respite services are not to supplant the responsibility of the parent or guardian.

Respite services may be provided through a combination of basic child care & support services required to meet the needs of a child. When respite is provided in a licensed day care facility, licensed day care home, or other lawful child care setting, waiver will only pay for the support staff required by the person's developmental disability. Parents & guardians will remain responsible for the cost of basic child care fees. Waiver will not pay for child care services.

Respite may be provided in the following locations:

1) Participant's home or private place of residence;

2) The private residence of a respite care provider;

3) Foster home;

4) Medicaid certified ICF;

5) Group home;

6) Licensed respite facility;

7) Other community residential facility approved by the state, not a private residence. Respite care may occur in a licensed or accredited residential mental health facility.

8) Licensed day care facility, licensed day care home or other lawful child care setting. Waiver will only pay for support staff required due to developmental disability. Waiver will not pay for day care fees.

Specify applicable (if any) limits on the amount, frequency, or duration of this service: There is a maximum daily rate for supportive living service and respite, collectively or individually. Supportive living includes provider indirect costs for each component in the array. Individual daily rates in all levels require prior approval by DDS staff.

1) Pervasive - maximum daily rate is $391.95 with a maximum of $143,061.75 annually.

2) Extensive - maximum daily rate is $184.80 with a maximum of $67,452.00 annually.

3) Limited - maximum daily rate is $176.00 with a maximum of $38,544.00 annually.

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Service Definition (Scope):

Supported employment services consist of intensive, ongoing supports that enable participants for whom competitive employment at or above the minimum wage is unlikely, or who because of their disabilities need ongoing supports to perform in a competitive work setting. Supported employment may include assisting the participant to locate a job or develop a job on behalf of the participant. Supported employment is conducted in a variety of settings, particularly work sites where persons without disabilities are employed. Supported employment includes activities needed to sustain paid work by participants, including supervision and training. When supported employment services are provided at a work site where persons without disabilities are employed, payment is made only for the adaptations, supervision and training required by participants receiving waiver services as a result of their disabilities. Coverage does not include payment for the supervisory activities rendered as a normal part of the business setting. The employer is responsible for making reasonable accommodations in accordance with the Americans with Disabilities Act. Supported employment is a collaborative service with Arkansas Rehabilitation Services (ARS). All new waiver participants receiving supported employment must be prior certified by ARS to assure the individual is qualified for supported employment and that ARS funding is accessed first.

Documentation is maintained in the file of each participant receiving this service that the service is not available under a program funded under Section 110 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act (20 U.S.C. 1401 et seq.). Federal financial participation is not claimed for incentive payments, subsidies, or unrelated vocational training expenses such as the following:

1) Incentive payments made to an employer to encourage or subsidize the employer's participation in a supported employment program;

2) Payments that are passed through to users of supported employment programs; or

3) Payments for training that is not directly related to an individual's supported employment program.

Transportation between the participant's place of residence and the employment site is included as a component of supported employment services. The cost for transportation is included as a part of the supported employment rate paid to providers.

Supported employment does not include sheltered workshops or other similar types of vocational services furnished in specialized facilities. Supported employment provides integrated work settings where there is frequent, daily social interaction among people without disabilities. Integration requires the person to work in a place where no more than 8 persons with disabilities work together. Further, co-workers without disabilities are to be present in the work setting or immediate vicinity thereof.

Supported employment services may be furnished by a co-worker or other job site personnel provided that the services which are furnished are not part of the normal duties of the co-worker or other personnel and these individuals meet the pertinent qualifications to be a provider of service.

Personal assistance may be a component part of supported employment services but may not comprise the entirety of the service.

Supported employment may include services and supports that assist the participant in achieving self-employment through the operation of a business. However, Medicaid funds may not be used to defray the expenses associated with starting up or operating a business. Assistance for self-employment may include:

1) Aiding the participant to identify potential business opportunities;

2) Assistance in the development of a business plan, including potential sources of business financing and other assistance in developing and launching a business;

3) Identification of the supports that are necessary for the participant to operate the business; and

4) Ongoing assistance, counseling and guidance once the business is launched.

Individuals receiving supported employment services may also receive educational, prevocational and day habilitation services. A participant's service plan may include two or more types of non-residential habilitation services. However, different types of non-residential habilitation services may not be billed during the same period of the day.

Supported Employment includes:

1) Activities needed to sustain paid work by waiver individuals, including supervision and training.

2) Re-Training, job retention, or job enhancement

3) Job site assessments - The job coach, after consultation with each person in supported employment, can determine on a case by case basis how to best acquire current information relevant to assessing job stability and the individual's needs.

4) Job maintenance visits with the employer for purposes of obtaining, maintaining and retaining current or new employment opportunities. If on site monitoring is not necessary to assess stability, alternative methods of gathering information for the twice monthly assessment may be permitted. This may take a variety of forms including telephone calls with supervisors and off site meetings with the individual participating in supported employment as well as visits to the work site.

Specify applicable (if any) limits on the amount, frequency, or duration of this service: Supported employment cannot exceed $3.59 per 15 minute unit with a maximum of 32 units a day. Supported Employment provided as long term support requires monitoring at a minimum of two meetings with the individual and one employer contact each month. The person is required to work 15 hours minimum per week in accordance with ARS regulations. Exceptions must be justified by the individual's case manager and prior approved by ARS. ARS approves the exception with monthly monitoring. Exception justifications (such as medical involvement) citing why the person cannot work at least 15 hours per week must be prepared in writing by the individual's case manager and submitted to the ARS counselor assigned to the case.

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Service Definition (Scope):

Supportive Living is an array of individually tailored services & activities to enable persons to reside successfully in their own home, with family, or in an alternative living residence or setting. Alternative living residences include apartments, homes of primary caregivers, leased or rented homes, or provider group homes. Supportive living services must be provided in integrated community settings. Services are flexible to allow for unforeseen changes needed in schedules and times of service delivery. Services are approved as maximum days that can be adjusted within the annual plan year to meet changing needs.

The payments for these services exclude the costs of the person's room & board expenses including general maintenance, upkeep or improvement to the person's home or their families.

Care & supervision for which payment will be made are those activities that directly relate to active treatment goals & objectives.

Residential habilitation supports are to assist the person to acquire, retain or improve skills in a wide variety of areas that directly affect the person's ability to reside as independently as possible in the community. These services provide the supervision & support necessary for a person to live in the community. The supports that may be provided to an eligible person include the following:

Decision making including the identification of & response to dangerously threatening situations, making decisions & choices affecting the person's life & initiating changes in living arrangement or life activities;

Money management consists of training, assistance or both in handling personal finances, making purchases & meeting personal financial obligations;

Daily living skills including habilitative training in accomplishing routine housekeeping tasks, meal preparation, dressing, personal hygiene, administration of medications (to the extent permitted under state law)& other areas of daily living including proper use of adaptive & assistive devices, appliances, home safety, first aid and emergency procedures;

Socialization including training, assistance or both in participation in general community activities, & establishing relationships with peers. Activity training includes assisting the person to continue to participate on an ongoing basis;

Community integration experiences include activities intended to instruct the person in daily living & community living skills in integrated settings. Included are such activities as shopping, church attendance, sports, participation in clubs, etc. Community experiences include activities & supports to accomplish individual goals or learning areas including recreation and specific training or leisure activities. Each activity is then adapted according to the participant's individual needs.

Transportation to or from community integration experiences is an integral part of this service and is included in the daily rate computation. DDS will assure duplicate billing between waiver services & other Medicaid state plan services will not occur. The habilitation objectives to be served by such training must be documented in the person's service plan;

Mobility including training, assistance or both aimed at enhancing movement within the person's living arrangement, mastering the use of adaptive aids and equipment, accessing & using public transportation, independent travel or movement within the community;

Communication including training in vocabulary building, use of augmentative communication devices & receptive and expressive language;

Behavior shaping and management includes training, assistance or both in appropriate expressions of emotions or desires, compliance, assertiveness, acquisition of socially appropriate behaviors or reduction of inappropriate behaviors;

Reinforcement of therapeutic services which consist of conducting exercises or reinforcing physical, occupational, speech & other therapeutic programs.

Companion & activities therapy are services and activities to provide reinforcement of habilitative training. This reinforcement is accomplished by using animals as modalities to motivate persons to meet functional goals established for the person's habilitative training. Through the utilization of an animal's presence, enhancement and incentives are provided to persons to practice and accomplish such functional goals as follows:

1) Language skills;

2) Increase range of motion;

3) Socialization by developing the interpersonal relationships skills of interaction, cooperation and trust & the development of self-respect, self-esteem, responsibility, confidence and assertiveness;

This service does not include veterinary or other care, food, or ancillary equipment that may be needed by the animal that is providing reinforcement.

The Direct Care Supervisor employed by the Supported Living provider is responsible for assuring the delivery of all supported living direct care services including the following activities:

1) The coordination of all direct service workers who provide care through the direct service provider;

2) Serving as liaison between the person, parents, legal representatives, case management entity & DDS officials;

3) Coordinating schedules for both waiver & generic service categories;

4) Providing direct planning input and preparing all direct service provider segments of any initial plan of care and annual continued stay review;

5) Assuring the integrity of all direct care service Medicaid waiver billing in that the service delivered must have DDS prior authorization & meet required waiver service definition and must be delivered before billing can occur;

6) Arranging for staffing of all alternative living settings;

7) Assuring transportation as identified in person's plan of care specific to supportive living services;

8) Timely collaboration with the case management entity to obtain comprehensive behavior & assessment reports, continued plans of care, revisions as needs change and information and documents required for ICF/ID level of care & waiver Medicaid eligibility determination;

9) Reviewing the persons records & environments in which services are provided by accessing appropriate professional sources to determine whether the person is receiving appropriate support in the management of medication.

Health maintenance activities may be provided by a designated care aide (supportive living worker). All health maintenance activities (to include oral medication administration/assistance, shallow suctioning, maintenance and use of intral-feeding and breathing apparatus /devices), except injections and IV's, can be done in the home by a designated care aide, such as a waiver worker. With the exception of injectable medication administration, tasks that consumers would otherwise do for themselves, or have a family member do, can be performed by a paid designated care aide at their direction, as long as the criteria specified in the Arkansas Nurse Practices Consumer Directed Care Act has been met. Health maintenance activities are available in the Arkansas Medicaid State Plan as self directed services. State Plan services must be exhausted before accessing waiver funding for health maintenance activities.

Persons may access both supportive living and respite on the same date as long as the two services are distinct, do not overlap and the daily rate maximum is correctly prorated as to the portion of the day that each respective service was actually provided. DDS monitors this provision through retrospective annual look behind with providers responsible to maintain adequate time records and activity case notes or activity logs that support the service deliveries. Maximum daily rate is established in accordance with budget neutrality wherein both supportive living and respite independently and collectively cannot exceed the daily maximum.

Controls to assure payments are only made for services rendered: Controls in place include requirement by assigned staff to complete daily activity logs for activities that occured during the work timeframe with such activities linked to the plan of care objectives; supervision of staff by the direct care supervisor with sign off on timesheets; audits & reviews conducted by DDS Quality Assurance (anually) & random; DDS Waiver Services annual reviews (retrospective), random attendance at planning meetings & visits to the home; DMS random audits; & oversight by the chosen and assigned case manager. Retainer payments are allowable to providers for the lesser of 14 consecutive days. Retainer payments may be made to providers of habilitation while the waiver participant is hospitalized or absent from his/her home.

1) Pervasive - maximum daily rate is $391.95 with a maximum of $143,061.75 annually.

2) Extensive - maximum daily rate is $184.80 with a maximum of $67,452.00 annually.

3) Limited - maximum daily rate is $176.00 with a maximum of $38,544.00 annually.

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Service Definition (Scope):

Specialized medical equipment and supplies include:

1) Items necessary for life support or to address physical conditions along with ancillary supplies and equipment necessary to the proper functioning of such items;

2) Such other durable and non-durable medical equipment not available under the State plan that is necessary to address participant functional limitations;

3) Necessary medical supplies not available under the State plan. Items reimbursed with waiver funds are in addition to any medical equipment and supplies furnished under the State plan and exclude those items that are not of direct medical or remedial benefit to the participant. All items shall meet applicable standards of manufacture, design and installation.

Additional supply items are covered as a waiver service when they are considered essential for home and community care. A physician must order all items. When such items are included as a Medicaid state plan service, this will be an extension of such services. A denial of extension of benefits by utilization review will be required prior to approval for waiver funding by DDS. Items covered include:

1) Nutritional supplements;

2) Non-prescription medications. Alternative medicines not Federal Drug Administration approved are excluded from coverage.

3) Prescription drugs minus the cost of drugs covered by Medicare Part D when extended benefits available under state plan are exhausted.

Specify applicable (if any) limits on the amount, frequency, or duration of this service: When a non-prescription or prescription medication is necessary to maintain or avoid health deterioration, the $3,690.00 limit can be increased with the difference in the Specialized Medical Supplies maximum allowance and the required amount being deducted from the supported living array maximum allowance. All such requests must be prior approved by the DDS Assistant Director of Waiver Services.

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Service Definition (Scope):

Adaptive Equipment means an item, piece of equipment, or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, or improve functional capabilities of participants.

This service includes adaptive, therapeutic and augmentative equipment that enables a person to increase, maintain or improve their functional capacity to perform daily life tasks that would not be possible otherwise. However, therapeutic tools that therapists employ in the course of therapy are not included. Educational aids are not included. Adaptive equipment needs for supported employment for a person is also included. This service may include specialized equipment such as devices, controls or appliances that will enable the person to perceive, control or communicate with the environment in which they live and to improve the person's functional capacity to perform daily life tasks that would not be possible otherwise. Equipment may only be purchased if not available to the person from any other source. When items are included as a Medicaid state plan service, a denial by utilization review will be required prior to approval for waiver funding by DDS. Professional consultation must be accessed to ensure that the equipment will meet the needs of the person when the purchase will at a minimum but not necessarily exceed $500.00. Consultation must be conducted by a medical professional applicable as determined by the individual's condition for which the equipment is needed. Computer equipment can be approved when it will allow the person control of their environment, to assist the person to gain independence, or it can be demonstrated as necessary to protect the health and safety of the person. Computers will not be purchased to improve socialization or educational skills. The waiver does not cover supplies. Printers may be approved for non-verbal persons. Computer desks or other furniture items will not be covered. Communication boards are an allowable device. Computers may be approved for communication when there is substantial documentation that a computer will meet the needs of the person more appropriately than a communication board. Software will be approved only when required to operate the accessories included for environmental control; or to provide text-to-speech capability.

Vehicle Modifications are adaptations to an automobile or van to accommodate the special needs of the participant. Vehicle adaptations are specified by the service plan as necessary to enable the participant to integrate more fully into the community and ensure the health, welfare and safety of the participant. Payment for permanent modification of a vehicle is based on the cost of parts and labor, which must be quoted and paid separately from the purchase price of the vehicle to which the modifications are or will be made. Transfer of any part of the purchase price of a vehicle, including preparation and delivery, to the price of a modification is fraudulent activity. All suspected fraudulent activity will be reported to the Utilization Review Section of Arkansas Division of Medical Services for investigation. Reimbursement for a permanent modification cannot be used or considered as down payment for a vehicle. Lifts that require vehicle modification and the modifications are, for purposes of approval and reimbursement, one project and cannot be separated by plan of care years in order to obtain up to the maximum of $7687.50 for each component. Permanent vehicle modifications may be replaced if the vehicle is stolen, damaged beyond repair as long as the damage is not through negligence of the vehicle owner, or used for more than its reasonable useful lifetime. A vehicle has reached its reasonable useful lifetime when repairs are required to make the vehicle useable, and the cost of the repairs exceeds the fair market value of the vehicle in repaired condition. Cost of repair shall be determined by repair estimates from three qualified repairers. Vehicle value shall be determined by reference to sales listing for similar vehicles within a 200 mile radius of the beneficiary's home, and to listings in Dallas, Kansas City, Saint Louis, and Memphis. If the participant or legally responsible party sells or trades a permanently modified vehicle before the vehicle reaches its reasonable useful lifetime, the modification will not be replaced on any replacement vehicle. Instead, only the estimated residual value of the vehicle modification will be considered for approval. Estimated residual value shall be determined by comparing the purchase price of the modified vehicle when acquired by the participant or legally responsible party with the vehicle value at the time of sale determined as stated above. Example: A permanently modified vehicle purchased for $30,000 is sold with a value of $20,000 (66% residual value). If parts and labor for the modification of the replacement vehicle are $10,000, the amount paid is $3,333 (33%). Vehicle modifications apply only to modifications and are not routine auto maintenance or repairs for the vehicle.

Exclusions: The following are specifically excluded:

1) Adaptations or improvements to the vehicle that are of general utility and are not of direct medical or remedial benefit to the individual;

2) Purchase, down payment or lease of a vehicle;

3) Regularly scheduled upkeep and maintenance of a vehicle except upkeep and maintenance of the modifications.

Personal Emergency Response Systems (PERS) can be approved when it can be illustrated to be necessary to protect the health and safety of the person. PERS is an electronic device that enables certain persons at high risk of institutionalization to secure help in an emergency. The person may also wear a portable "help" button to allow for mobility. The system is connected to the person's phone and programmed to signal a response center once a "help" button is activated. The response center is staffed by trained professionals. PERS services are limited to those persons who live alone or who are alone for significant parts of the day and have no regular caregiver for extended periods of time, and who would otherwise require extensive routine supervision. Included in this support are assessment, purchase, installation and monthly rental fee.

Conditions - The care and maintenance of environmental equipment, adaptive equipment and personal emergency response systems are entrusted to the individual or legally responsible person for whom the aids are purchased. Negligence (defined as failure to properly care for or perform routine maintenance) shall mean that the service will be denied for a minimum of two plan years. Any abuse or unauthorized selling of aids by the individual or legally responsible person shall mean that the aids will not ever be replaced using Waiver funding. Deterrent for non-compliance is in the form of public comment through promulgation of this stipulation; notice of cause and effect at the time of individual equipment approval; monitoring is accomplished when the item is later requested again with denial if the original item is found to been sold; identification of other funding sources when the item is needed to help assure health and safety. Examples: Special needs (100% state general revenue) funding is available for persons not receiving waiver services. If waiver services are not available then special needs is an option. Another example or option is that waiver services would continue but not in the home of the person who was responsible for the loss.

All adaptive equipment must be solely for the waiver individual and used only by that individual. All purchases must meet the conditions for desired quality at the least expensive cost. Generally, any modifications over

$1,000.00 will require three bids with the lowest bid with comparable quality being awarded; however, DDS

authority may require 3 bids for any requested purchase. Swimming pools (in-ground or above ground) and hot tubs are not allowable as either an environmental modification or adaptive equipment. Therapy and educational aids are not allowable. Medicaid purchased equipment cannot be donated if the equipment being donated is needed for use of another waiver individual residing in the residence.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

The annual expenditure cap for environmental modifications and adaptive equipment, collectively or individually,

is $7,687.50.

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Service Definition (Scope):

Community Transition Services are non-recurring set-up expenses for individuals who are transitioning from an institutional or another provider-operated living arrangement to a living arrangement in a private residence where the person is directly responsible for his or her own living expenses. Waiver funds can be accessed once it has been determined that the waiver is the payer of last resort. Allowable expenses are those necessary to enable a person to establish a basic household that do not constitute room and board and may include:

(a) security deposits that are required to obtain a lease on an apartment or home; (b) essential household furnishings and moving expense required to occupy and use a community domicile, including furniture, window coverings, food preparation items, and bed/bath linens; (c) set-up fees or deposits for utility or service access, including telephone, electricity, heating and water; (d) services necessary for the individual's health and safety such as pest eradication and one-time cleaning prior to occupancy; (e) moving expenses; and (f) necessary home accessibility adaptations; Community Transition Services are furnished only to the extent that they are reasonable and necessary as determined through the service plan development process, clearly identified in the service plan and the person is unable to meet such expense or when the services cannot be obtained from other sources.

Duplication of environmental modifications will be prevented through DDS control of prior authorizations for approvals.

Costs for Community Transition Services furnished to individuals returning to the community from a Medicaid institutional setting through entrance to the waiver, are considered to be incurred and billable when the person leaves the institutional setting and enters the waiver. The individual must be reasonably expected to be eligible for and to enroll in the waiver. If for any unseen reason, the individual does not enroll in the waiver (e.g., due to death or a significant change in condition), transitional services may be billed to Medicaid as an administrative cost.

Exclusions: Community Transition Services may not include payment for room and board; monthly rental or mortgage expense; food, regular utility charges; and/or household appliances or items that are intended for purely diversional/recreational purposes. Community Transition Services may not be used to pay for furnishing living arrangements that are owned or leased by a waiver provider where the provision of these items and services are inherent to the service they are already providing. Diversional or recreational items such as televisions, cable TV

access or VCR's are not allowable.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

The maximum annual allowance for Supplemental Support Services, Community Transition Services and

Specialized Medical Supplies, collectively or individually, is $3,690.00.

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Service Definition (Scope):

Consultation services are clinical and therapeutic services which assist the individual, parents, legally responsible persons, responsible individuals and service providers in carrying out the person's service plan. Consultation activities are provided by professionals licensed as one of the following:

1) Psychologist

2) Psychological Examiner

3) Mastered Social Worker

4) Professional counselor

5) Speech pathologist

6) Occupational therapist

7) Registered Nurse

8) Certified parent educator or provider trainer

9) Certified communication and environmental control specialist

10) Qualified Developmental Disabled Professional (QDDP)

11) Positive Behavior Support (PBS) Specialist

12) Physical therapist

13) Rehabilitation counselor

14) Dietitian

15) Recreational Therapist

16) Behavior Analyst

These services are direct in nature. The parent educator or provider trainer is authorized to provide the activities identified below in items 2, 3, 4, 5, 7 and 13. The provider agency will be responsible for maintaining the necessary information to document staff qualifications. Staff, who meets the certification criteria necessary for other consultation functions, may also provide these activities. Selected staff or contract individuals may not provide training in other categories unless they possess the specific qualifications required to perform the other consultation activities. Use of this service for provider training CANNOT be used to supplant provider trainer responsibilities that are included in provider indirect costs. These activities include:

1) Provision of updated psychological and adaptive behavior assessments;

2) Screening, assessing and developing therapeutic treatment plans;

3) Assisting in the design and integration of individual objectives as part of the overall individual service planning process as applicable to the consultation specialty;

4) Training of direct services staff or family members in carrying out special community living services strategies identified in the person's service plan as applicable to the consultation specialty;

5) Providing information and assistance to the persons responsible for developing the person's overall service plan as applicable to the consultation specialty;

6) Participating on the interdisciplinary team, when appropriate to the consultant's specialty;

7) Consulting with and providing information and technical assistance with other service providers or with direct service staff or family members in carrying out the person's service plan specific to the consultant's specialty;

8) Assisting direct services staff or family members to make necessary program adjustments in accordance with the person's service plan applicable to the consultant's specialty;

9) Determining the appropriateness and selection of adaptive equipment to include communication devices, computers and software consistent with the consultant's specialty;

10) Training or assisting persons, direct services staff or family members in the set up and use of communication devices, computers and software consistent with the consultant's specialty;

11) Screening, assessing and developing positive behavior support plans; assisting staff in implementation, monitoring, reassessment and plan modification consistent with the consultant's specialty;

12) Training of direct services staff or family members by a professional consultant in:

a) Activities to maintain specific behavioral management programs applicable to the person,

b) Activities to maintain speech pathology, occupational therapy or physical therapy program treatment modalities specific to the person,

c) The provision of medical procedures not previously prescribed but now necessary to sustain the person in the community.

13) Training or assisting by advocacy consultants to individuals and family members on how to self-advocate.

14) Rehabilitation Counseling for the purposes of supported employment supports that do not supplant the federal Rehabilitation Act of 1973 and PL 94-142 and the supports provided through the Arkansas Rehabilitation Services.

15) Training and assisting persons, direct services staff or family members in proper nutrition and special dietary needs.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

The maximum annual amount is $1,320.00 the first waiver year and is reimbursable at no more than $136.40 per hour.

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Service Definition (Scope):

Crisis Intervention is delivered in the eligible person's place of residence or other local community site by a mobile intervention team or professional. Intervention shall be available 24 hours a day, 365 days a year. Intervention services shall be targeted to provide technical assistance and training in the areas of behavior already identified. Services are limited to a geographic area conducive to rapid intervention as defined by the provider responsible to deploy the team or professional. Services may be provided in a setting as determined by the nature of the crisis; i.e., residence where behavior is happening, neutral ground, local clinic or school setting, etc., for persons participating in the Waiver program and who are in need of non-physical intervention to maintain or reestablish a behavior management or positive programming plan.

Specify applicable (if any) limits on the amount, frequency, or duration of this service: The maximum rate is $127.10 per hour.

This waiver service is only provided to individuals age 21 and over. All medically necessary Crisis Intervention services for children under the age of 21 are covered in the state plan pursuant to the EPSDT benefit.

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Service Definition (Scope):

Environmental Modifications are modifications made to or at the home, required by the individual's plan of care, which are necessary to ensure the health, welfare and safety of the individual and without which, the individual would require institutionalization. Such environmental modifications may include the installation of ramps, widening of doorways, modification of bathroom facilities, installation of specialized electric and plumbing systems which are necessary to accommodate the medical equipment, installation of sidewalks or pads to accommodate ambulatory impairments, and home property fencing when medically necessary to assure non-elopement, wandering or straying of persons who have dementia, Alzheimer's disease, other causes of memory loss or confusion as to location or decreased mental capacity or aberrant behaviors.

Expenses for the installation of the modification and any repairs made necessary by the installation process are allowable. Portable or detachable modifications that can be re-located with the individual and that have a written consent from the property owner or legal designee will be considered. All services shall be provided in accordance with applicable state and local building codes. Requests for modifications must include an original photo of the site where modifications will be done; to scale sketch plans of the proposed modification project; identification of other specifications relative to materials, time for project completion and expected outcomes; labor and materials breakdown and assurance of compliance with any local building codes. Final inspection for the quality of the modification and compliance with specifications and local codes is the responsibility of the waiver case manager. Payment to the contractor is to be withheld until the work meets specifications.

Exclusions: Outside fencing is limited to one fence per lifetime. Total parameter fencing is excluded. Excluded are those modifications or improvements to the home which are of general utility, and are not of direct medical and remedial benefit to the individual, such as carpeting, roof repair, central air conditioners, etc. Modifications that add to the total square footage of the home are excluded from this benefit. Expenses for remodeling or landscaping which are cosmetic, designed to hide the existence of the modification, or result from erosion are not allowable. Environmental modifications that are permanent fixtures will not be approved for rental property without the prior written authorization and a release of current or future liability by the residential property owner. Environmental modifications may not be used to adapt living arrangements that are owned or leased by providers of waiver services. Requests that fall within the category of general home repairs or modifications will not be allowable. Swimming pools (both in and out of ground) and hot tubs are not allowable.

Conditions - The care and maintenance of environmental equipment is entrusted to the individual or legally responsible person for whom the aids are purchased. Negligence, which is defined as failure to properly care for or perform routine maintenance, shall mean the service will be denied for a minimum of two plan years. Deterrent for non-compliance is in the form of public comment through promulgation of this stipulation; notice of cause and effect at the time of individual equipment approval; monitoring is accomplished when the item is later requested again with denial if the original item is found to been sold; identification of other funding sources when the item is needed to help assure health and safety. Examples: Special needs (100% state general revenue) funding is available for persons not receiving waiver services. If waiver services are not available then special needs is an option. Another example or option is that waiver services would continue but not in the home of the person who was responsible for the loss.

All purchases must meet the conditions for desired quality at the least expensive cost. Generally, any modifications over $1,000.00 will require three bids with the lowest bid with comparable quality being awarded; however, DDS authority may require 3 bids for any requested modification. All modifications must be completed within the plan of care year in which the modifications are approved.

Environmental modifications may only be funded by waiver if not available to the person from any other source.

When environmental modifications are included as a Medicaid state plan service, a denial by utilization review will be required prior to approval for waiver funding by DDS.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

The annual expenditure cap for environmental modifications and adaptive equipment, collectively or individually,

is $7,687.50.

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Service Definition (Scope):

Supplemental Support services meet the needs of the person to improve or enable the continuance of community living. This service is only available in response to crisis, emergency or life threatening situations. Supplemental Support Services will be based upon demonstrated needs as identified in a person's plan of care as emergencies arise. Waiver funds will be used as the payer of last resort.

Supplemental support services include:

1) Ancillary supports such as non-recurring set-up expenses for individuals for persons in the event of a disaster, crisis, emergency or life threatening situation. Allowable expenses are those necessary to enable a person to establish a basic household that do not constitute room and board and may include:

(a) security deposits that are required to obtain a lease on an apartment or home; (b) essential household furnishings and moving expense required to occupy and use a community domicile, including furniture, window coverings, food preparation items, and bed/bath linens; (c) set-up fees or deposits for utility or service access, including telephone, electricity, heating and water; (d) services necessary for the individual's health and safety such as pest eradication and one-time cleaning prior to occupancy; and (e) moving expenses. This service is furnished only to the extent that it is reasonable and necessary as determined through the service plan development process, clearly identified in the service plan and the person is unable to meet such expense or when the services cannot be obtained from other sources.

2) Drug and alcohol screening in accordance with the individual's treatment plan.

3) Activity Fees such as dues at a YMCA, Weight Watchers, etc., used for behavior reinforcement or sensory stimulation. Fees are approved for the individual only and for such time as to abate the life threatening condition. These services must be prescribed and monitored by medical professionals.

Exclusions: Supplemental Support may not include payment for room and board; monthly rental or mortgage expense; food, regular utility charges; and/or household appliances or items that are intended for purely diversional/recreational purposes. Supplemental Support may not be used to pay for furnishing living arrangements that are owned or leased by a waiver provider where the provision of these items and services are inherent to the service they are already providing. Diversional or recreational items such as televisions, cable TV access or VCR's are not allowable.

This service can be accessed ONLY as a last resort. Lack of other available resources must be proven. Specify applicable (if any) limits on the amount, frequency, or duration of this service: The maximum annual allowance for Supplemental Support Services, Community Transition Services and Specialized Medical Supplies, collectively or individually, is $3,690.00.

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C-1: Summary of Services Covered (2 of 2)

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C-2: General Service Specifications (1 of 3)

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i. Types of Facilities Subject to §1616(e). Complete the following table for each type of facility subject to §1616(e) of the Act:

Facility Type

Supported living arrangement apartments owned and operated by waiver providers

Group Homes

ii. Larger Facilities: In the case of residential facilities subject to §1616(e) that serve four or more individuals unrelated to the proprietor, describe how a home and community character is maintained in these settings.

The State has undertaken activities as described in the transition plan to ensure that all residential settings comply with the characteristics described in the Final Rule.The group homes are community based and located in residential areas. The homes provide access to typical facilities in a home such as a kitchen with cooking facilities, small dining areas, and provide for privacy and easy access to resources and activities in the community. Each group home contains bedrooms and bathrooms that allow privacy . Individuals are allowed free use of all space within the group home with due regard for privacy, personal possessions of other residents and staff and reasonable house rules. The living and dining areas are provided with furnishings that promote the functions of daily living and social activities. Persons are provided access to community resources and supports and are encouraged to build community relationships. Persons are granted access to visitors at times convenient to the individual. Individuals are allowed a choice of roommates, if they are in a shared bedroom.

Group homes, owned and operated by Waiver certified providers, must meet all the applicable state and federal laws and regulations. Existing group homes licensed by DDS prior to July 1, 1995 may serve groups of no more than fourteen unrelated adults, age 18 years and above, with developmental disabilities. Arkansas imposed a moratorium and no additional group homes have been approved since July 1, 1995. Group homes built after July 1, 1995 are limited to a capacity of no more than 4 unrelated adults with developmental disabilities.

The capacity for supported living apartments owned and operated by waiver providers, regardless of date of DDS licensing, may serve a number of persons consistent with the number of bedrooms each apartment contains, but in no event more than four unrelated adults, age 18 and above, with developmental disabilities in each self-contained apartment unit.

C-2: Facility Specifications

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Appendix C: Participant Services

Quality Improvement: Qualified Providers

As a distinct component of the State's quality improvement strategy, provide information in the following fields to detail the State's methods for discovery and remediation.

a. Methods for Discovery: Qualified Providers

The state demonstrates that it has designed and implemented an adequate system for assuring that all waiver services are provided by qualified providers.

i. Sub-Assurances:

a.Sub-Assurance: The State verifies that providers initially and continually meet required licensure and/or certification standards and adhere to other standards prior to their furnishing waiver services.

Performance Measures

For each performance measure the State will use to assess compliance with the statutory assurance, complete the following. Where possible, include numerator/denominator.

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b.Sub-Assurance: The State monitors non-licensed/non-certified providers to assure adherence to waiver requirements.

For each performance measure the State will use to assess compliance with the statutory assurance, complete the following. Where possible, include numerator/denominator.

c.Sub-Assurance: The State implements its policies and procedures for verifying that provider training is conducted in accordance with state requirements and the approved waiver.

For each performance measure the State will use to assess compliance with the statutory assurance, complete the following. Where possible, include numerator/denominator.

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C-3: Waiver Services Specifications

Section C-3 'Service Specifications' is incorporated into Section C-1 'Waiver Services.'

C-4: Additional Limits on Amount of Waiver Services

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C-5: Home and Community-Based Settings

Explain how residential and non-residential settings in this waiver comply with federal HCB Settings requirements at 42 CFR 441.301(c)(4)-(5) and associated CMS guidance. Include:

1. Description of the settings and how they meet federal HCB Settings requirements, at the time of submission and in the future.

2. Description of the means by which the state Medicaid agency ascertains that all waiver settings meet federal HCB Setting requirements, at the time of this submission and ongoing.

Note instructions at Module 1, Attachment #2, HCB Settings Waiver Transition Plan for description of settings that do not meet requirements at the time of submission. Do not duplicate that information here.

Please Refer to Main, Attachment # 2

Appendix D: Participant-Centered Planning and Service Delivery D-1: Service Plan Development (1 of 8)

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c. Supporting the Participant in Service Plan Development. Specify:

(a) the supports and information that are made available to the participant (and/or family or legal representative, as appropriate) to direct and be actively engaged in the service plan development process and (b) the participant's authority to determine who is included in the process.

DDS starts the flow of information about the person's direction of and engagement in PCSP development during the intake and referral process for waiver services. Intake and Referral staff provide this information in written format and through conversations with the person and any legal representative. DDS staff provide the same information after the person has been determined eligible and is approved for HCBS Waiver services when the person chooses a provider. The entity chosen by the person for PCSP development (case manager) reinforces these rights and assures active participation by the person and any legal representative. DDS Waiver Handbooks, found on the DDS website and the website of the Arkansas Waiver Association, share this information in a user-friendly format and include contact information regarding the PCSP, provider choice, and rights and responsibilities.

The person served may invite any person they choose to participate at any step of the PCSP development process. DDS staff and the chosen provider inform all persons of any confidentiality and conflict of interest issues.

The case manager must participate as the person who will develop, oversee implementation, and update the PCSP. DDS staff and the case manager inform the person served about the benefits of inviting other individuals, such as direct service providers, professionals associated with other services (e.g., representatives of public school, other DHS Divisions, generic community supports), and DDS staff. It remains the decision of the person served to invite others to participate in the process.

When necessitated by the support needs of the person, advocates or other support person identified by the consumer may accompany the individual to help assure that the person understands the discussion and can make their desires understood. All persons responsible for implementation of the PCSP, as well as the individual, must sign the PCSP. the case manager ensures that the plan is distributed to the person served and other people involved in the implementation of HCBS services included in the plan.

If the case manager fails to include the person served and any legal representative in the PCSP development process, the

PCSP is not a valid PCSP. DDS staff provide information to the person served regarding their direction of and engagement in the PCSP development process. People with complaints about a person's direction of, engagement in, or satisfaction with the outcome of the PCSP development process may call DDS Quality Assurance, which will investigate the complaint in compliance with DDS Policy 1010, Service Concern Investigation. DDS Quality Assurance conducts an on-site review of each provider annually and cites deficient practices related to each person's direction of and engagement in the PCSP development process.

Appendix D: Participant-Centered Planning and Service Delivery D-1: Service Plan Development (4 of 8)

d. Service Plan Development Process. In four pages or less, describe the process that is used to develop the participant-centered service plan, including:

(a) who develops the plan, who participates in the process, and the timing of the plan;

(b) the types of assessments that are conducted to support the service plan development process, including securing information about participant needs, preferences and goals, and health status;

(c) how the participant is informed of the services that are available under the waiver;

(d) how the plan development process ensures that the service plan addresses participant goals, needs (including health care needs), and preferences;

(e) how waiver and other services are coordinated;

(f) how the plan development process provides for the assignment of responsibilities to implement and monitor the plan; and,

(g) how and when the plan is updated, including when the participant's needs change. State laws, regulations, and policies cited that affect the service plan development process are available to CMS upon request through the Medicaid agency or the operating agency (if applicable):

a. Interim Service Plan (ISP):

When a person accesses HCBS Waiver services for the first time, the person is issued a prior approved interim service plan for up to 60 days. The Interim Service plan may include case management and supportive living for direct case supervision.

DDS staff track the expiration dates of ISPs and ensure that a PCSP is complete before the interim plan expires. b.PCSP:

1. Development, Participation and Timing

The case manager is responsible for scheduling and coordinating the PCSP development meeting, including inviting other participants and making sure that the location and the participants are acceptable to the HCBS Waiver participant. If the HCBS Waiver participant objects to the presence of any individual, that person may not attend the meeting. Aside from any objections from the HCBS Waiver participant or their legal guardian, the team may consist of professionals who might assist with generic resources, professionals who conducted assessments or evaluations, and friends and persons who support the participant may attend the meetings. DDS staff will attend if the participant invites them. The case manager is responsible for managing and resolving any disagreements which occur during the PCSP development meeting.

2. Assessment Types, Needs, Preferences, Goals and Health Status

Prior to development of the PCSP, DDS requires that the case manager secures a functional assessment and any evaluations that are specific to the needs of the individual. In addition to psychological testing to include a measure of IQ and the adaptive behavior assessments conducted to establish eligibility, the case manager may secure social histories, medical, physical and mental histories, a current physician evaluation, an assessment of educational needs, physical, speech and occupational therapy evaluations, as well as a risk assessment. Licensed professionals conduct applicable assessments. Other assessments which do not require a licensed person, are conducted by persons who are most familiar with the individual.

3. Information regarding availability of services

The DDS staff informs the participant of available waiver services at the time of initial application. After the case manager has completed the functional assessment and met with the individual to discuss which services are needed based on the services, DDS meets with the individual again to offer choice of provider for each service need identified that will be addressed through the provision of HCBS services in the PCSP. The case manager has the responsibility to present information regarding service availability during the PCSP development process.

4. Addressing goals, needs and preferences and assignment of responsibilities

DDS prescribes the elements of the PCSP that requires that PCSP developers address how the team discussed, planned for and incorporated the individual's goal, needs (including health care needs), and preferences, as well as any cultural considerations. DDS requires that the developers designate who is responsible for implementation of and monitoring the PCSP. DDS requires that the PCSP be reviewed and prior authorized prior to implementation of services. During the onsite review of each provider, Certification and Licensure staff review PCSPs to make sure all elements are included.

5. Coordination of services

The case manager has the responsibility for coordinating and monitoring the implementation of all services identified in the PCSP, including waiver, state plan and generic services. The case manager must coordinate with the direct service providers to ensure quality service delivery.

6. Updating PCSP

The case manager is responsible for making sure that the PCSP is updated at least annually. They are also responsible for making sure that the PCSP is reviewed quarterly so that the team may identify goals that may need to be added, removed or revised and that there are no unnecessary or inappropriate services and supports. The team uses the data gathered by the implementer of the PCSP as they work with the individual to determine if goals should change. The team also relies on input from the individual regarding whether they want to work on new or revised goals. The participant may request an update of their PCSP at any time.

7. Participant Engagement

From the time an individual first makes contact with DDS to apply for HCBS Waiver services, they are informed of their rights to make choices about each aspect of the services that are available. It is the responsibility of every person at the state and the provider level to make sure that the individual is aware of and exercises their rights and to ensure that the process is driven to the maximum extent possible by the individual. During the person-centered planning meeting, every person present is responsible for supporting and encouraging the individual to express their wants and desires and to then incorporate those into the PCSP.

Appendix D: Participant-Centered Planning and Service Delivery D-1: Service Plan Development (5 of 8)

e. Risk Assessment and Mitigation. Specify how potential risks to the participant are assessed during the service plan development process and how strategies to mitigate risk are incorporated into the service plan, subject to participant needs and preferences. In addition, describe how the service plan development process addresses backup plans and the arrangements that are used for backup.

DDS requires that the Interdisciplinary Team address risks to the participant during the PCSP development process. In conjunction with the participant and their legal guardian, the team must address health and behavioral risks and risks to personal safety, either real or perceived, and known or potential. The team must document each identified risk and write PCSP with individualized mitigation strategies. The strategies must be designed to respect the needs and preferences of the participant. The team must identify how and who will be responsible for the ongoing monitoring of risk levels and risk management strategies as well as addressing how key staff will be trained regarding those risks. Additionally, the case manager must make sure that the team analyzes the risk management strategies and how effective those strategies are. The analysis must occur at least quarterly as part of the quarterly PCSP review.

DDS does not require a specific risk assessment tool, but does require that providers document practices and decisions regarding risk assessment and the ongoing management of risks. Providers must specify the tool they use. HCBS Waiver participants, as they exercise their rights about their services, make choices about the amount of risk they wish to take. In negotiating trade-offs between choice and safety, providers are required to document the concerns of the team members, the negotiation process and the analysis and rationale for the decisions made and the actions taken.

DDS Certification Standards require that case management providers in conjunction with the direct service provider develop and implement behavior management plans to address behavioral risks. The specific details of behavior management plans are addressed in Appendix G2,Ai. The Standards also require that case management and direct service provider minimize certain personal safety risks by imposing certain "physical plant" requirements without compromising the natural, home-like atmosphere in any setting in which the individual resides.

DDS requires that providers develop backup plans to address contingencies such as emergencies, including the failure of a support worker to appear when scheduled. Complete descriptions of backup arrangements must be included in the PCSP. Each provider must specify the type of back-up arrangements that are employed, and make sure that each PCSP addresses the unique needs and circumstances of the individual.

f. Informed Choice of Providers. Describe how participants are assisted in obtaining information about and selecting from among qualified providers of the waiver services in the service plan.

DDS staff explain the HCBS Waiver program, service options, and provider choice and give written information in a face-to-face meeting with the person and any legal representative. When desired by the person and any legal representative, DDS provides information by phone, mail, or email. The DDS staff gives the person and any legal representative a copy of the HCBS Waiver Certified Provider List prepared and maintained by DDS Quality Assurance initially as services begin, annually, and upon request. DDS staff encourages the person and any legal representative to visit, call, or look at the website of a provider if the person lacks experience with that provider. DDS ensures that person may choose providers of each service in the service plan.

Annually, DDS staff offer each person and any legal representative an opportunity to change their choice of setting of service from community (HCBS Waiver) services to services in an ICF/IID. DDS staff also offer a choice of a different provider initially as services begin, annually, and upon request. DDS staff supports the person to make a choice of provider without any specific recommendations that could sway the person's choice. DDS prohibits providers from soliciting persons to choose their organization. Providers are permitted to engage in marketing of their services consistent with DDS Policy 1091 and DDS Certification Standards. The Arkansas Waiver Association has a checklist that may assist people in choosing a provider; it is available at http://arkansaswaiver.com/resources/Prov_Select.pdf

DDS provides information to promote awareness of a person's right to change providers annually and upon request in the Waiver Handbooks posted on the DDS and Arkansas Waiver Association websites, in the promulgated Medicaid provider manual, and on the Rights and Choice Form that is given annually to persons served. The Rights and Choice Form states, "I have the right to change providers at any time I may choose without fear of retaliation". People with complaints about obtaining information about and selecting from among qualified providers may call DDS Quality Assurance, which will investigate the complaint in compliance with DDS Policy 1010, Service Concern Investigation. The DDS Ombudsman works with people to obtain information about and select from among qualified providers.

Appendix D: Participant-Centered Planning and Service Delivery D-1: Service Plan Development (7 of 8)

g. Process for Making Service Plan Subject to the Approval of the Medicaid Agency. Describe the process by which the service plan is made subject to the approval of the Medicaid agency in accordance with 42 CFR § 441.301(b)(1)(i):

DMS arranges with DDS for a specified number of service plans to be reviewed annually as specified in the interagency agreement with DMS in their role as overseer. DMS conducts a retrospective review of identified program, financial and administrative elements critical to CMS quality assurance. DMS randomly reviews plans and ensures that they have been developed in accordance with applicable policies and procedures, that plans ensure the health and welfare of the waiver recipient and that financial components or prior authorizations, billing and utilization are correct and in accordance with applicable policies and procedures. DMS oversight results are reconciled quarterly with DDS. Where applicable individual actions to correct any known non-compliance or questionable practice are taken with the service provider or DDS staff, sometimes a change in policy or procedure may be necessary when systemic issues are discovered.

DMS uses the sampling guide "A Practical Guide for Quality Management in Home & Community-Based Waiver Programs" developed by Human Services Research Institute and the Medstat Group for CMS in 2006. A systematic random sampling of the active case population was drawn whereby every "nth" name in the population was selected for inclusion in the sample. The sample size, based on a 95% confidence level with a margin of error of +/- 8%, is drawn. An online calculator was used to determine the appropriate sample size for this waiver population. To determine the "nth" integer, the sample is divided by the population. Those names are drawn until the sample size is reached.

To provide PCSP for this review, DMS requires providers to submit an electronic copy of the PCSP, including all components described in Appendix D.1.d and D.1.e, to DDS. DMS communicates findings from the review to DDS for remediation. Systemic findings may necessitate a change in policy, standards, or manuals.

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D-2: Service Plan Implementation and Monitoring

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Quality Improvement: Service Plan

As a distinct component of the State's quality improvement strategy, provide information in the following fields to detail the State's methods for discovery and remediation.

a. Methods for Discovery: Service Plan Assurance/Sub-assurances

The state demonstrates it has designed and implemented an effective system for reviewing the adequacy of service plans for waiver participants.

i. Sub-Assurances:

a.Sub-assurance: Service plans address all participants' assessed needs (including health and safety risk factors) and personal goals, either by the provision of waiver services or through other means.

Performance Measures

For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

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b.Sub-assurance: The State monitors service plan development in accordance with its policies and procedures.

Performance Measures

For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

c.Sub-assurance: Service plans are updated/revised at least annually or when warranted by changes in the waiver participant's needs.

Performance Measures

For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

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d.Sub-assurance: Services are delivered in accordance with the service plan, including the type, scope, amount, duration and frequency specified in the service plan.

Performance Measures

For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

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e.Sub-assurance: Participants are afforded choice: Between/among waiver services and providers.

Performance Measures

For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

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ii. If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible. The state operates a system of review that assures completeness, appropriateness, and accuracy of the PCSP development and service delivery, and assures freedom of choice by the participant. The system focuses on participant-centered service planning and delivery, participant rights and responsibilities, and participant outcomes.

During onsite provider certification reviews, DDS Certification and Licensure staff review PCSP for 10% of the population served for verification of service delivery in the type, scope, amount, frequency and duration specified. They also review to determine if the PCSP address assessed needs, personal goals, risk factors, and were developed according to established procedures. They also review to determine if PCSP are updated annually or when needs change.

b. Methods for Remediation/Fixing Individual Problems

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Appendix E: Participant Direction of Services

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Appendix E: Participant Direction of Services E-1: Overview (1 of 13)

Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.

Appendix E: Participant Direction of Services E-1: Overview (2 of 13)

Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.

Appendix E: Participant Direction of Services E-1: Overview (3 of 13)

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Appendix E: Participant Direction of Services E-1: Overview (4 of 13)

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Appendix E: Participant Direction of Services E-1: Overview (5 of 13)

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Appendix E: Participant Direction of Services E-1: Overview (6 of 13)

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Appendix E: Participant Direction of Services E-1: Overview (7 of 13)

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Appendix E: Participant Direction of Services E-1: Overview (8 of 13)

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Appendix E: Participant Direction of Services E-1: Overview (9 of 13)

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Appendix E: Participant Direction of Services E-1: Overview (10 of 13)

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Appendix E: Participant Direction of Services E-1: Overview (11 of 13)

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Appendix E: Participant Direction of Services E-1: Overview (12 of 13)

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Appendix E: Participant Direction of Services E-1: Overview (13 of 13)

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Appendix E: Participant Direction of Services

E-2: Opportunities for Participant Direction (1 of 6)

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Appendix E: Participant Direction of Services

E-2: Opportunities for Participant-Direction (2 of 6)

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Appendix E: Participant Direction of Services

E-2: Opportunities for Participant-Direction (3 of 6)

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Appendix E: Participant Direction of Services

E-2: Opportunities for Participant-Direction (4 of 6) Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.

Appendix E: Participant Direction of Services

E-2: Opportunities for Participant-Direction (5 of 6)

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Appendix E: Participant Direction of Services

E-2: Opportunities for Participant-Direction (6 of 6)

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Appendix F: Participant Rights

Appendix F-1: Opportunity to Request a Fair Hearing

The State provides an opportunity to request a Fair Hearing under 42 CFR Part 431, Subpart E to individuals:

(a) who are not given the choice of home and community-based services as an alternative to the institutional care specified in Item 1-F of the request; (b) are denied the service(s) of their choice or the provider(s) of their choice; or, (c) whose services are denied, suspended, reduced or terminated. The State provides notice of action as required in 42 CFR § 431.210.

Procedures for Offering Opportunity to Request a Fair Hearing. Describe how the individual (or his/her legal representative) is informed of the opportunity to request a fair hearing under 42 CFR Part 431, Subpart E. Specify the notice(s) that are used to offer individuals the opportunity to request a Fair Hearing. State laws, regulations, policies and notices referenced in the description are available to CMS upon request through the operating or Medicaid agency.

It is initially the responsibility of the DDS Intake and Referral Specialist to inform the person or the legally responsible representative of appeal rights specific to application intake policies and procedures:

1) As HCBS Waiver services are requested; and

2) When initial choice of home and community based services as an alternative to institutional care is offered.

It is the responsibility of DDS to inform the person or the legally responsible representative of appeal rights specific to the applicant or program denial of ICF/IID Level of Care or Medicaid Income Eligibility.

It is the responsibility of DDS staff to inform the person or legally responsible representative of appeal rights specific to closure of an application case for failure of the person or legal representative to comply with requests for required application assessment information. DDS staff sends copies of official letters to the DDS Psychology Team. When the determination is favorable to the applicant the team issues a notice of approval.

When the applicant is determined to meet eligibility criteria DDS staff inform the person or the legally responsible person of appeal rights specific to:

1) Continued choice for institutional or community based services;

2) Provider choice;

3) Service denials;

4) When their chosen providers refuse to serve them, and

5) Case closure.

The right to change providers more frequently than annually is specified in the Waiver handbook that is published on the DDS website, the promulgated Medicaid provider manual, and on the Rights and Choice form that is given to the participants annually. The form states: "I have the right to change providers at any time I may choose without fear of retaliation." This topic is covered on NCI surveys conducted by the DDS Quality Assurance Section.

Thereafter, the case manager provides continued education at each annual review and provides support at any time a service request is denied. The individual or the legal representative may file an appeal or may authorize the case manager to file an appeal on behalf of the individual.

When any adverse action occurs, including reduction, suspension or termination of HCBS Waiver services, written notice is provided to the individual, the legally responsible person, and both the case management provider and the providers of other HCBS waiver services in accordance with DDS Appeals Policy 1076 . A copy of the policy is enclosed with the notice to the individual,the legal representative, and the providers. The notice with the enclosure is sent both through regular and certified mail. This policy provides for resolution by the applicable DDS Assistant Director or designee and specifies, "If a participant is not satisfied with the result of the administrative review a fair hearing may be requested." Within ten working days of receiving the decision of the administrative review, an appeal may be filed with the Office of Policy and Legal Services (OPLS), Office of Appeals and Hearings.

Requests for fair hearing shall include:

1) The name, address, and telephone number of the person filing the appeal;

2) The relationship of the person who is filing the appeal to the individual requesting or receiving waiver services;

3) The decision that is being appealed;

4) The reasons the decision is being appealed;

5) The desired outcome of the appeal;

6) The law or facts that are being relied upon in the filing of the appeal;

7) The person who will present the appeal; and

8) Whether the person will be represented and, if so, the name, address and telephone number of the representative. This is not limited to legal representation.

Notices of adverse action and the opportunity to request a fair hearing are maintained in the case file. When the adverse action is case closure, services may continue during the appeal process if a fair hearing is requested and the service provider agrees to assume the risk of nonpayment for services delivered during this time. If the HCBS Waiver participant does not request a fair hearing during the time allowed the case will be closed.

Appendix F: Participant-Rights

Appendix F-2: Additional Dispute Resolution Process

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Appendix G: Participant Safeguards

Appendix G-1: Response to Critical Events or Incidents

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Appendix G: Participant Safeguards

Appendix G-2: Safeguards Concerning Restraints and Restrictive Interventions (1 of 3)

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Appendix G-3: Medication Management and Administration (1 of 2)

This Appendix must be completed when waiver services are furnished to participants who are served in licensed or unlicensed living arrangements where a provider has round-the-clock responsibility for the health and welfare of residents. The Appendix does not need to be completed when waiver participants are served exclusively in their own personal residences or in the home of a family member.

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Appendix G: Participant Safeguards

Quality Improvement: Health and Welfare

As a distinct component of the State's quality improvement strategy, provide information in the following fields to detail the State's methods for discovery and remediation.

a. Methods for Discovery: Health and Welfare

The state demonstrates it has designed and implemented an effective system for assuring waiver participant health and welfare. (For waiver actions submitted before June 1, 2014, this assurance read "The State, on an ongoing basis, identifies, addresses, and seeks to prevent the occurrence of abuse, neglect and exploitation.")

i. Sub-Assurances:

a.Sub-assurance: The state demonstrates on an ongoing basis that it identifies, addresses and seeks to prevent instancesof abuse, neglect, exploitation and unexplained death. (Performance measures in this sub-assurance include all Appendix G performance measures for waiver actions submitted before June 1, 2014.)

Performance Measures

For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

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b.Sub-assurance: The state demonstrates that an incident management system is in place that effectively resolves those incidents and prevents further similar incidents to the extent possible.

Performance Measures

For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

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c.Sub-assurance: The state policies and procedures for the use or prohibition of restrictive interventions (including restraints and seclusion) are followed.

Performance Measures

For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

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d.Sub-assurance: The state establishes overall health care standards and monitors those standards based on the responsibility of the service provider as stated in the approved waiver.

Performance Measures

For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

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ii. If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible. (HW 1) DDS mails the DDS ACS 106 "Waiver Rights and Choice Form" to each individual annually. The form contains a statement which informs them that they have the right to report abuse and contains the contact information for Child and Adult Hotlines. Individuals are required to return the signed form to DDS Waiver section.

(HW4) Prior to initiation of an annual onsite provider certification review, Certification and Licensure (C&L) staff gathers incident reports which the provider has submitted throughout the year. C&L staff identifies reports that describe incidents which require protective actions, such as behavior management plans, changes in staffing levels, or changes in goals. During the onsite review, the reviewers will determine, through the use of interviews, observations and file reviews, if the provider has taken necessary action to protect the individual in question.

(HW 5) DDS investigative staff reviews criminal background checks which are provided to DDS by the Arkansas State Police, The Online Criminal Background System. Staff accesses the system each Friday and provides a written response to the provider who requested the background check. If a disqualifying conviction appears on the background check, DDS staff includes a determination that the prospective employee is disqualified from employment. The staff must provide the response to the provider within 14 calendar days.

(HW 6) DDS Policy 1010, Service Concern Resolution, requires that DDS investigative staff completes investigations within 30 calendar days of receipt of the concern.

(HW 8) DDS requires that providers submit incident reports each time they utilize a restrictive intervention. DDS investigative staff reviews each report and determines if the methods described in the incident report adhere to the requirements for the use of the type intervention used. DDS staff may contact the provider to obtain additional information, if necessary.

b. Methods for Remediation/Fixing Individual Problems

(HW 1) If the signed form is not in the DDS file, the Specialist will contact the individual to ensure that they received the form and will secure a signed form for the file.

(HW 2) When DDS determines, during an investigation, or based on Incident Reports submitted by the provider, that the provider has consistently not complied with reporting time frames, or has not complied with reporting requirements with regard to critical incidents, the investigation manager cites a deficiency and requires that the provider submit an Assurance of Adherence to Standards. The Assurance must include a description of the processes the provider will put in place to assure the deficiencies do not occur again.

(HW3) Additionally, when the DDS staff reviews an Incident Report and determines that the described incident is reportable to APS or CPS and has not been reported by the provider, the DDS staff immediately calls the appropriate hotline to report the incident.

(HW6) If DDS staff consistently does not complete investigations within required time frames, or if DDS staff does not provide timely responses to providers requesting criminal background checks, the Certification and Licensure Manager counsels the staff and utilizes the DHS Minimum Conduct Standards for Employees and DHS Employee Discipline policy to ensure compliance.

(HW8) If DDS staff determines that a provider did not adhere to regulations regarding the use of restrictive interventions, the DDS staff issues a deficiency and requires an Assurance of Adherence to Standards from the provider. DDS investigative staff may conduct an onsite investigation if determined necessary.

(HW 7) The Death Review Coordinator prepares an annual report that addresses any trend identified by the Committee as well as the identification of any prevention activities proposed because of any review. The report contains recommendations regarding specific actions such as:

1. Revision of provider or Division policy or forms,

2. Development of new provider or Division policy to address systemic issues discovered in the review process,

3. Training, either on a statewide or individual provider basis,

4. Facilitation of best practice, including new risk-prevention practices, through dissemination of recommendations for development of or modification to provider policies, or

5. Issuance of a statewide safety alert. ii. Remediation Data Aggregation

Remediation-related Data Aggregation and Analysis (including trend identification)

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Appendix H: Quality Improvement Strategy (1 of 2)

Under §1915(c) of the Social Security Act and 42 CFR § 441.302, the approval of an HCBS waiver requires that CMS determine that the State has made satisfactory assurances concerning the protection of participant health and welfare, financial accountability and other elements of waiver operations. Renewal of an existing waiver is contingent upon review by CMS and a finding by CMS that the assurances have been met. By completing the HCBS waiver application, the State specifies how it has designed the waiver's critical processes, structures and operational features in order to meet these assurances.

* Quality Improvement is a critical operational feature that an organization employs to continually determine whether it operates in accordance with the approved design of its program, meets statutory and regulatory assurances and requirements, achieves desired outcomes, and identifies opportunities for improvement.

CMS recognizes that a state's waiver Quality Improvement Strategy may vary depending on the nature of the waiver target population, the services offered, and the waiver's relationship to other public programs, and will extend beyond regulatory requirements. However, for the purpose of this application, the State is expected to have, at the minimum, systems in place to measure and improve its own performance in meeting six specific waiver assurances and requirements.

It may be more efficient and effective for a Quality Improvement Strategy to span multiple waivers and other long-term care services. CMS recognizes the value of this approach and will ask the state to identify other waiver programs and long-term care services that are addressed in the Quality Improvement Strategy.

Quality Improvement Strategy: Minimum Components

The Quality Improvement Strategy that will be in effect during the period of the approved waiver is described throughout the waiver in the appendices corresponding to the statutory assurances and sub-assurances. Other documents cited must be available to CMS upon request through the Medicaid agency or the operating agency (if appropriate).

In the QIS discovery and remediation sections throughout the application (located in Appendices A, B, C, D, G, and I), a state spells out:

* The evidence based discovery activities that will be conducted for each of the six major waiver assurances; * The remediation activities followed to correct individual problems identified in the implementation of each of the assurances;

In Appendix H of the application, a State describes (1) the system improvement activities followed in response to aggregated, analyzed discovery and remediation information collected on each of the assurances; (2) the correspondent roles/responsibilities of those conducting assessing and prioritizing improving system corrections and improvements; and (3) the processes the state will follow to continuously assess the effectiveness of the OIS and revise it as necessary and appropriate.

If the State's Quality Improvement Strategy is not fully developed at the time the waiver application is submitted, the state may provide a work plan to fully develop its Quality Improvement Strategy, including the specific tasks the State plans to undertake during the period the waiver is in effect, the major milestones associated with these tasks, and the entity (or entities) responsible for the completion of these tasks.

When the Quality Improvement Strategy spans more than one waiver and/or other types of long-term care services under the Medicaid State plan, specify the control numbers for the other waiver programs and/or identify the other long-term services that are addressed in the Quality Improvement Strategy. In instances when the QIS spans more than one waiver, the State must be able to stratify information that is related to each approved waiver program. Unless the State has requested and received approval from CMS for the consolidation of multiple waivers for the purpose of reporting, then the State must stratify information that is related to each approved waiver program, i.e., employ a representative sample for each waiver.

H-1: Systems Improvement

a. System Improvements

i. Describe the process(es) for trending, prioritizing, and implementing system improvements (i.e., design changes) prompted as a result of an analysis of discovery and remediation information.

DDS and DMS, in consultation with a CMS technical assistance contractor, developed the framework for a Performance Measure report in May 2013 as the basis for the Quality Improvement System (QIS). The purpose of the Performance Measure report is to produce acceptable evidence for Arkansas' compliance with HCBS Subassurances. The Performance Measure report accomplishes this purpose by prioritizing areas of discovery, gathering data in those areas, analyzing trends among the data, and determining how best to implement system improvements.

DDS Quality Assurance staff and DDS ACS Waiver staff refined the measurements within the framework. DDS Quality Assurance staff developed a format for the report and began gathering data on specific measures from sections for each subassurance in July 2013. The first Performance Measure report was published in October 2013 and was reviewed by the DDS Quality Assurance Committee on 10/22/13. A quarterly Performance Measure report has been reviewed in each DDS Quality Assurance Committee since that time. The first Annual report was reviewed by the DDS Quality Assurance Committee on 07/21/14.

In addition to the Performance Measure report, DDS performs an on-site review of each provider annually, reviews incident reports, performs investigations of service concerns, and performs Mortality Review. Information from these activities provide the data for the Performance Measure report.

1) Roles and Responsibilities - DMS remains responsible for the administration and oversight of all Medicaid waivers, including those operated by other divisions. DMS Waiver Quality Assurance Administrator represents DMS in the development and implementation of the QIS and monitors each 1915(c) HCBS waiver. The DMS Waiver QA Administrator works closely with the operating agencies and serves as primary liaison with CMS regarding the waivers. This position serves to centralize responsibility and accountability for the waiver with DMS, and also provides leadership in promoting and improving quality in 1915(c) HCBS waivers. The DMS Waiver QA Administrator reports to the DMS Assistant Director, who keeps the DMS Director informed of concerns about and activities related to the waiver. DMS Waiver Quality Assurance Administrator serves on the DDS Quality Assurance Committee.

The DDS Assistant Director for Waiver Services is responsible for the operation of the waiver program. This includes helping design, develop and implement portions of the QIS for the waiver. The DDS Assistant Director, managers and staff are responsible for technical assistance to providers, monitoring person centered service plan (PCSP) implementation by providers, financial and statistical reports, prior authorization of individual PCSP budgets, internal operations, application processing, PCSP database system,participation on the DDS Quality Assurance Committee and regular contact with people served.

DDS Quality Assurance Unit develops and reviews DDS' compliance with Performance Measures. The Performance Measure report is posted quarterly and reviewed at DDS Quality Assurance meetings . DDS Quality Assurance section performs an on-site review of each provider annually, reviews incident reports, performs investigations of service concerns, and performs Mortality Review.

The DMS Waiver Quality Assurance Unit reviews a representative sample of individual case files annually. This unit reviews for compliance with assurances including level of care, PCSP, qualified providers, health and welfare, administrative authority, and financial accountability. The DMS Waiver Quality Assurance Unit reports findings to DMS Division Director, the DDS Assistant Director for Waiver Services and the DDS Assistant Director for Quality Assurance, advises on any needed remediation and tracks system improvement.

2) Processes to Establish Priorities and Develop Strategies for Remediation & Improvement -

The DDS Waiver Program and Quality Assurance Assistant Directors and managers share Performance Measure report and other reports with DMS Waiver QA Unit, discuss findings of the reports, and address any issues or concerns. DDS and DMS establish priorities and develop strategies for any necessary remediation and system improvement. DDS personnel are responsible to track data, perform remediation activities, and report improvement to their Assistant Directors.

When major issues are identified that impact one or more of the Subassurances, the DDS Waiver Program and Quality Assurance Assistant Directors and managers will inform the DDS and DMS Directors and Assistant Directors and seek their input on the issues and any needed remediation.

3) Compiling and Communicating Quality Management Information - At the end of each waiver year, the DMS QA Administrator will compile a report based on findings from DDS, DMS Quality Assurance, and the CMS 372 report. This annual report will include key information relevant to each subassurance, information about participation in and cost of the waiver based on the CMS 372 report and information on any key findings, including status of remediation and improvement activities. The DMS QA Administrator will make the report available to DDS and DMS administration.

4) Periodic Evaluation and Revision of the QMS - The QIS, including Performance Measure report, will be revised during implementation as DDS measures performance related to the subassurances and the evidence that is produced. The DMS Waiver QA Administrator and the DDS Waiver Program and Quality Assurance Assistant Directors and managers will meet annually to review and discuss the QIS, including the performance Measure report and to make any necessary changes. If the QIS is revised as a result of this annual review, the DMS Waiver QA Administrator will send the revised QIS to CMS.

DDS section responsibilities within the Quality Improvement Strategy are:

1) Quality Assurance:

a) Provider Certification and recertification b) Review of provider compliance with DDS Standards c) Intake and Referral and initial application for services d) Eligibility e) Service concern investigation f) Critical incident review g) Initial Informed choice between institutional and community services h)

2) DDS Waiver Services:

a) Annually and as requested - Informed choice between institutional and community services.

b) Application process monitoring c) Provider choice d) Oversight of implementation of Person centered service plan e) Providing information on Person rights and responsibilities

3) DDS Children's Services a) Intake and Referral and initial application for services b) Initial Informed choice between institutional and community services

ii. System Improvement Activities

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b. System Design Changes

i. Describe the process for monitoring and analyzing the effectiveness of system design changes. Include a description of the various roles and responsibilities involved in the processes for monitoring & assessing system design changes. If applicable, include the State's targeted standards for systems improvement.

Arkansas DDS has developed and implemented an HCBS quality improvement strategy that includes a continuous improvement process, measures of program performance, and measures of experience of care.

Components:

Continuous improvement process: DDS convened in November of 2011 a Quality Assurance Committee, made up of state agency staff, providers, and other stakeholders. This Committee meets at least quarterly. Measures of program performance: DDS has developed robust measures of program performance though Performance

Measures related to the subassurances.

Experience of care: DDS has conducted the National Core Indicator Adult Consumer Survey since July of 2006.

During these seven survey cycles, DDS has improved its process and the transparency of its results. NCI survey data is on the DDS webpage.

ii. Describe the process to periodically evaluate, as appropriate, the Quality Improvement Strategy.

DDS and DMS will review the Quality Improvement Strategy annually. Review consists of analyzing reports and progress toward stated initiatives, resolution of individual and systemic issues found through discovery and notating of desired outcomes. When change in the strategy is indicated, a collaborative effort between DMS and DDS is set in motion to complete a revision to the Quality Management Strategy that may include changes for submission as an amendment of the HCBS Waiver to CMS. The collaborative process includes participation by the section or unit who has specific strategy responsibility with open discussion opportunity prior to a strategy change of direction.

Appendix I: Financial Accountability

I-1: Financial Integrity and Accountability

Financial Integrity. Describe the methods that are employed to ensure the integrity of payments that have been made for waiver services, including:

(a) requirements concerning the independent audit of provider agencies; (b) the financial audit program that the state conducts to ensure the integrity of provider billings for Medicaid payment of waiver services, including the methods, scope and frequency of audits; and, (c) the agency (or agencies) responsible for conducting the financial audit program. State laws, regulations, and policies referenced in the description are available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

MMIS claims data are audited periodically for program policy alignment, and claims processing worksheets are audited, processed and returned on a daily basis. Discovery and monitoring also includes an ongoing review of CMS- 372 reports and CMS-64 reports.

The entity responsible for the periodic independent audit of the waiver program is Arkansas Legislative Audit. Audits are conducted in compliance with state law. All providers who receive a total of $100,000 up to $500,000 in state funding are required to submit a GAS audit annually. Providers who receive $500,000 or more are required to submit an A133 audit annually. The audit is required to be an independent audit of the provider's financial statements. All audits are reviewed by the Department of Human Services, Office of Chief Counsel (OCC) audit staff for compliance with audit requirements. If there are any concerns or problems noted, the OCC Audit staff will notify the funding division. The funding division (in this case DDS) defers the notifications to the DDS Quality Assurance Services Section for dispensation.

Waiver programs and providers must use the Medicaid Management Information System (MMIS) for billing and payment. The Division of Medical Services (DMS) and its fiscal agent are responsible for maintaining the MMIS and the Decision Support System (data warehouse for reporting). The Division of Developmental Disabilities Services (DDS) is responsible for identifying necessary edits and audits to be used in the MMIS for proper billing and payment, and for notifying DMS of the changes needed in MMIS. DMS is responsible to determine priority for programming changes requested of Electronic Data Systems to include denial or non-priority of the change request. DMS may review claims activity through utilization review and conduct random financial audits for billing practices and utilization.

DDS is responsible for reviewing billing claims activity for each provider with DDS Specialists conducting a 100% post payment financial audit annually. This audit consists of a paper review of paid services based on MMIS records as compared to DDS prior approved waiver services for the plan of care being reviewed. This audit occurs prior to approval of all new continued plans of care with providers required to justify any underutilization and correct any billing errors found. When payment is questioned, a referral is made to the DMS Program Integrity for onsite resolution.

The Office of Medicaid Inspector General (OMIG) conducts an annual random review of HCBS Waiver programs. If the review finds errors in billing, and fraud is not suspected, Medicaid recoups the money from the HCBS Waiver provider. If fraud is suspected, a referral of the HCBS Waiver provider is made to the Arkansas Attorney General's Office for appropriate action.

DDS Individual File Reviews include a review of claims paid to provider agencies for services specified in the service plan. DMS arranges with DDS for a specified number of service plans to be reviewed annually as specified in the interagency agreement with DMS in their role as overseer. DMS conducts a retrospective review of identified program, financial and administrative elements critical to CMS quality assurance. DMS randomly reviews plans and ensures that they have been developed in accordance with applicable policies and procedures, that plans ensure the health and welfare of the waiver recipient and that financial components or prior authorizations, billing and utilization are correct and in accordance with applicable policies and procedures. DMS uses the sampling guide "A Practical Guide for Quality Management in Home & Community-Based Waiver Programs" developed by the Human Services Research Institute and the Medstat Group for CMS in 2006. A systematic random sampling of the active case population is drawn whereby every "nth" name in the population is selected for inclusion in the sample for Individual File Review. The sample size is based on a 95% confidence level with a margin of error of +/-8%. An online calculator was used to determine the appropriate sample size for this waiver population. To determine the "nth" integer, the sample is divided by the population. Those names are drawn until the sample size is reached. The sample is divided by twelve for monthly review. DMS oversight results are reconciled quarterly with DDS. Where applicable individual actions to correct any known non-compliance or questionable practice are taken with the service provider or DDS staff, sometimes a change in policy or procedure may be necessary when systemic issues are discovered. Corrective action plans are required if indicated by file review. Payment Integrity would look at the circumstances to determine if fraud was suspected in which case we would forward the case to Office of Medicaid Inspector General. If manual or rules change are indicated, a recommendation is made to Medicaid Program, Planning and Development.

DDS Waiver Specialists, in addition to the annual retrospective review of billing utilization with any underutilization requiring explanation from the provider, randomly attends a minimum of 10% of the person centered planning meetings for their caseload and conducts visits to the home. DDS billing claims activity compares billing utilization to services approved on the person centered plan of care. DDS Individual File Reviews monitors choice forms, billing, person centered service plans and level of care. DDS Individual File Reviews are a more complete review as opposed to just a billing review.

OMIG performs regular reviews of waiver service providers. During the course of our last 2 state fiscal years 21% of our audits were devoted to waiver providers. There are a number of ways in which OMIG selects providers and identifies claims for reviews. They may audit provides due to a complaint, issues identified through data analytics, and follow ups from previous audits which resulted in findings. When identifying claims selected for review, OMIG considers a number of different factors. In the event that potential issues are identified through complaints and data analytics, the claims identified by those sources will be reviewed. OMIG also may choose to audit a random sampling of claims submitted by that provider from a specific time period. That process is completed by their data analytics department and follows the following process:

There are no generally accepted principles of statistical sampling; however, it is the goal of the data analytics department to ensure that the frames for the planned sample of claims are appropriate for the review and are composed of a representative sample of that provider's population. OMIG does not extrapolate overpayments, they only use statistically valid random sampling as a means to conduct a probe audit of a providers' claims when the sampling frame is too large for a full review.

OMIG utilizes a basic procedure that is reproducible and results in a probability sample. The methodology allows for an unlimited set of distinct samples that could be selected if applied to the target sampling frame. Given the random sampling methodology, it is important to note that each sampling unit has an equal probability of being selected from the sampling frame for review. The basic methodology is as follows:

1. Select a provider for review

2. Select a period to be reviewed

3. Define the claims universe, the sampling unit (number of recipients), and sampling frame (recipients to choose from)

4. Design a sampling plan and select the sample for review

OMIG utilizes a few different sampling techniques, including simple random, stratified, and cluster samples. The application of sampling technique is largely dependent upon data hypothesis and sampling frame. If a provider contains subpopulations that are necessary for review, then a stratified or cluster sample would be most appropriate. If not, the default sampling methodology is a simple random sample.

The recommended sample size based on a defined sampling frame has a 95% confidence interval with a 5% margin of error. However, sample sizes are no less than a 90% confidence interval with 10% margin of error, and this is only in the case of a very large provider with a prohibitively large patient population. This sample size would only be intended to be a probe of that patient population, with the option to drill down and expand the sample size if necessary based on findings.

The sample size is calculated using a sample size calculator by Raosoft. This calculator can be accessed at http://www.raosoft.com/samplesize.html. The calculator provides the desired sample size by prompting for margin of error, confidence interval, population size, and response distribution. Once the desired sample size has been identified, a random number generator is applied to the recipient list for a provider selected for review for a defined time period. The random recipients identified in the sampling frame then constitute the sample for review, and all other recipients' claims are removed from the claims universe; this only leaves the selected sample of recipients' claims for review.

Appendix I: Financial Accountability

Quality Improvement: Financial Accountability

As a distinct component of the State's quality improvement strategy, provide information in the following fields to detail the State's methods for discovery and remediation.

a. Methods for Discovery: Financial Accountability Assurance:

The State must demonstrate that it has designed and implemented an adequate system for ensuring financial accountability of the waiver program. (For waiver actions submitted before June 1, 2014, this assurance read "State financial oversight exists to assure that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver.")

i. Sub-Assurances:

a.Sub-assurance: The State provides evidence that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver and only for services rendered.

(Performance measures in this sub-assurance include all Appendix I performance measures for waiver actions submitted before June 1, 2014.)

Performance Measures

For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

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b.Sub-assurance: The state provides evidence that rates remain consistent with the approved rate methodology throughout the five year waiver cycle.

Performance Measures

For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

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b. Methods for Remediation/Fixing Individual Problems

The Division of Developmental Disabilities Services (operating agency) and the Division of Medical Services (Medicaid agency) participate in periodic team meetings to discuss and address individual problems related to financial accountability, as well as problem correction and remediation. DDS and DMS have an Interagency Agreement that includes measures related to financial accountability for the HCBS Waiver.

The performance measure for number and percent of HCBS Waiver claims paid using the correct rate specified in the HCBS Waiver application will always result in 100% compliance because the rates for services are already set in MMIS; therefore, claims will not be paid at any other rate.

DDS's remediation for claims without specified services includes writing deficiencies to providers based on discovery of their failure to provide services specified in the PCSP, training providers and conducting a face-to-face visit with the participant to determine if there are negative outcomes as a result of the lack of services. DDS also reviews the file to determine if the provider has reported a lapse in services which may have resulted in a failure to provide services.

The tool used for record review captures and tracks remediation in these areas.

ii. Remediation Data Aggregation

Remediation-related Data Aggregation and Analysis (including trend identification)

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I-2: Rates, Billing and Claims (1 of 3)

a. Rate Determination Methods. In two pages or less, describe the methods that are employed to establish provider payment rates for waiver services and the entity or entities that are responsible for rate determination. Indicate any opportunity for public comment in the process. If different methods are employed for various types of services, the description may group services for which the same method is employed. State laws, regulations, and policies referenced in the description are available upon request to CMS through the Medicaid agency or the operating agency (if applicable).

Case Management - The monthly rate for case management is $117.70. This rate is consistent with the rate paid for the preceding five years of this waiver.

Supportive Living - The maximum daily rate for supportive living is $391.95. Service providers develop a budget for each individual which justifies costs based upon the assessed need and the resulting level of support identified in the person-centered service plan. The budget to support the daily cost of supportive living must include the anticipated hourly rate to be paid each direct service staff, and the associated fringe costs, up to a maximum of 32%. The initial fringe costs associated with the waiver were set in 1990 and were based on the cost of fringe for state employees. A fringe benefit is a form of pay for the performance of services. DDS uses the IRS definition of fringe benefits. Examples of fringe benefits are holidays, annual leave, sick leave, FICA, SUTA, life insurance, retirement, WC, and health and medical insurance.The budget may also include a monthly fee of $100.00 for the cost of direct service staff supervision that rate was established in 1990. Providers may include up to 20% of the cost of salary and fringe, as indirect, administrative costs. Administrative costs include clerical/bookkeeping support, rent, supervisory support, utilities, salary fringe for supervisory/support staff, supplies/materials, quality assurance and training, advertising for recruiting/employing waiver direct delivery of service staff and other expenses. The salaries of senior executives and cost of general services (such as accounting, contracting, and industrial relations) fall under administrative costs. The budget may also include the costs of non-medical transportation as part of implementation of the PCSP. The rate for transportation is .42 cents per mile and is not subject to the 20% indirect cost charge. Each provider is responsible for independently setting the hourly rate paid for direct service staff. It is basically whatever the labor market pool will tolerate. Providers must be in compliance with Department of Labor relative to minimum wage but other than that DDS only deals with a capitated daily rate.

Respite Care - The prospective rate is developed as described for supportive living, with the exception that transportation costs and the supervisory fee may not be included. The maximum daily rate is the same. This maximum rate is applied to two waiver services (supportive living and respite) because these waiver services are closely related and can serve as a substitute for one another. Without respite there would be a need for increased supportive living staff/hours to be approved in order to assure health and safety in the absence of the unpaid caregiver. There are many components of supportive living to include transportation, but the waiver recipients would only be approved for the components that they need based on a person centered service plan as approved by a physician and DDS.

Adaptive Equipment, PERS and Environmental Modifications - the rate is prospective based on actual cost with a cost maximum of $7,687.50 per individual per year. The maximum was based on average consumer needs at the time of limitation setting in 1990. The annual maximum includes Adaptive Equipment, PERS and Environmental

Modifications.

Personal Emergency Response System - the rate is prospective based on actual cost of installation, purchase and monthly service fees.

Specialized Medical Supplies, Supplemental Supports, and Community Transition - the rate is prospective based on actual costs with a maximum of $3,690.00 per year. The maximum was based on average consumer needs at the time of limitation setting in 1990. The annual maximum includes Specialized Medical Supplies, Supplemental Support and Community Transition.

Consultation - the annual maximum for an individual is $1320.00. This maximum is increased from the previous 5 years of the waiver.

Crisis Intervention - The maximum rate is $127.10 per hour. The annual maximum is $2640.00. There was no annual maximum for this service in the preceding 5 years of the waiver.

Supported Employment - Supported employment cannot exceed $3.59 per 15 minute unit with a maximum of 32 units a day, 5 days per week for the first year. The service may be provided up to 52 weeks in a year. The resulting maximum is $29,868.00 per year.

The rates included in this waiver were initially set in 1990. The State proposes that within 12 months from the effective date of this waiver renewal, AR will submit an amendment to implement a new rate methodology for all services. AR will consult with CMS during the development of the rate methodology and will comply with all public notice requirements.

Arkansas will submit a timeline for rate methodology amendment, well in advance, but no longer than three months after approval date of this renewal.

Rate Determination Responsibility: DDS is responsible to develop and present all proposed rates to the DMS. The Division of Medical Services is responsible for the approval of rates and methodologies.

Rate Determination Public Comments: Public comments are sought on an informal basis as the State develops the draft waiver document. Public comments are sought on a formal basis as the State promulgates the waiver document according to the AR Administrative Procedures Act. The Act requires advertisement in a newspaper of statewide circulation, and public hearings. the State collects all comments and makes changes as necessary. The Act requires that the document is presented for legislative review and recommendations. After legislative review and advice the document is duly promulgated.

The budget for each individual is determined through the Person Centered Service Plan development process. The multi-agency team includes the chosen case manager, the individual or their legal representative. All other persons attending are at the discretion of the individual or their legal representative and include other professionals as invited. The members of the team will determine services to be provided, frequency of service provision, number of units of service, cost for those services, and ensure the participant's desired outcomes, needs and preferences are addressed. The team members and a physician via a 703 certify the person's condition (level of care) and appropriateness of services initially and at the annual continued stay review date. A person centered services plan revision can be requested at any time that the person's needs change. The waiver services included in the plan of care must be prior approved by DDS.

b. Flow of Billings. Describe the flow of billings for waiver services, specifying whether provider billings flow directly from providers to the State's claims payment system or whether billings are routed through other intermediary entities. If billings flow through other intermediary entities, specify the entities:

Providers bill directly through the state Medicaid Management Information System (MMIS).

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d. Billing Validation Process. Describe the process for validating provider billings to produce the claim for federal financial participation, including the mechanism(s) to assure that all claims for payment are made only:

(a) when the individual was eligible for Medicaid waiver payment on the date of service; (b) when the service was included in the participant's approved service plan; and, (c) the services were provided:

The assessed needs of each person are identified by the provider case manager through a functional assessment. Services to meet assessed needs are authorized by DDS staff prior to the beginning of services through input into the MMIS system. MMIS edits prevent payment of unauthorized services or of amounts above the authorized limit. The provider case manager develops, oversees, and coordinates a written plan, called the Person Centered Service

Plan. Providers assure that services are delivered in accordance with the Person Centered Service Plan prior to billing for services.

Providers maintain case notes of each service day with the person served. Providers maintain administrative records such as timesheets and payroll records for provider staff. MMIS verifies eligibility of both the person and the billing provider prior to payment for billed services. DDS Waiver staff perform service-to-billing audits annually which include off-site desk review of 100% files and on-site interview with 10% of people served. DDS Quality Assurance staff perform an on-site review of 100% of providers annually using interview, observation, and record review of a random sample of persons served by each provider.

To assure that claims through MMIS are processed correctly and in a timely manner, amounts and codes are compared to MMIS edits and the services and amounts that were prior authorized by DDS. DDS Provider Standards mandate that providers report any 30 consecutive day interruptions in the provision of services to a person. These processes ensure that services are paid at the correct rate, billing does not exceed maximum approved amounts, and gaps in services are reported and investigated. When a provider becomes aware of errors, the provider performs remediation through adjusting the claim in error in future billings. DDS refers issues that were not or cannot be remediated through adjusted provider billing to the Medicaid audit unit for recoupment and other remedies.

DDS Quality Assurance unit performs an on-site review of 100% of providers annually. When issues related to scope, frequency, or duration of services are discovered during this review or as the result of a complaint investigation, DDS refers issues to the Medicaid audit unit for adjusted billing, recoupment and other remedies and notifies the DDS Waiver unit of the referral.

The MMIS system also edits for qualified providers by requiring an active certification date in the system. DDS Quality Assurance works with the Medicaid MMIS contractor to insure timely and correct dates are entered into the system. The DDS Medicaid Income Eligibility Unit, a part of DDS Quality Assurance, verifies that each person receiving waiver services has a valid code (W1) in the MMIS system before the first service can be billed. This assures that the person is approved for Medicaid prior to the delivery of services. MMIS requires that prior authorization data to be entered by the DDS Waiver unit prior to the provider billing for services. Data fields include beginning and ending dates, total plan amount, and procedure codes. Adjustments may be made for a service set that includes more than one service, such as supportive living and respite.

e. Billing and Claims Record Maintenance Requirement. Records documenting the audit trail of adjudicated claims (including supporting documentation) are maintained by the Medicaid agency, the operating agency (if applicable), and providers of waiver services for a minimum period of 3 years as required in 45 CFR § 92.42.

Appendix I: Financial Accountability I-3: Payment (1 of 7)

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Section II

DDS Alternative Community Services (ACS) Waiver

202.200 HCBS Settings Requirements 9-1-16

Home and Community-Based Services (HCBS) Settings

The settings rule is a federal regulation intended to ensure the chosen provider is allowing the beneficiary optimal independence. However, beneficiary and guardian choice is paramount and must be documented in the PCSP when it deviates from the federal regulation.

All providers must meet the following Home and Community-Based Services (HCBS) Settings regulations as established by CMS. The federal regulation for the new rule is 42 CFR 441.301(c) (4)-(5).

Settings that are HCBS must be integrated in and support full access of beneficiaries receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources and receive services in the community, to the same degree of access as beneficiaries not receiving Medicaid HCBS.

HCBS settings must have the following characteristics:

A. Chosen by the individual from among setting options including non-disability specific settings (as well as an independent setting) and an option for a private unit in a residential setting.

1. Choice must be included in the person-centered service plan.

2. Choice must be based on the individual's needs, preferences and, for residential settings, resources available for room and board.

B. Ensures an individual's rights of privacy, dignity and respect and freedom from coercion and restraint.

C. Optimizes, but does not regiment, individual initiative, autonomy and independence in making life choices, including but not limited to, daily activities, physical environment, and with whom to interact.

D. Facilitates individual choice regarding services and supports and who provides them.

E. The setting is integrated in and supports full access of beneficiaries receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources and receive services in the community, to the same degree of access as beneficiaries not receiving Medicaid HCBS.

F. In a provider-owned or -controlled residential setting (e.g., Group Homes), in addition to the qualities specified above, the following additional conditions must be met:

1. The unit or dwelling is a specific physical place that can be owned, rented, or occupied under a legally enforceable agreement by the individual receiving services, and the individual has, at a minimum, the same responsibilities and protections from eviction that tenants have under the landlord/tenant law of the State, county, city, or other designated entity. For settings in which landlord/tenant laws do not apply, the State must ensure that a lease, residency agreement or other form of written agreement will be in place for each HCBS participant and that the document provides protections that address eviction processes and appeals comparable to those provided under the jurisdiction's landlord/tenant law.

2. Each individual has privacy in their sleeping or living unit:

a. Units have entrance doors lockable by the individual, with only appropriate staff having keys to doors.

b. Beneficiaries sharing units have a choice of roommates in that setting.

c. Beneficiaries have the freedom to furnish and decorate their sleeping or living units within the lease or other agreement.

3. Beneficiaries have the freedom and support to control their own schedules and activities and have access to food at any time.

4. Beneficiaries are able to have visitors of their choosing at any time.

5. The setting is physically accessible to the beneficiary.

6. Any modification of the additional conditions specified in items 1 through 4 above must be supported by a specific assessed need and justified in the person-centered service plan. The following requirements must be documented in the person-centered service plan:

a. Identify a specific and individualized assessed need.

b. Document the positive interventions and supports used prior to any modifications to the person-centered service plan.

c. Document less intrusive methods of meeting the need that have been tried but did not work.

d. Include a clear description of the condition that is directly proportionate to the specific assessed need.

e. Include regular collection and review of data to measure the ongoing effectiveness of the modification.

f. Include established time limits for periodic reviews to determine if the modification is still necessary or can be terminated.

g. Include the informed consent of the beneficiary.

h. Include an assurance that interventions and supports will cause no harm to the beneficiary.

210.000 PROGRAM COVERAGE

211.000 Scope 9-1-16

The Medicaid program offers certain home- and community-based services (HCBS) as an alternative to institutionalization. These services are available for eligible beneficiaries with a developmental disability who would otherwise require an intermediate care facility for individuals with intellectual disabilities (ICF/IID) level of care. This waiver does not provide education or therapy services.

The purpose of the ACS waiver is to support beneficiaries of all ages who have a developmental disability, meet the institutional level of care, and require waiver support services to live in the community and thus prevent institutionalization.

The goal is to create a flexible array of services that will allow people to reach their maximum potential in decision making, employment and community integration, thus giving their lives the meaning and value they choose.

The objectives are as follows:

A. To transition eligible persons who choose the waiver option from residential facilities into the community

B. To provide priority services to persons who meet the pervasive level of service (imminent danger and requiring supports 24 hours a day, seven days a week)

C. To enhance and maintain community living for all persons participating in the waiver program

DDS is responsible for day-to-day operation of the waiver. All waiver services are accessed through DDS Adult Services, DDS Children's Services or the ICF/IID services intake and referral staff.

All ACS waiver services must be prior authorized by DDS. All services must be delivered based on the approved person-centered service plan.

Waiver services will not be furnished to persons while they are inpatients of a hospital, nursing facility (NF), or ICF/IID unless payment to the hospital, NF, or ICF/IID is being made through private pay or private insurance.

A person may be placed in abeyance in three-month increments (with status report every month) for up to 12 months when the following conditions are met:

A. The need for absence must be for the purposes of treatment in a licensed or certified program or facility for the purposes of behavior stabilization or physical or mental health treatment.

B. The loss of home or loss of the primary non-paid caregiver.

C. The request must be in writing with supporting evidence included.

D. The request must be prior approved by DDS.

E. A minimum of one visit or one contact each month is required.

NOTE: The DDS Specialist is responsible for conducting or assuring the conducting of the contacts or monitoring visits with applicable documentation filed in the case record.

F. All requests for abeyance are to be faxed to the DDS Waiver Program Director for Adult and Waiver Services. Monthly status reports are required to be submitted to the DDS Waiver Program Director as long as the person is in abeyance. Each request for continuance must be submitted in writing and supported by evidence of treatment status or progress. Requests for continuance must be made prior to the expiration of the abeyance period.

In order for beneficiaries to continue to be eligible for waiver services while they are in abeyance the following two requirements must be met:

A. It must be demonstrated that a beneficiary needs at least one waiver service as documented in their person-centered service plan.

B. Beneficiaries must receive at least one waiver service per month or monthly monitoring.

As stated in the Medical Services Manual, Section 1348, an individual living in a public institution is not eligible for Medicaid.

A. Public institutions include county jails, state and federal penitentiaries, juvenile detention centers and other correctional or holding facilities.

B. Wilderness camps and boot camps are considered a public institution if a governmental unit has any degree of administrative control.

C. Inmate status will continue until the indictment against the individual is dismissed or until he or she is released from custody either as "not guilty" or for some other reason (bail, parole, pardon, suspended sentence, home release program, probation, etc.)

Thus, a person who is living in a public institution as defined above would be ineligible under Medicaid and also under the waiver program.

211.200 Risk Assessment 9-1-16

A. DDS will not authorize or continue waiver services under the following conditions:

1. The health and safety of the beneficiary, the beneficiary's caregivers, workers or others are not assured.

2. The beneficiary or legally responsible person has refused or refuses to participate in the plan of care development or to permit implementation of the person-centered service plan or any part thereof that is deemed necessary to assure health and safety.

3. The beneficiary or legally responsible person refuses to permit the on-site entry of: case manager to conduct required visits, caregivers to provide scheduled care, DDS, DMS, DHS or CMS officials acting in their role as oversight authority for compliance or audit purposes.

4. The beneficiary applying for, or receiving, waiver services requires 24 hour nursing care on a continuous basis as prescribed by a physician.

5. The beneficiary participating in the waiver program is incarcerated, adjudicated as guilty or is an inmate in a state or local correctional facility.

6. The person is deemed ineligible based on DDS Psychological Team assessment or reassessment for meeting ICF/IID level of care.

7. The beneficiary is deemed ineligible based on not meeting or not complying with requirements for determining continued Medicaid income eligibility.

B. Safeguards concerning the use of restraints or seclusion:

1. Personal restraints (use of a staff member's body to prevent injury to the individual or another person) are allowed in cases of emergency. An emergency exists for any of the following situations:

a. The individual has not responded to de-escalation techniques and continues to escalate behavior.

b. The individual is a danger to self or others.

c. The safety of the individual and those nearby cannot be assured through positive reinforcers.

An individual must be continuously under direct observation of staff members during any use of restraints.

If the use of personal restraints occurs more than three times per month, use should be discussed by the interdisciplinary team and addressed in the person-centered service plan. When emergency procedures are implemented, person-centered service plan revisions including but not limited to psychological counseling, review of medications with possible medication change or a change in environmental stressors that are noted to precede escalation of behavior may be implemented.

1. Mechanical restraints fall under the same requirements as the use of personal restraints in that they may only be used in emergency circumstances that place the individual or others around the individual at serious threat of violence or risk of injury if no intervention occurs. If emergency procedures are used more than three times in six months, the interdisciplinary team must meet to revise the person-centered service plan.

2. DDS standards require that providers will not allow maltreatment or corporal punishment (the application of painful stimuli to the body in an attempt to terminate behavior or as a penalty for behavior) of individuals. Provider's policies and procedures must state that corporal punishment is prohibited.

3. Providers must develop a written behavior management policy to ensure the rights of individuals. The policy must include a provision for alternative methods to avoid the use of restraints and seclusions.

The behavior management plan must specify what behaviors will constitute the use of restraints or seclusion, the length of time to be used, who will authorize the use of restraints or seclusion and the methods for monitoring the individual.

Behavior management plans cannot include procedures that are punishing, physically painful, emotionally frightening, depriving or that put the individual at a medical risk.

When the behavior plan is implemented, all use of restraint must be documented in the individual's case record, including the initiating behavior, length of time of restraint, name of authorizing personnel, names of all individuals involved and outcomes of the event.

1. The use of restraints or seclusion must be reported to the DDS Quality Assurance section via an incident report form that must be submitted no later than the end of the second business day following the incident. The DDS Quality Assurance staff investigates each incident and monitors use of restraints for possible overuse or inappropriate use of restraints or seclusion. DDS Quality Assurance staff will notify entities involved with the complaint or service concern the results of their review. If there is credible evidence to support the complaint or concern, the provider will be required to submit a plan of correction. Failure to complete corrective action measures may result in the provider being placed on provisional status or revocation of certification.

2. Each person working within the provider agency must complete Introduction to Behavior Management, Abuse and Neglect and any other training as deemed necessary as a result of deficiencies or corrective actions.

C. Safeguards concerning the use of restrictive intervention:

1. DDS standards require the use of a behavior management plan for all individuals whose behavior may warrant intervention. The behavior management plan must specify what will constitute the use of restrictive interventions, the length of time to be used, who will authorize the use of restrictive intervention and the methods for monitoring the individual.

When the behavior plan is implemented, all use of restrictive interventions must be documented in the individual's case record and should include the initiating behavior, length of time of restraint, name of authorizing personnel, names of all individuals involved and outcomes of the event.

2. Restrictive interventions include:

a. Absence from a specific social activity b. Temporary loss of a personal possession

These interventions might be implemented to deal with aggressive or disruptive behaviors related to the activity or possession. Staff, families and the beneficiary are trained by the provider to recognize and report unauthorized use of restrictive interventions.

Before absence from a specific social activity or temporary loss of personal possession is implemented, the beneficiary is first counseled about the consequences of the behavior and the choices they can make.

1. All personnel who are involved in the use of restrictive interventions must receive training in behavior management techniques as well as training in abuse and neglect laws, rules and regulations and policies. The personnel must be qualified to perform, develop, implement and monitor or provide direction intervention as applicable.

2. Use of restrictive interventions requires submission of an incident report that must be submitted no later than the end of the second business day following the incident. The DDS Quality Assurance staff investigates each incident and monitors use of restrictive interventions for possible overuse or inappropriate use. DDS Quality Assurance staff will notify entities involved with the complaint or service concern the results of their review. If there is credible evidence to support the complaint or concern, the provider will be required to submit a plan of correction. Failure to complete corrective action measures may result in the provider being placed on provisional status or revocation of certification.

213.000 Supportive Living 9-1-16

Supportive living is an array of individually tailored services and activities provided to enable eligible beneficiaries to reside successfully in their own homes, with their family, or in an alternative-living residence or setting. Alternative living residences include apartments, homes of primary caregivers, leased or rented homes, or provider group homes. Supportive living services are provided in integrated community settings. The services are designed to assist beneficiaries in acquiring, retaining and improving the self-help, socialization and adaptive skills necessary to reside successfully in the home- and community-based setting. Services are flexible to allow for unforeseen changes needed in schedules and times of service delivery. Services are approved as maximum days that can be adjusted within the annual plan year to meet changing needs. The total number of days cannot be increased or decreased without a revision. The payments for these services exclude the costs of the beneficiary's room and board expenses including general maintenance, upkeep or improvement to the beneficiary's home or their family's home. Retainer payments may be made to providers of habilitation while the waiver participant is hospitalized or absent from his/her home.

A. Residential Habilitation Supports

Care and supervision of activities that directly relate to treatment goals and objectives. The supports that may be provided to a beneficiary include the following:

1. Decision-making including the identification of and response to dangerously threatening situations, making decisions and choices affecting the person's life and initiating changes in living arrangement or life activities.

2. Money management consisting of training, assistance or both in handling personal finances, making purchases and meeting personal financial obligations.

3. Daily living skills including habilitative training in accomplishing routine housekeeping tasks, meal preparation, dressing, personal hygiene, administration of medications (to the extent permitted under state law) and other areas of daily living including proper use of adaptive and assistive devices, appliances, home safety, first aid and emergency procedures.

4. Socialization, including training, assistance or both, in participation in general community activities and establishing relationships with peers. Activity training includes assisting the beneficiary to continue to participate on an ongoing basis.

5. Community experiences include activities intended to instruct the person in daily living and community living skills in a clinic and integrated setting. Included are such activities as shopping, church attendance, sports, participation in clubs, etc. Community experiences include activities and supports to accomplish individual goals or learning areas including recreation and specific training or leisure activities. Each activity is then adapted according to the beneficiary's individual needs.

6. Non-medical transportation to or from community integration experiences is an integral part of this service and is included in the daily rate computation. DDS will assure duplicate billing between waiver services and other Medicaid state plan services will not occur. The habilitation objectives to be served by such training must be documented in the beneficiary's service plan. Whenever possible, family, neighbors, friends or community agencies that can provide this service without charge must be utilized.

Exclusions: Transportation to and from medical, dental and professional appointments inclusive of therapists. Non-medical transportation does not include transportation for other household members.

7. Mobility including training, assistance or both aimed at enhancing movement within the person's living arrangement, mastering the use of adaptive aids and equipment, accessing and using public transportation, independent travel or movement within the community.

8. Communication including training in vocabulary building, use of augmentative communication devices and receptive and expressive language.

9. Behavior shaping and management including training, assistance or both in appropriate expressions of emotions or desires, compliance, assertiveness, acquisition of socially appropriate behaviors or reduction of inappropriate behaviors.

10. Reinforcement of therapeutic services which consist of conducting exercises or reinforcing physical, occupational, speech and other therapeutic programs.

11. Performance of tasks to assist or supervise the person in such activities as meal preparation, laundry, shopping and light housekeeping that are incidental to (not to exceed 20% of the total weekly hours worked) the care and supervision of the beneficiary but cannot be performed separately from other waiver services.

a. Assistance is defined as hands-on care both of a supportive and health-related nature; supports that substitute for the absence, loss, diminution, or impairment of a physical or cognitive function; homemaker or chore services; or fellowship and protection that includes medical oversight permitted under state law.

b. Services are furnished to beneficiaries who receive these services in conjunction with residing in an alternate-living setting.

c. The total number of individuals (including beneficiaries served in the waiver) living in an alternate-living setting who are unrelated to the principle care provider cannot exceed four except where congregate settings are used that were licensed by DDS prior to 1995.

12. Health maintenance activities may be provided by a designated-care aide (supportive-living worker). All health maintenance activities (to include oral medication administration or assistance, shallow suctioning, maintenance and use of intra-feeding and breathing apparatus or devices), except injections and IVs, can be done in the home by a designated-care aide, such as a supportive-living worker. With the exception of injectable medication administration, tasks that beneficiaries would otherwise do for themselves, or have a family member do, can be performed by a paid designated-care aide at their direction, as long as the criteria specified in the Arkansas Nurse Practices Consumer Directed Care Act has been met. Health maintenance activities are available in the Arkansas Medicaid State Plan as self-directed services. State plan services must be exhausted before accessing waiver funding for health maintenance activities.

B. Companion and Activities Therapy

Companion and activities therapy services provide reinforcement of habilitative training. This reinforcement is accomplished by using animals as modalities to motivate persons to meet functional goals. Through the utilization of an animal's presence, enhancement and incentives are provided to beneficiaries to practice and accomplish such functional goals as:

1. Language skills

2. Increased range of motion

3. Socialization by developing the interpersonal relationships skills of interaction, cooperation and trust and the development of self-respect, self-esteem, responsibility, confidence and assertiveness

NOTE: This service does not include the purchase of animals, veterinary or other care, food, shelter or ancillary equipment that may be needed by the animal that is providing reinforcement.

C. Direct-Care Supervision

The direct-care supervisor employed by the supported-living provider is responsible for assuring the delivery of all supported living direct-care services including the following activities:

1. Coordinating all direct-service workers who provide care through the direct-service provider

2. Serving as liaison between the beneficiary, parents, legal representatives, case management entity and DDS officials

3. Coordinating schedules for both waiver and generic service categories

4. Providing direct planning input and preparing all direct-service provider segments of any initial plan-of-care and annual continued-stay review

5. Assuring the integrity of all direct-care service Medicaid waiver billing

6. Arranging for staffing of all alternative-living settings

7. Assuring transportation as identified in person-centered service plan specific to supportive-living services

8. Assuring advance collaboration with the case management entity to obtain comprehensive behavior and assessment reports, continued-stay reviews, revisions as needs change and information and documents required for ICF/IID level of care and waiver Medicaid eligibility determination

9. Reviewing the beneficiary's records and environments in which services are provided by accessing appropriate professional sources to determine whether the person is receiving appropriate support in the management of medication. Minimum components are as follows:

The direct-care supervisor has an on-going responsibility for monitoring beneficiary medication regimens. While the provider may not staff a person on a 24/7 schedule, the provider is responsible around the clock to assure that the person-centered service plan identifies and addresses all the needs with other supports as necessary to assure the health and welfare of the beneficiary.

a. Staff, at all times, are aware of the medications being used by the beneficiary.

b. Staff are knowledgeable of potential side effects of the medications being used by the beneficiary through the prescribing physician, nurse and pharmacist at the time medications are ordered.

c. All medications consumed are prescribed or approved by the beneficiary's physician or other health care practitioner.

d. The beneficiary or legally responsible person is informed by the prescribing physician about the nature and effect of medication being consumed and consents to the consumption of those medications prior to consumption.

e. Staff are implementing the service provider's policies and procedures as to medication management, appropriate to the beneficiary's needs as monitored by the direct-care supervisor in accordance with acceptable personnel policies and practices and by the case manager at least monthly.

f. If psychotropic medications are being used for behavior, the direct-care supervisor and case manager are responsible to assure appropriate positive-behavior programming is present and in use with programming reviews at least monthly.

g. The consumption of medications is monitored at least monthly by the direct-care supervisor to ensure that they are accurately consumed as prescribed.

h. Toxicology screenings are conducted on a frequency determined by the prescribing physician with case manager oversight.

i. Any administration of medication or other nursing tasks or activities are performed in accordance with the Nurse Practice and Consumer Directed Care Acts and monitored by the direct-care supervisor in accordance with acceptable personnel practices and by the case manager at least monthly.

j. Medications are regularly reviewed to monitor their effectiveness, to address the reason for which they were prescribed and for possible side effects.

k. Medication errors are effectively detected by the direct-care supervisor by review of the medication log and with appropriate response up to and inclusive of incident reporting and reporting to the appropriate nursing board.

l. Frequency of monitoring is based on the physician's prescription for administration of medication.

m. The physician approving the service level of support and the person-centered service plan is responsible for monitoring and determining contraindications when multiple medications are prescribed. At a minimum, the PCSP must be reviewed annually for approval and recertification.

Direct-care staff are required to complete daily activity logs for activities that occur during the work timeframe with such activities linked to the person-centered service plan objectives. The direct-care supervisor is required to monitor the work of the direct-care staff and to sign off on timesheets maintained to document work performed. All monitoring activities, reviews and reports must be documented and available upon request from authorized DDS or DMS staff.

NOTE: Failure to satisfactorily document activities according to DMS requirements may result in non-payment of services.

Persons may access both supportive living and respite on the same date as long as the two services are distinct, do not overlap and the daily rate maximum is correctly prorated as to the portion of the day that each respective service was actually provided. DDS monitors this provision through an annual retrospective review with providers responsible to maintain adequate time records and activity case notes or activity logs that support the service deliveries. Maximum daily rate is established in accordance with budget neutrality wherein both supportive living and respite independently and collectively cannot exceed the daily maximum.

Controls in place to assure payments are only made for services rendered include requirement by assigned staff to complete daily activity logs for activities that occurred during the work timeframe with such activities linked to the plan-of-care objectives; supervision of staff by the direct-care supervisor with sign-off on timesheets maintained weekly; audits and reviews conducted by DDS Quality Assurance annually and at random; DDS Waiver Services annual retrospective reviews, random attendance at planning meetings and visits to the home; DMS random audits; and oversight by the chosen and assigned case team.

213.200 Supportive Living Exclusions 9-1-16

Only hired caregivers may be reimbursed for supportive living services provided.

The payments for these services exclude the costs of room and board, including general maintenance, upkeep or improvement to the beneficiary's own home or that of his or her family.

Routine care and supervision for which payment will not be made are defined as those activities that are necessary to assure a person's well-being but are not activities that directly relate to active treatment goals and objectives.

It is the responsibility of the provider to assure compliance with state and federal Department of Labor wage and hour laws.

Software will be approved only when required to operate the accessories included for environmental control or to provide text-to-speech capability.

Note: Adaptive equipment must be an item that is modified to fit the needs of the beneficiary. Items such as toys, gym equipment, sports equipment, etc. are excluded as not meeting the service definition.

Conditions: The care and maintenance of adaptive equipment, vehicle modifications, and personal emergency response systems are entrusted to the beneficiary or legally responsible person for whom the aids are purchased. Negligence (defined as failure to properly care for or perform routine maintenance of) shall mean that the service will be denied for a minimum of two plan years. Any unauthorized use or selling of aids by the beneficiary or legally responsible person shall mean the aids will not be replaced using waiver funding.

Exclusions:

A. Swimming pools (in-ground or above-ground) and hot tubs are not allowable as either an environmental modification or adaptive equipment.

B. Therapeutic tools similar to those therapists employ during the course of therapy are not included.

C. Educational aids are not included.

D. Computers will not be purchased to improve socialization or educational skills.

E. Computer supplies.

F. Computer desks or other furniture items are not covered.

G. Medicaid-purchased equipment cannot be donated if the equipment being donated is needed by another waiver beneficiary residing in the residence.

220.000 Case Management Services 9-1-16

Case management services assist beneficiaries in gaining access to needed waiver services and other Arkansas Medicaid State Plan services, as well as medical, social, educational and other generic services, regardless of the funding source to which access is available.

Case management services include responsibility for guidance and support in all life activities. The intent of case management services is to enable waiver beneficiaries to receive a full range of appropriate services in a planned, coordinated, efficient and effective manner.

These activities include locating, coordinating, assuring the implementation of and monitoring:

A. All proposed waiver services

B. Other Medicaid state plan services

C. Needed medical, social, educational and other publically-funded services, regardless of the funding source

D. Informal community supports

Case management services consist of the following activities:

A. Arranging for the provision of services and additional supports

B. Monitoring and reviewing beneficiary services included in the person-centered service plan

C. Facilitating crisis intervention

D. Guidance and support to obtain generic services and supports

E. Case planning

F. Needs assessment and referral for resources

G. Monitoring to assure quality of care

H. Case reviews that focus on the beneficiary's progress in meeting goals and objectives established through the case plan

I. Providing assistance relative to obtaining Medicaid waiver eligibility and ICF/IID level-of-care eligibility determinations

J. Assuring the integrity of all case management Medicaid waiver billing in that the service delivered must have prior authorization and meet required waiver service definitions and must be delivered before billing can occur

K. Assuring submission of timely (advance) and comprehensive behavior and/or assessment reports, continued plans of care, revisions as needs change, and information and documentation required for ICF/IID level-of-care and Medicaid waiver eligibility determinations

L. Arranging for access to advocacy services as requested by the beneficiary.

M. Monitoring and reviewing services to assure health and safety of the beneficiary.

N. Upon receipt of DDS approvals or denials of requested services, the case manager ensures that a copy is provided to the beneficiary or legal representative.

O. Provides assistance with the appeals process when the appeal option is chosen by the beneficiary or legal representative.

P. Planning meetings are scheduled by the case manager on behalf of the waiver participant, at a time and in a location that is convenient for the waiver participant or legal representative. The planning meeting will only include the case manager, the waiver participant or legal representative and other persons invited by the waiver participant.

Case Management will be provided up to a maximum of a 90-day transition period for all beneficiaries who seek to voluntarily withdraw from waiver services unless the individual does not want to continue to receive the service. The transition period will allow for follow-up to ensure that the person is referred to other available services and to ensure that the person's needs can be met through optional services. It also serves to ensure that the person understands the effects and outcomes of withdrawal and to ascertain if the person was coerced or otherwise unduly influenced to withdraw. During this 90-day timeframe, the beneficiary remains enrolled in the waiver, the case remains open, and waiver services will continue to be available until the beneficiary finalizes their intent to withdraw.

The State of Arkansas adheres to CMS regulation as it relates to conflict-free case management. Case Management services may not include the provision of direct services to the beneficiary that are typically or otherwise covered as service under HCBS Waiver of State Plan. The organization may not provide case management services to any person to whom they provide any direct services.

Service gaps of thirty (30) consecutive days must be reported to the DDS Specialist assigned to the case with a copy of the report sent to the DDS Program Director. The report must include the reason for the gap and identify remedial action to be taken.

Case management services are available at three levels of support. They are:

A. Pervasive - Minimum of one face-to-face visit AND one other contact with the beneficiary or legal representative monthly. At least one visit must be made annually at the beneficiary's place of residence.

B. Extensive - Minimum of one face-to-face visit with the beneficiary or legal representative each month. At least one visit must be made annually at the beneficiary's place of residence.

C. Limited - Minimum of one face-to-face visit with the beneficiary or legal representative each quarter and a minimum of one contact monthly for the months when a face-to-face visit is not made. At least one visit must be made annually at the beneficiary's place of residence.

The level of support is determined by the needs or options of the person receiving waiver services as defined in Sections 230.211, 230.212 and 230.213.

See Section 260.000 for billing information.

221.000 Consultation Services 9-1-16

Consultation services are clinical and therapeutic services which assist waiver beneficiaries, parents, guardians, legally responsible individuals, and service providers in carrying out the beneficiary's person-centered service plan.

A. Consultation activities may be provided by professionals who are licensed as:

1. Psychologists

2. Psychological examiners

3. Mastered social workers

4. Professional counselors

5. Speech pathologists

6. Occupational therapists

7. Physical therapists

8. Registered nurses

9. Certified parent educators or provider trainers

10. Certified communication and environmental control specialists

11. Dietitians

12. Rehabilitation counselors

13. Recreational therapists

14. Qualified Developmental Disabilities Professionals (QDDP)

15. Positive Behavioral Support (PBS) specialists

These services are indirect in nature. The parent educator or provider trainer is authorized to provide the activities identified below in items 2, 3, 4, 5, 7, and 13. The provider agency will be responsible for maintaining the necessary information to document staff qualifications. Staff who meet the certification criteria necessary for other consultation functions may also provide these activities. Selected staff or contract individuals may not provide training in other categories unless they possess the specific qualifications required to perform the other consultation activities. Use of this service for provider training cannot be used to supplant provider trainer responsibilities included in provider indirect costs.

B. Activities involved in consultation services include:

1. Providing updated psychological and adaptive behavior assessments

2. Screening, assessing and developing therapeutic treatment plans

3. Assisting in the design and integration of individual objectives as part of the overall individualized service planning process as applicable to the consultation specialty

4. Training of direct services staff or family members in carrying out special community living services strategies identified in the person-centered service plan as applicable to the consultation specialty

5. Providing information and assistance to the individuals responsible for developing the beneficiary's person-centered service plan as applicable to the consultation specialty

6. Participating on the interdisciplinary team, when appropriate to the consultant's specialty

7. Consulting with and providing information and technical assistance with other service providers or with direct service staff and/or family members in carrying out a beneficiary's person-centered service plan specific to the consultant's specialty

8. Assisting direct services staff or family members in making necessary program adjustments in accordance with the person's person-centered service plan as applicable to the consultation specialty

9. Determining the appropriateness and selection of adaptive equipment to include communication devices, computers and software consistent with the consultant's specialty

10 Training and/or assisting beneficiaries, direct services staff or family members in the setup and use of communication devices, computers and software consistent with the consultant's specialty

11. Screening, assessing and developing positive behavior support plans; assisting staff in implementation, monitoring, reassessment and modification of the positive behavior support plan consistent with the consultant's specialty

12. Training of direct services staff and/or family members by a professional consultant in:

a. Activities to maintain specific behavioral management programs applicable to the beneficiary b. Activities to maintain speech pathology, occupational therapy or physical therapy program treatment modalities specific to the beneficiary c. The provision of medical procedures not previously prescribed but now necessary to sustain the beneficiary in the community

13. Training or assisting by advocacy to beneficiaries and family members on how to self-advocate

14. Rehabilitation counseling for the purposes of supported employment supports that do not supplant the Federal Rehabilitation Act of 1973 and PL 94-142 and the supports provided through Arkansas Rehabilitation Services

15. Training and assisting persons, direct services staff or family members in proper nutrition and special dietary needs.

224.000 Payment to Relatives or Legal Guardians 9-1-16

Payment for waiver services will not be made to the adoptive or natural parent, step-parent or legal representative or legal guardian of a beneficiary less than 18 years old. Payments will not be made to a spouse or a legal representative for a beneficiary 18 years of age or older. The employment of eligible relatives (regardless of the waiver beneficiary's age) shall require prior approval from DDS authority.

Payment to relatives, other than parents of minor children, legal guardians, custodians of minors or adults, or the spouse of adults, must be prior approved by DDS to provide services. For purposes of exclusion, "parent" means natural or adoptive parents and step-parents. For any service provider, all DDS qualifications and standards must be met before the person can be approved as a paid service provider. Qualified relatives, other than as specified in the foregoing, can provide any service.

In no case will a parent or legal guardian be reimbursed for the provision of transportation for a minor.

Controls for services rendered: All care staff are required to document all services provided daily according to their work schedules, direct-care support service supervisors are responsible for day-to-day supervision and monitoring of the direct-care staff; case managers are responsible for periodically reviewing with the beneficiary any problems in care delivery and reporting any deficiencies to the Waiver DD Specialist and DDS Quality Assurance provider certification staff. DDS specialists conduct a 100% review of service utilization for each plan of care at the time of each plan of care 12-month expiration date to identify any gaps in approved services with corrective action by the provider to be taken; DDS Quality Assurance conducts annual provider reviews; and DMS conducts both random Quality Assurance audits and audits specific to the financial integrity of services delivered.

230.000 Eligibility Assessment 9-1-16

The intake and assessment process for the DDS ACS Waiver Program includes:

A. Determination of categorical eligibility

B. Level-of-care determination

C. Comprehensive diagnosis and evaluation

D. Development of a person-centered service plan

E. Cost comparison to determine cost-effectiveness

F. Notification of a choice between home and community-based services and institutional services

230.200 Level-of-Care Determination 9-1-16

Based on intellectual and behavioral assessment submitted by the provider, the ICF/IID level-of-care determination is performed by the Division of Developmental Disabilities. The ICF/IID level-of-care criteria provides an objective and consistent method for evaluating the need for institutional placement in the absence of community alternatives. The level-of-care determination must be completed and the beneficiary deemed eligible for an ICF/IID level of care prior to receiving ACS waiver services.

Recertification, based on intellectual and behavioral assessments submitted by the provider at appropriate age milestones, will be performed by DDS to determine the beneficiary's continuing need for an ICF/IID level of care.

The annual level-of-care determination is made by a QDDP.

230.211 Pervasive Level of Support 9-1-16

The pervasive level of support is defined as needs that require constant supports provided across environments that are intrusive, long term and include a combination of any available waiver supports provided 24 hours a day, 7 days a week for 365 days a year.

A. This level may include persons in need of priority consideration who are currently served through Act 609; Department of Human Services (DHS) integrated supports; are civil commitments; are children in custody of the Division of Children and Family Services (DCFS) and who are receiving services through the Child and Adolescent Service System Program; ICF/IID; nursing facilities and persons who have compulsive behavior disorders.

B. People who meet the pervasive level of support definition are determined eligible based on the Inventory for Client and Agency Planning (ICAP) assessment process.

C. Procedures for requesting pervasive level of support:

1. To request pervasive level of support, the case manager must submit the following items to the DDS Waiver Specialist:

a. Documentation of changes in medical, behavioral or other condition that would justify the need for pervasive level of support. Include all incident reports b. Copy of the current person-centered service plan c. Copy of the person's case management and supportive-living staff notes for the past year if request is due to behavior or medical d. If the reason for pervasive level of support is in whole or in part due to behavior issues, a copy of the most recent psychological information on behavioral intervention efforts to include:

(1) A functional behavior analysis of inappropriate behavior including possible antecedents

(2) Description of inappropriate behaviors and consequences

(3) Information related to increases or decreases in inappropriate behavior including time involved and frequency

(4) Positive programming changes to include a description of the behaviors attempting to be established to replace the inappropriate behavioral expression e. Copy of the computer generated or signed narrative report for the ICAP results which includes:

(1) ICAP Domain scores (age scores and standard scores)

(2) Information on problem behaviors recorded in the ICAP

(3) ICAP Maladaptive Behavior Index Scores

(4) ICAP Service Score/Level

(5) The name and relationship of respondent must be clearly noted

(6) The name and credentials of the person administering and writing the report must be clearly noted

2. Upon receipt of a request for pervasive level of support,

a. The DDS Waiver Specialist will check with the DDS Licensure unit to determine if any incident reports have been filed related to the beneficiary. If incident reports have been filed, a copy will be obtained for the plan-of-care meeting.

b. The DDS Waiver Area Manager will check the Incident Reporting Information System (IRIS) to see if reports have been filed related to the beneficiary. If any reports have been filed on IRIS, a summary will be compiled for the plan-of-care meeting. The summary will include any variances between the submitted reports and those found or not found in the DDS reporting systems.

c. The DDS Waiver Specialist will check the Medicaid Management Information System (MMIS) and all waiver prior authorizations issued and payments for waiver services for the past year. The case manager will be required to justify any under-utilization.

3. If the request packet is not complete, it will not be accepted. Retroactive approval will not be granted on pervasive level of support although emergency approval, pending receipt of required documents and determination, may be obtained from the Assistant Director of Adult and Waiver Services. Emergency requests may be made via secure e-mail. For emergency requests, all the required documentation listed in this rule must be submitted within two working days. If the documentation does not support there was an emergency, the emergency approval will be suspended or rescinded.

4. If the Person-Centered Service Plan Review Team cannot make a decision on pervasive level of support and needs additional information, they will request assistance from the DDS Psychological Team.

5. If assistance is requested from the DDS Psychological Team, they will convene within five working days following the Person-Centered Service Plan Team meeting.

6. If the Person-Centered Service Plan Review Team requires additional information based on incident reports or IRIS summaries, the timeframe for approving pervasive level of support will start over.

7. All requests for pervasive level of support will be reviewed at the weekly Person-Centered Service Plan Review Team meetings.

230.400 Person-Centered Service Plan 9-1-16

During the initial sixty (60) days of DDS ACS waiver services, a beneficiary receives services based on a DDS pre-approved initial person-centered service plan that provides for case management at the prevailing rate, up to sixty (60) days; and supportive living services for direct-care supervision at a rate of $100.00 per month, up to sixty (60) days. It may include transitional funding when the person is transitioning from an institution to the community. Persons residing in a Medicaid-reimbursed facility may receive case management the last 180 consecutive days of the institutional stay.

NOTE: The fully-developed person-centered service plan may be submitted, approved and implemented prior to the expiration of the initial person-centered service plan. The initial plan period is simply the maximum time frame for developing, submitting, obtaining approval from DDS and implementing the person-centered service plan. An extension may be granted when there is supporting documentation justifying the delay.

Prior to expiration of the interim plan of care, each beneficiary eligible for ACS waiver services must have an individualized, specific, written person-centered service plan developed by a multi-agency team and approved by the DDS authority. The members of the team will determine services to be provided, frequency of service provision, number of units of service and cost for those services while ensuring that the beneficiary's desired outcomes, needs and preferences are addressed. Team members and a physician, via the DDS 703 form, certify the beneficiary's condition (level of care) and appropriateness of services initially and at the annual continued-

stay review. The person-centered service plan is conducted once every 12 months in accordance with the continued-stay review date or as changes in the beneficiary's condition require a revision to the person-centered service plan.

The person-centered service plan must be designed to assure that services provided will be:

A. Specific to the beneficiary's unique circumstances and potential for personal growth.

B. Provided in the least restrictive environment possible.

C. Developed within a process assuring participation of those concerned with the beneficiary's welfare. Participants of the multi-agency team included the beneficiary's chosen case manager, the beneficiary or legal representative and additional persons whom the beneficiary chooses to invite to the planning meeting, as long as all rules pertaining to confidentiality and conflict of interest are met. If invited, the DDS Waiver Specialist attends the planning meetings randomly, in an effort to assure an annual 10% attendance ratio. If invited, the DDS Waiver Specialist must attend all planning meetings if the beneficiary is believed to be eligible for the pervasive level of support. Mandatory attendance by the case manager is required to assure the written person-centered service plan meets the requirements of regulations, the desires of the beneficiary or legal representative, is submitted timely, and is approved by DDS prior to service delivery.

D. Monitored and adjusted to reflect changes in the beneficiary's needs. A person-centered service plan revision may be requested at any time the beneficiary's needs change.

E. Provided within a system which safeguards the beneficiary's rights.

F. Documented carefully, with assurance that appropriate records will be maintained.

G. Will assure the beneficiary's and others' health and safety. The person-centered service plan development process identifies risks and makes sure that they are addressed through backup plans and risk management agreements. A complete description of backup arrangements must be included in the person-centered service plan.

230.410 Person-Centered Service Plan Required Documentation 9-1-16

A. General Information Identification information must include:

1. Beneficiary's full name and address

2. Beneficiary's Medicaid number

3. Guardian or Power of Attorney with an address (when applicable)

4. Number of individuals with IID residing in home of waiver beneficiary and type of residence.

5. Physician Level-of-Care Certification

6. Names, titles and signatures of the multi-agency team members responsible for the development of the beneficiary's person-centered service plan.

B. Budget Sheet, Worksheets and Provider Information Information must include:

1. Identification of the type of waiver services to be provided

2. The name of the provider delivering the service

3. Total amount by service.

4. Total plan amount authorized

5. Beginning and ending date for each service

6. Supported Living Array worksheet listing units and total cost by service and level of support

7. Adaptive Equipment, Environmental Modifications, Specialized Medical Supplies, Supplemental Support, and Community Transition worksheets listing units and total cost by service

8. Provider Information sheet showing case management provider, case manager, supportive living provider, and direct-care supervisor.

C. Narrative justification for the revision to the initial person-centered service plan must, at a minimum justify the need for requested services. Narrative justification for annual continued-stay reviews must address utilization of services used or unused within the past year, justify new services requested and address risk assessment.

D. The person-centered service plan must include:

1. Identification of individual objectives.

2. Frequency of review of the objectives.

3. List of medical and other services, including waiver and non-waiver services necessary to obtain expected objectives.

4. Expected outcomes including any service barriers

E. Product and service cost-effectiveness certification statement, with supporting documentation, certifying that products, goods and services to be purchased meet applicable codes and standards and are cost-competitive for comparable quality.

241.000 Approval Authority 9-1-16

For the purpose of person-centered service plan approvals, DDS is the Medicaid authority.

A. The DDS prior authorization process requires that all pervasive level of support service plans, problematic service plans, or plans not clearly based on documented need must have approval by the DDS Person-Centered Service Plan Review Team.

1. Problematic is based on individual circumstances, a change in condition, or a new service request as determined by the DDS Waiver Specialist or by request of the case manager.

2. The DDS Person-Centered Service Plan Review Team consists of the DDS Waiver Program director or designee, DDS Waiver Area Managers, DDS Psychology Team member and other expert professionals such as nurses, physicians or therapists. The DDS Waiver Specialist is responsible for presenting the case to the team. The waiver participant or legal representative is permitted to attend the meeting and present supporting evidence why the services requested should be approved, as long as all rules pertaining to confidentiality and conflict of interest are met.

3. The DDS Waiver Specialist must conduct an in-home visit for all pervasive level of support requests and may conduct an in-home visit for problematic service plans or plans that are not based on documented needed. Failure of the beneficiary or legal representative to permit DDS from conducting the in-home visit may result in the denial of service request and may result in case closure.

B. All extensive and limited service plans will be subject to a local-level approval process.

C. All waiver services must be needed to prevent institutionalization.

D. All beneficiaries receiving medications must also receive appropriate support in the management of medication(s). The use of psychotropic medications for behavior will require the development, implementation and monitoring of a written positive behavior plan.

E. Service requests that will supplant Department of Education responsibilities WILL NOT be approved. This includes voluntary decisions to withdraw from, or never enter the Department of Education, public school system. The waiver does not provide educational services, including educational materials, equipment, supplies or aids.

F. All person-centered service plans are subject to review by a qualified physician and random audit scrutiny by DDS Specialists, DDS Area Managers, DDS Licensure staff or DMS Quality Assurance staff. In addition, the following activities will occur:

1. Review of provider standards and actions that provide for the assurance of a person's health and welfare

2. Monitoring of compliance with standards for any state licensure or certification requirement for persons furnishing services provided under this waiver

3. Assurance that the requirements are met on the date that the service is furnished

4. Quality assurance reviews by DDS staff include announced and unannounced quarterly on-site home visits.

5. Random review equal to a percent as prescribed by DDS Licensure Unit's certification policy

G. All service requests are subject to review by DDS and may necessitate the gathering and submission of additional justification, information and clarification before prior approval is made. In this event, it is the primary responsibility of the case management provider, with cooperation from the procurement source, to satisfy the request(s) within the prescribed time frames.

H. It is the responsibility of the case management services provider with cooperation from the direct services providers to ensure that all requests for services are submitted in a timely manner to allow for DDS prior authorization activities prior to the expiration of existing plans or expected implementation of revisions.

I. Initially, a beneficiary receives up to three months of DDS ACS waiver services based on a DDS pre-approved interim person-centered service plan. The pre-approved interim plan will include case management and supportive living service for direct-care supervision and may include community transition services when the person is transitioning from an institution to the community. For transitional case management, the 60-day interim plan begins with the date of discharge.

1. At any time during the initial 60 days or transitional case management period, the case manager will complete the planning process and submit a detailed person-centered service plan that identifies all needed, medically necessary services for the remainder of the plan of care year. Once approval is obtained, these services may be implemented.

2. Waiver services will not be reimbursed for any date of service that occurs prior to the date the beneficiary's person-centered service plan is approved, the date the beneficiary is determined to be ICF/IID eligible, or the date the beneficiary is deemed Medicaid waiver eligible, whichever date is last.

3. All changes of service or level of support revisions must have prior authorization. Services that are not prior authorized will not be reimbursed.

J. Emergency approvals may be obtained via telephone, facsimile or e-mail, with retroactive reimbursement permitted as long as the notice of emergency, with request for service change, is received by DDS within 24 hours from the time the emergency situation was known. All electronically transmitted requests for emergency services must be followed with written notification and requests must be supported with documented proof of emergency. Failure to properly document proof of emergency shall result in approval being rescinded.

016.05.17 Ark. Code R. 001

6/21/2017