10 Colo. Code Regs. § 2505-10-8.515

Current through Register Vol. 47, No. 16, August 25, 2024

Section 10 CCR 2505-10-8.515 - [Repealed effective 9/14/2024] HOME AND COMMUNITY BASED SERVICES FOR PERSONS WITH BRAIN INJURY (HCBS-BI)

8.515.1LEGAL BASIS

The Home and Community-based Services for Persons with Brain Injury (HCBS-BI) program is authorized by waiver of the amount, duration, and scope of services requirements contained in Section 1902(a)(10)(B) of the Social Security Act, 42 U.S.C. Section 1396a(a)(10)(B) (2018). This waiver is granted by the United States Department of Health and Human Services under Section 1915(c) of the Social Security Act, 42 U.S.C. Section 1396n (2018). This regulation is adopted pursuant to the authority in Section 25.5-1-303, C.R.S. and is intended to be consistent with the requirements of the State Administrative Procedures Act, Sections 24-4-101 et seq., C.R.S. and the Home and Community-based Services for Persons with Brain Injury Act, Sections 25.5-6-701 et seq., C.R.S.

8.515.2HCBS-BI WAIVER SERVICES

8.515.2.A SERVICES PROVIDED

1. Adult Day Services

2. Behavioral Programming and Education

3. Consumer Directed Attendant Support Services (CDASS)

4. Counseling Services

5. Day Treatment

6. Electronic Monitoring Services

7. Home Delivered Meals

8. Home Modification

9. Independent Living Skills Training (ILST)

10. Non-Medical Transportation Services

11. Peer Mentorship

12. Personal Care

13. Respite Care

14. Specialized Medical Equipment and Supplies

15. Substance Abuse Counseling

16. Supported Living

17. Transition Setup

18. Transitional Living Program

8.515.2.B DEFINITIONS OF SERVICES

1. Adult Day Services means services as defined at Section 8.491.

2. Behavioral Programming and Education means services as defined at Section 8.516.40.

3. Consumer Directed Attendant Support Services (CDASS) means services as defined at Section 8.510.

4. Counseling Services means services as defined at Section 8.516.50.

5. Day Treatment means services as defined at Section 8.515.80.

6. Electronic Monitoring Services means services as defined at Section 8.488.

7. Home Delivered Meals means services as defined at Section 8.553.

8. Home Modification means services as defined at Section 8.493.

9. Independent Living Skills Training (ILST) means services as defined at Section 8.516.10.

10. Non-Medical Transportation Services means services as defined at Section 8.494.

11. Peer Mentorship means services as defined at Section 8.553.

12. Personal Care means services as defined at Section 8.489.

13. Respite Care means services as defined at Section 8.516.70.

14. Specialized Medical Equipment and Supplies means services as defined at Section 8.515.50.

15. Substance Abuse Counseling means services as defined at Section 8.516.60.

16. Supported Living means services delivered by a community-based residential program that has been certified by the Department to provide the services defined at Section 25.5-6-703(8), C.R.S.

17. Transition Setup means services defined at Section 8.553.

18. Transitional Living Program means services as defined at Section 8.516.30.

8.515.3GENERAL DEFINITIONS

Brain Injury means an injury to the brain of traumatic or acquired origin which results in residual physical, cognitive, emotional, and behavioral difficulties of a non-progressive nature and is limited to the following broad diagnoses found within the most current version of the International Classification of Diseases (ICD) at the time of assessment:

1. Nonpsychotic mental disorders due to brain damage; or

2. Anoxic brain damage; or

3. Compression of the brain; or

4. Toxic encephalopathy; or

5. Subarachnoid and/or intracerebral hemorrhage; or

6. Occlusion and stenosis of precerebral arteries; or

7. Acute, but ill-defined cerebrovascular disease; or

8. Other and ill-defined cerebrovascular disease; or

9. Late effects of cerebrovascular disease; or

10. Fracture of the skull or face; or

11. Concussion resulting in an ongoing need for assistance with activities of daily living; or

12. Cerebral laceration and contusion; or

13. Subarachnoid, subdural, and extradural hemorrhage, following injury; or

14. Other unspecified intracranial hemorrhage following injury; or

15. Intracranial injury; or

16. Late effects of musculoskeletal and connective tissue injuries; or

17. Late effects of injuries to the nervous system; or

18. Unspecified injuries to the head resulting in ongoing need for assistance with activities of daily living.

Case Management Agency means the agency designated by the Department to provide the Single Entry Point Functions detailed at Section 8.393.

Individual Cost Containment Amount means the average cost of services for a comparable population institutionalized at the appropriate level of care, as determined annually by the Department.

Person-Centered Support Plan means as defined in Section 8.390.1 DEFINITIONS.

8.515.4SCOPE AND PURPOSE

The HCBS-BI program provides those services listed at Section 8.515.2.A to eligible individuals with brain injury that require long-term supports and services in order to remain in a community-based setting.

8.515.5ELIGIBLE PERSONS

HCBS-BI program enrollment and services shall be offered only to individuals determined by the Department or its agent to have met all eligibility requirements in this Section 8.515.5.

8.515.5.A LEVEL OF CARE

Eligible individuals shall be determined by the Department or its agent to require one of the following levels of care:

1. Hospital Level of Care as evidenced by:

a. The individual shall have been:

i. Referred to the Case Management Agency while receiving inpatient care in an acute care or rehabilitation hospital for the treatment of the individual's brain injury; or

ii. Determined by the Department or its agent to have require a hospital level of care as determined using the Department prescribed LOC Screen.

c. The individual shall require goal-oriented therapy with medical management by a physician; and

d. The individual cannot be therapeutically managed in a community-based setting without significant supervision and structure, specialized therapy, and support services.

2. Nursing Facility Level of Care as evidenced by all the following:

a. The individual shall have been determined by the Department or its agent to require nursing facility level of care as determined using the Department prescribed LOC Screen.

b. The individual shall require long-term support services at a level comparable to those services typically provided in a nursing facility.

8.515.5.B TARGET GROUP

Eligible individuals shall be determined by the Department or its agent to meet all the following target group criteria:

1. The individual shall have a diagnosis of Brain Injury. This diagnosis must be documented on the individual's Professional Medical Information Page (PMIP) and the LOC Screen.

2. Age Limit a. Individuals enrolled in the Brain Injury waiver shall be aged 16 years and older and shall have sustained the brain injury prior to the age of 65.

8.515.5.C FINANCIAL ELIGIBILITY

Individuals must meet the financial requirements for long-term care medical assistance eligibility specified at Section 8.100.7.

8.515.5.D NEED FOR HCBS-BI SERVICES

1. Only Clients that currently receive HCBS-BI services, or that have agreed to accept HCBS-BI services as soon as all other eligibility criteria have been met, are eligible for the HCBS-BI program.

a. Case management is provided as an administrative function, not an HCBS-BI service, and shall not be used to satisfy this requirement.

b. The desire or need for any Medicaid services other than HCBS-BI services, as listed at Section 8.515.1, shall not satisfy this eligibility requirement.

2. Clients that have not received an HCBS-BI service for a period greater than 30 consecutive days shall be discontinued from the program.

8.515.5.E EXCLUSIONS FROM ELIGIBILITY

1. Individuals who are residents of nursing facilities, hospitals, or other institutional settings are not eligible to receive HCBS-BI services.

2. HCBS-BI Clients that enter a nursing facility or hospital may not receive HCBS-BI services while admitted to the nursing facility or hospital.

a. HCBS-BI Clients admitted to a nursing facility or hospital for 30 consecutive days or longer shall be discontinued from the HCBS-BI program.

b. HCBS-BI Clients entering a nursing facility for Respite Care as an HCBS-BI service shall not be discontinued from the HCBS-BI program.

8.515.5.F COST CONTAINMENT AND SERVICE ADEQUACY OF SERVICES

1. The Client shall not be eligible for the HCBS-BI program if the case manager determines any of the following during the initial assessment and service planning process:

a. The Client's needs cannot be met within the Individual Cost Containment Amount.

b. The Client's needs are more extensive than HCBS-BI program services are able to support and/or that the Client's health and safety cannot be assured in a community setting.

2. The Client shall not be eligible for the HCBS-BI program at reassessment if the case manager determines the Client's needs are more extensive than HCBS-BI program services are able to support and/or that the Client's health and safety cannot be assured in a community setting.

3. If the case manager determines that the Client's needs are more extensive than the HCBS-BI services are able to support and/or that the Client's health and safety cannot be assured in a community setting, the case manager must document:

a. The results of an Adult Protective Services assessment;

b. A statement from the Client's physician attesting to the Client's mental competency status; and

c. Any other documentation necessary to support the determination

4. The Client may be eligible for the HCBS-BI program at reassessment if the case manager determines that HCBS-BI program services are able to support the Client's needs and the Client's health and safety can be assured in a community setting.

a. If the case manager expects that the services required to support the Client's needs will exceed the Individual Cost Containment Amount, the Department or its agent will review the service plan to determine if the Client's request for services is appropriate and justifiable based on the Client's condition.

i. The Client may request of the case manager that existing services remain intact during this review process.

ii. In the event that the request for services is denied by the Department or its agent, the case manager shall provide the Client with:

1) The Client's appeal rights pursuant to Section 8.057; and

2) Alternative options to meet the Client's needs that may include, but are not limited to, nursing facility placement.

8.515.6START DATE FOR SERVICES

8.515.6.A. The start date of eligibility for HCBS-BI services shall not precede the date that all of the requirements in Section 8.515.5 have been met. The first date for which HCBS-BI services may be reimbursed shall be the later the following:

1. The date at which financial eligibility is effective.

2. The date at which the Department or its agent has made a Level of Care Determination that the Client has met all level of care eligibility requirements at Section 8.515.5.

3. The date at which the Client agrees to accept services and signs all necessary intake and Person-Centered Support Planning forms.

4. The date of discharge from an institutional setting.

8.515.7PRIOR AUTHORIZATION OF SERVICES

8.515.7.A. All HCBS-BI services must be prior authorized by the Department or its agent.

8.515.7.B. The Department shall develop the Prior Authorization Request (PAR) form to be used by case managers in compliance with all applicable regulations.

8.515.7.C. The Department or its agent shall determine if the services requested are:

1. Consistent with the Client's documented medical condition and functional capacity;

2. Reasonable in amount, scope, frequency, and duration;

3. Not duplicative of the other services or supports included in the Client's PCSP;

4. Not for services for which the Client is receiving funds to purchase; and

5. Do not total more than 24 hours per day of care.

8.515.7.D. Revisions to the PAR that are requested six months or more after the end date shall be disapproved.

8.515.7.E. Approval of the PAR by the Department or its agent shall authorize providers of HCBS-BI services to submit claims to the fiscal agent and to receive payment for authorized services provided during the period of time covered by the PAR.

1. Payment for HCBS-BI services is also conditional upon:

a. The Client's eligibility for HCBS-BI services;

b. The provider's certification status; and

c. The submission of claims in accordance with proper billing procedures.

8.515.7.F. The prior authorization of services does not constitute an entitlement to those services.

All services provided and reimbursed must be delivered in accordance with regulation and be necessary to meet the Client's needs.

8.515.7.G. Services requested on the PAR shall be supported by information on the PCSP and the LOC Screen.

8.515.7.H. The PAR start date shall not precede the start date of HCBS-BI eligibility in accordance with Section 8.515.6.

8.515.7.I. The PAR end date shall not exceed the end date of the HCBS-BI eligibility certification period.

8.515.8WAITING LIST

8.515.8.A. Persons determined eligible for HCBS-BI services that cannot be served within the capacity limits of the HCBS-BI waiver shall be eligible for placement on a waiting list.

1. The waiting list shall be maintained by the Department.

2. The date used to establish the person's placement on the waiting list shall be the date on which all other eligibility requirements at Section 8.515.5 were determined to have been met and the HCBS-BI Program Administrator was notified.

3. As openings become available within the capacity limits of the federal waiver, persons shall be considered for services based on the date of their waiting list placement.

8.515.9CASE MANAGEMENT FUNCTIONS

The requirements at Section 8.393 shall apply to the Case Management Agencies performing the case management functions of the HCBS-BI program.

8.515.10PROVIDER AGENCIES

HCBS-BI providers shall abide by all general certification standards, conditions, and processes established at Section 8.487.

8.515.50ASSISTIVE AND SPECIAL MEDICAL EQUIPMENT

A. DEFINITIONS

Specialized medical equipment and supplies includes devices controls, or appliances specified in the plan of care, which enable recipients to increase their abilities to perform activities of daily living, or to perceive, control, or communicate with the environment in which they live.

Assistive Devices include equipment which meets one of the following criteria:

1. Is useful in augmenting an individual's ability to function at a higher level of independence and lessen the number of direct human service hours required to maintain independence;

2. Is necessary to ensure the health, welfare and safety of the individual;

3. Enables the individual to secure help in the event of an emergency;

4. Is used to provide reminders to the individual of medical appointments, treatments, or medication schedules; or

5. Is required because of the individual's illness impairment or disability, as documented on the screening assessment form and the plan of can.

B. INCLUSIONS

1. Items necessary for life support, ancillary supplies, and equipment necessary to the proper functioning of such items, and durable and non-durable medical equipment not available under the Medicaid State Plan.

2. Items which are not of direct medical or remedial benefit to the recipient are excluded.

3. Assistive devices to augment cognitive processes, "cognitive-orthotics" or memory prostheses are included in this service area. Examples of cognitive orthotic devices include informational data bases, spell checkers, text outlining programs, timing devices, security systems, car finders, sounding devices, cuing watches, telememo watches, paging systems, electronic monitoring, tape recorders, electronic checkbooks, electronic medication monitors, and memory telephone.

C. CERTIFICATION REQUIREMENTS

Certification standards refer to both the supplier of equipment as well as the actual product or equipment itself.

1. All items shall meet applicable standards of manufacture, design and installation.

2. All equipment materials or appliances used as pan of monitoring systems shall carry a UL (Underwriter's Laboratory) number or an equivalent standard.

3. All telecommunications equipment shall be FCC registered.

4. All equipment materials, or appliances shall be installed by properly trained individuals, and the installer shall train the Client in the use of the device.

5. All equipment, materials or appliances shall be tested fir proper functioning at the time of installation and at periodic intervals thereafter by a properly trained individual.

6. Any malfunction shall be promptly repaired by a properly trained technician supplied at the provider agency's expense. Equipment shall be replaced when necessary, including buttons and batteries.

7. Assistive equipment providers shall send written information to each Client's case manager about the item, how it works, and how it should be maintained.

D. REIMBURSEMENT METHOD FOR ASSISTTVE DEVICES

Reimbursement for assistive devices will be on a per unit basis. If assistive devices are to be used primarily in a vocational application, devices should be funded through the Division of Vocational Rehabilitation with secondary funding from Medicaid.

8.515.70ADULT DAY SERVICES

A. DEFINITIONS

1.Adult Day Services means both health and social services furnished on a regularly scheduled basis in an Adult Day Services center two or more hours per day, one or more days per week to ensure the optimal functioning of the client Services are directed towards recreation and socialization as well as maintaining a safe and supportive environment. A participant can receive either Center-Based ADS, Non-Center-Based ADS, or a combination of Center-Based ADS and Non-Center-Based ADS within the same week.

a.Adult Day Services provider means a non-institutional entity that conforms to requirements for maintenance model.

b.Center-Based Adult Day Services are services provided in a certified ADS Center.

c.Non-Center-Based Adult Day Services are services that may be provided outside of the certified ADS Center, where participants can engage in activities and community life, either in-person or through virtual means.

d.Telehealth Adult Day Services are provided through virtual means in a group or on an individual basis. Telehealth ADS are ways for participants to engage in activities, with their community, and connect to staff and other ADS participants virtually or over the phone, only if a participant does not have access or the ability to use video chat technology. Services provided through Telehealth are not required to provide nutrition services.

e. Maintenance Model means services in health monitoring and individual and group therapeutic and psychological activities which serve as an alternative to long-term nursing home care.

2. Adult Day Services include:

a. Daily monitoring to assure that clients are maintaining personal hygiene and participating in age appropriate social activities as prescribed; and assisting with activities prescribed; and assisting with activities of daily living (e.g., eating, dressing).

b. Emergency services including whiten procedures to meet medical crises.

c. Assistance in the development of self-care capabilities personal hygiene, and social support services.

d. Provision of nutritional needs appropriate to the hours in which the client is served. Nutrition services are not required during the delivery of Telehealth ADS.

e. Nursing services as necessary to supervise medication regimen of trained medication aides and carry out any of the services listed as SKILLED CARE in SECTION 8.489.30.

f. Social and recreational services as prescribed to meet the client's needs.

g. Documentation specifically stating the types of services and monitoring that were provided when services are provided via Telehealth, ensuring the integrity of the service provided and the benefit that service provides the participant.

B. CERTIFICATION STANDARDS

All Adult Day Service providers shall conform to all of the following Departmental standards

1. All providers must conform to all established departmental standards in the general certification standards section.

2. All providers of Adult Day Services shall operate in full compliance with all applicable federal, state and local fire, health, safety, sanitation and other standards prescribed in law or regulation.

3. The Adult Day Service Center shall provide a clean environment, free of obstacle; that could pose a hazard to client health and safety.

4. Adult Day Service Centers shall provide lockers or a safe place for clients' personal items.

5. Adult Day Service Centers shall provide recreational areas and activities appropriate to the number and needs of the recipients.

6. Adult Day Service Centers shall have drinking facilities located within easy access to clients.

7. Adult Day Service Centers shall provide eating and resting areas consistent with the number and needs of the clients being served.

8. Adult Day Service Centers shall provide easily accessible toilet facilities, hand washing facilities and paper towel dispensers.

9. The center shall be accessible to clients with supportive devices for ambulation or who an in wheelchairs.

C. RECORDS AND INFORMATION

Adult Day Service providers shall keep such records and information necessary to document the services provided to clients receiving Adult Day Services. Medical Information Records shall include but not be limited to:

1. Medications the client is taking and whether they are being self-administered.

2. Special dietary needs, if any.

3. Restrictions on activities identified by physician in the case plan.

D. STAFFING

All Adult Day Service providers shall have staff who have been trained in current cardiopulmonary resuscitation, seizure prophylaxis and control and brain injury. Adequate staff shall available at all times to ensure:

1. Supervision of clients at all times during the operating hours of the program.

2. Immediate response to emergency situations to assure the welfare of clients.

3. Provision of prescribed recreational and social activities.

4. Provision of administrative, recreational, social and supportive functions of the Adult Day Services Center.

E. POLICIES

The Adult Day Service provider shall have a written policy relevant to the operation of the Adult Day Services. Such policy shall include but not be limited to statements describing:

1. Admission criteria that qualify clients to be appropriately served by the provider.

2. Interview procedures conducted for qualified clients and/or family members prior to admission to the provider.

3. The meals and nourishments that will be provided, including special diets, at Center-Based ADS.

4. The hours that the clients will be served by the provider and days of the week services will be available.

5. The personal items participants may bring with them to the center.

6. A written signed contract to be drawn up between the client or responsible party and the Center outlining rules and responsibilities of the provider and of the client. Each party of the contract will have a copy.

7. A statement of the center's policy for providing drop-in care or day respite.

F. REIMBURSEMENT METHOD FOR ADULT DAY SERVICES

1. Reimbursement information for BI ADS is outlined in Section 8.491.5.B.

F. EXCLUSIONS

1. The delivery of a meal, workbook, activity packet, etc. does not constitute rendered ADS and therefore are not reimbursable, unless in-person ADS service was provided in addition to the delivery of food or item.

8.515.80DAY TREATMENT

A. DEFINITION

Day Treatment means intensive therapeutic services scheduled on a regular basis for two or more hours per day, one or more days per week directed at the ongoing development of community living skills. Services take place in a non-residential setting separate from the home in which the recipient lives.

B. PROGRAM COMPONENTS, POLICIES AND PROCEDURES

1. Treatment plans are coordinated by a comprehensive interdisciplinary team which includes the recipient and his/her family and provides for consolidation of services in one location.

2. Professional services including occupational therapy, physical therapy, speech therapy, vocational counseling, nursing, social work, recreational therapy, case management, and neuropsychology should be directly available from the provider or available as contracted services when deemed medically necessary by the treatment plan.

3. Certified occupational therapy aides, physical therapy aides, and communication aides may be used in lieu of direct therapy with fully licensed therapists to the extent allowed in existing state statue.

4. The provider shall network with all allied medical professionals and other community-based resource providers.

5. Services include social skills training, sensory motor development, reduction/elimination of maladaptive behavior and services aimed at preparing the individual for community reintegration (reaching concepts such as compliance, attending, task completion, problem solving, safety, money management).

6. Crisis situations with family, Client or staff shall be addressed through counseling and referral to appropriate professionals.

7. Behavioral programs shall contain specific guidelines on treatment parameters and methods.

8. There shall be regular contact and meetings with the Clients and their families to discuss treatment plan progress and revision.

9. Discharge planning will include the development of a plan which considers safety, environmental modification to support individual function, education of the family and caregiver, recommendations for the future, and referral to additional community resources.

10. Each entity must have a process, verified in writing, by which a Client is made aware of the process for filing a grievance.

11. Complaints by the Client or family are handled within a 24-hour period from the time of complaint by at least telephone contact.

12. Transportation between therapeutic tasks in the community shall be included in the per diem cost of day treatment.

13. There shall be an inform and consent mechanism by which the Client, family medical proxy or substitute decision maker is made aware of the inherent risks associated with community-based rehabilitation programs. Examples of such risks might include a greater likelihood of falling accidents, traffic hazards and access to drugs or alcohol.

C. HUMAN RIGHTS

Every person receiving HCBS-BI services has the following rights:

1. Every person shall mutually develop and sign their treatment plan.

2. Every person has the right to enjoy freedom of thought, conscience, and religion.

3. Every person has the right to live in a clean, safe environment.

4. Every person has the right to have his or her opinions heard and be included, to the greatest extent possible when any decisions are being made affecting his or her life.

5. Every person has the right to be free from physical abuse and inhumane treatment.

6. Every person has the right to be protected from all forms of sexual exploitation.

7. Every person has the right to access necessary medical care which is adequate and appropriate to their condition.

8. Every person has the right to communicate with significant others.

9. Every person has the right to reasonable enjoyment of privacy in personal conversations.

10. Every person has the right to have access to telephones, both to make and receive calls in privacy.

11. Every person has the right to have frequent and convenient opportunities to meet with visitors.

12. Every person has the right to the same consideration and treatment as anyone else regardless of race, color, national origin, religion, age, sex, political affiliation, sexual orientation, financial status, or disability.

13. Every person who acts as his own legal guardian has the right to accept treatment of his/her own free will.

14. Nothing in this pan shall be construed to prohibit necessary assistance as appropriate, to those individuals who may require such assistance to exercise their rights.

15. Every person has the right to be free of physical restraint unless physical intervention is necessary to prevent such body movement that is likely to result in imminent injury to self or others, and only if alternative techniques have failed. Mechanical restraints are not allowed.

D. DOCUMENTATION

1. Intake information shall include a complete neuropsychological assessment and all pertinent medical documentation from inpatient and outpatient therapy and social history to identify key treatment components and communicate the functional implications of treatment goals.

2. Initial treatment plan development and evaluations will occur within a two-week period following admission.

3. Treatment plan goals and objectives shall reference specific outcomes in the degree of personal and living independence, work productivity, and psychological and social adjustment, quality of life and degree of community participation.

4. Specific treatment modalities outlined in the treatment plan shall be systematically implemented with techniques that are consistent, functionally based, and active throughout the day. Treatment methods will be appropriate to the goals and treatment plans will be reviewed and modified as appropriate.

5. Progress notes will be kept to document specific treatment modalities rendered by date and signed by the therapist providing the service.

E. CERTIFICATION STANDARDS

1. Directors of day treatment programs shall have professional licensure in a health-related program in combination with at least 2 years of experience in head trauma rehabilitation programming.

2. All providers shall operate in full compliance with all applicable federal, state and local fire, health, safety, sanitation and other standards prescribed in law or regulation.

3. The agency shall provide a clean environment, free of obstacles that could pose a hazard to Client health and safety.

4. Agencies shall provide lockers or a safe place for Clients' personal items.

5. Day treatment centers shall provide age appropriate activities and provide eating and resting areas consistent with the number and needs of the Clients being served.

6. The center shall be accessible according to guidelines established by the Americans with Disabilities Act.

7. Personnel shall have training appropriate to the medical needs of the Clients served including seizure management training, CPR certification, non-violent crisis intervention, and personal care standards according to SECTION-PERSONAL CARE 8.489.40.

F. REIMBURSEMENT

Day treatment services will be paid on a per diem basis at a rate to be determined by the Department In order for a provider to be paid for a day of treatment, a Client must have attended and received therapeutic intervention which is substantiated by case file notes signed by the rendering therapist

8.515.85SUPPORTIVE LIVING PROGRAM

8.515.85.A DEFINITIONS

1. Activities of Daily Living (ADLs) mean basic self-care activities, including mobility, bathing, toileting, dressing, eating, transferring, support for memory and cognition, and behavioral supervision.

2. Assistance means the use of manual methods to guide or assist with the initiation or completion of voluntary movement or functioning of an individual's body through the use of physical contact by others, except for the purpose of providing physical restraint.

3. Assistive Technology Devices means any item, piece of equipment, or product system that is used to increase, maintain, or improve functional capabilities of individuals with disabilities.

4. Authorized Representative means an individual designated by the Client or the legal guardian, if appropriate, who has the judgment and ability to assist the Client in acquiring and utilizing supports and services.

5. Behavioral Management and Education means services as defined in § 8.516.40.A, and Inclusions as defined at § 8.516.40.B, provided as an individually developed intervention designed to decrease/control the Client's severe maladaptive behaviors which, if not modified, will interfere with the Client's ability to remain integrated in the community.

6. Case Management Agency (CMA) means an agency within a designated service area where an applicant or Client can obtain Case Management services. CMAs include Single Entry Points (SEPs), Community Centered Boards (CCBs), and private case management agencies.

7. Case Manager means an individual employed by a CMA who is qualified to perform the following case management activities: determination of an individual Client's functional eligibility for the Home and Community-based Services - Brain Injury (HCBS-BI) waiver, development and implementation of an individualized and person-centered Service Plan for the Client, coordination and monitoring of HCBS-BI waiver services delivery, evaluation of service effectiveness, and the periodic reassessment of such Client's needs.

8. Critical Incident means an actual or alleged event or situation that creates a significant risk of substantial or serious harm to the health or welfare of a Client that could have, or has had, a negative impact on the mental and/or physical well-being of a Client in the short or long-term. A critical incident includes accidents, a suspicion of, or actual abuse, neglect, or exploitation, and criminal activity.

9. Department means the Department of Health Care Policy and Financing.

10. Health Maintenance Activities means those routine and repetitive health-related tasks which are necessary for health and normal bodily functioning, that an individual with a disability would carry out if he/she were physically able, or that would be carried out by family members or friends if they were available. These activities include, but are not limited to, catheter irrigation, administration of medication, enemas, suppositories, and wound care.

11. Independent Living Skills Training means services designed and directed toward the development and maintenance of the Client's ability to independently sustain himself/herself physically, emotionally, and economically in the community.

12. Instrumental Activities of Daily Living (IADLs) means activities related to independent living, including preparing meals, managing money, shopping for groceries or personal items, performing light or heavy housework and communication.

13. Interdisciplinary Team means a group of people responsible for the implementation of a Client's individualized care plan, which includes the Client receiving services, the parent or guardian of a minor, a guardian or an authorized representative, as appropriate, the person who coordinates the provision of services and supports, and others as determined by the Client's needs and preferences, who are assembled in a cooperative manner to develop or review the person-centered care plan.

14. Personal Care Services includes providing assistance with eating, bathing, dressing, personal hygiene or other activities of daily living. When specified in the service plan, Personal Care Services may also include housekeeping chores such as bed making, dusting, and vacuuming. Housekeeping assistance must be incidental to the care furnished or essential to the health and welfare of the individual rather than for the benefit of the individual's family.

15. Person-Centered Care Plan is a service plan created by a process that is driven by the individual and can also include people chosen by the individual pursuant to 42 C.F.R. § 441.540. It provides necessary information and support to the individual to ensure that the individual directs the process to the maximum extent possible. It documents Client choice, establishes goals, identifies potential risks, assures health and safety, and identifies the services and supports the Client needs to function safely in the community.

16. Protective Oversight is defined as monitoring and guidance of a Client to assure their health, safety, and well-being. Protective oversight includes but is not limited to: monitoring the Client while on the premises, monitoring ingestion and reactions to prescribed medications, if appropriate, reminding the Client to carry out activities of daily living, and facilitating medical and other health appointments. Protective oversight includes the Client's choice and ability to travel and engage independently in the wider community and providing guidance on safe behavior while outside the Supportive Living Program.

17. Room and Board is defined as a comprehensive set of services that include lodging, routine or basic supplies for comfortable living, and nutritional and healthy meals and food for the Client, all of which are provided by the Supportive Living Program provider, and are not included in the per diem.

18. Supportive Living Program (SLP) certification means documentation from the Colorado Department of Public Health and Environment (CDPHE) recommending certification to the Department after the SLP provider has met all licensing requirements found in 6 C.C.R. 1011-1; Chapter 2, and either Chapter 7 or 26, in addition to all requirements in § 8.515.85.

8.515.85.B CLIENT ELIGIBILITY

1. SLP services are available to individuals who meet all of the following requirements:

a. Clients are determined functionally eligible for HCBS-BI waiver by a certified case management agency;

b. Clients are enrolled in the HCBS-BI waiver; and

c. Clients require the specialized services provided under the SLP as determined by assessed need.

2. Person-Centered Care Planning

SLP providers must comply with the Person-Centered Care Planning process. Providers must work with CMAs to ensure coordination of a Client's Person-Centered Care Plan. Additionally, SLP providers must provide the following actionable plans for all HCBS-BI waiver Clients, updated every six (6) months:

a. Transition Planning; and

b. Goal Planning.

These elements of a Person-Centered Care Plan are intended to ensure the Client actively engages in his or her care and activities, as is able to transition to any other type of setting or service at any given time.

3. Exclusions

The following are not included as components of the SLP:

a. Room and board; and

b. Additional services which are available as a State Plan benefit or other HCBS-BI waiver service. Examples include, but are not limited to physician visits, mental health counseling, substance abuse counseling, specialized medical equipment and supplies, physical therapy, occupational therapy, long-term home health, and private duty nursing.

8.515.85.C SUPPORTIVE LIVING PROGRAM INCLUSIONS

1. SLP services consist of structured services designed to provide:

a. Assessment;

b. Protective Oversight and supervision;

c. Behavioral Management and Education;

d. Independent Living Skills Training in a group or individualized setting to support:

i. Interpersonal and social skill development;

ii. Improved household management skills; and

iii. Other skills necessary to support maximum independence, such as financial management, household maintenance, recreational activities and outings, and other skills related to fostering independence;

e. Community Participation;

f. Transportation between therapeutic activities in the community;

g. Activities of Daily Living (ADLs);

h. Personal Care and Homemaker services; and

i. Health Maintenance Activities.

2. Person-Centered Care Planning

a. Transition Planning; and

b. Goal Planning.

3. Exclusions

The following are not included as components of the SLP:

a. Room and board; and

8.515.85.D PROVIDER LICENSING AND CERTIFICATION REQUIREMENTS

1. To be certified as an SLP provider, the entity seeking certification must be licensed by CDPHE as an Assisted Living Residence (ALR) pursuant to 6 CCR 1011-1, Ch. 7, except as provided below.

a. Subject to Department approval, providers that have been in continuous operation at the same address prior to 1987 may continue to furnish SLP services under a Home Care Agency (HCA) license pursuant to 6 CCR 1011-1, Ch. 26 instead of the ALR license.

i. Providers furnishing SLP services under a Department-approved exception are required to comply with this § 8.515.85, regardless of licensure type.

ii. Providers furnishing SLP services under a Department-approved exception are required to comply with the medication administration requirements pursuant to both the HCA licensure requirements found at 6 CCR 1011-1, Chapters 7 and 26, and Section 25-1.5-301 through 304, C.R.S. 6 CCR 1011-1, Ch. 7, Section 14, (2018) is hereby incorporated by reference. The incorporation of this regulation excludes later amendments to, or editions of the referenced material. Pursuant to Section 24-4-103 (12.5), C.R.S. the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 1570 Grant Street, Denver, CO, 80203. Certified copies of incorporated materials are provided at cost upon request. Copies are also available from CDPHE at 4300 Cherry Creek Drive South, Denver, CO 80246.

2. In addition to the requirements of § 8.515.85.D.1, SLP providers must also receive SLP Certification from CDPHE. CDPHE issues or renews a Certification when the provider is in full compliance with the requirements set out in these regulations. Certification is valid for three years from the date of issuance unless CDPHE revokes, suspends, or takes other disciplinary action against the licensee, or the certification is voluntarily relinquished by the provider.

3. No Certification shall be issued or renewed by CDPHE if the owner, applicant, or administrator of the SLP has been convicted of a felony or of a misdemeanor, which felony or misdemeanor involves moral turpitude or involves conduct that the Department determines could pose a risk to the health, safety, or welfare of residents of the assisted living residence.

8.515.85.E PROVIDER RESPONSIBILITIES

SLP providers must follow all person-centered planning initiatives undertaken by the State to ensure Client choice.

8.515.85.F HCBS PROGRAM CRITERIA

1. In accordance with 42 C.F.R. § 441.530, Home and Community-based settings must:

a. Be integrated in and support full access to the greater community;

b. Be selected by the Client from among setting options;

c. Ensure Client rights of privacy, dignity, and respect, and freedom from coercion and restraint;

d. Optimize individual initiative, autonomy, and independence in making life choices;

e. Facilitate Client choice regarding services and supports, and who provides them;

f. Be 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;

g. Ensure privacy in the Client's unit including lockable doors, choice of roommates, and freedom to furnish or decorate the unit;

h. Ensure that Clients have the freedom and support to control their own schedules and activities, and have access to food at any time;

i. Ensure each Client has the right to receive and send packages. No Client's outgoing packages shall be opened, delayed, held, or censored by any person;

j. Ensure each Client has the right to receive and send sealed, unopened correspondence. No Client's incoming or outgoing correspondence shall be opened, delayed, held, or censored by any person;

k. Enable Clients to have visitors of their choosing at any time; and

l. Be physically accessible.

2. Exceptions

The Department may grant exceptions to HCBS Program Criteria listed in § 8.515.85.F.1, a through h, when reasonable, as follows:

a. Requirements of program criteria may be modified if supported by a specific assessed need and justified in the person-centered care plan. The following requirements must be documented in the person-centered care plan:

i. Identify a specific and individualized assessed need.

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

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

iv. Include a clear description of the modification that is directly proportionate to the specific assessed need.

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

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

vii. Include the informed consent of the individual.

viii. Include an assurance that interventions and supports will cause no harm to the individual.

b. HCBS Program Criteria under 8.515.85.F.1.b and e:

i. When a Client chooses to receive HCBS in a provider-owned or controlled setting where the provider is paid a single rate to provide a bundle of services, the Client cannot choose an alternative provider to deliver services that are included in the bundled rate.

ii. For any services that are not included in the bundled rate, the Client may choose any qualified provider, including the provider who controls or owns the setting, if the provider offers the service separate from the bundle.

c. HCBS Program Criteria under 8.515.85.F.1.c:

When a Client needs assistance with challenging behavior, including a Client whose behavior is dangerous to himself, herself, or others, or when the Client engages in behavior that results in significant property destruction, the SLP must create detailed service and support plans that describe how to appropriately address these behaviors.

d. HCBS Program Criteria under 8.515.85.F.1.g:

Requirements for a lockable entrance door may be modified if supported by a specific assessed need and justified in the person-centered service plan.

8.515.85.G STAFFING

1. The SLP provider shall ensure sufficient staffing levels to meet the needs of Clients.

2. The operator, staff, and volunteers who provide direct Client care or protective oversight must be trained in precautions and emergency procedures, including first aid, to ensure the safety of the clientele.

3. The SLP provider shall adhere to regulations at 6 CCR 1011-1, Ch. 7, Sections 6, 7, and 8, (2018) which are hereby incorporated by reference. The incorporation of this regulation excludes later amendments to, or editions of the referenced material. Pursuant to Section 24-4-103 (12.5) C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 1570 Grant Street, Denver, CO, 80203. Certified copies of incorporated materials are provided at cost upon request. Copies are also available from CDPHE at 4300 Cherry Creek Drive South, Denver, CO 80246.

4. Within one month of the date of hire, the SLP provider shall provide adequate training for staff on each of the following topics:

a. Crisis prevention;

b. Identifying and dealing with difficult situations;

c. Cultural competency;

d. Infection control; and

e. Grievance and complaint procedures.

5. Prior to providing direct care, the SLP provider shall provide to the operator, staff, and volunteers an orientation to the location in which the program operates, and adequate training on person-centered care planning.

6. All staff training shall be documented. Copies of person-centered care plan training and related documentation must be submitted to the Department upon request. Prior to any subsequent change in the training curriculum, the provider must submit copies to the Department for review and approval.

7. In addition to the requirements of 6 CCR 1011-1 Ch. 7, the Department requires that the program director shall have an advanced degree in a health or human service related profession plus two years of experience providing direct services to persons with a brain injury. A bachelor's or nursing degree with three years of similar experience, or a combination of education and experience shall be an acceptable substitute.

8. The provider shall employ or contract for behavioral services and skill training services according to Client needs.

9. The SLP shall ensure that provision of services is not dependent upon the use of Clients to perform staff functions. Volunteers may be utilized in the home but shall not be included in the provider's staffing plan in lieu of employees.

10. The SLP provider shall maintain written personnel policies and shall provide a copy of these policies to each staff member upon employment. The administrator or designee shall explain such policies during the initial staff orientation period.

11. The SLP provider shall conduct a criminal background check through the Colorado Bureau of Investigation for all staff, prospective staff, and volunteers. The provider shall not employ any person convicted of an offense that could pose a risk to the health, safety, and welfare of Clients. The provider shall bear all costs related to obtaining a criminal background check.

8.515.85.H CLIENT RIGHTS AND PROPERTY

1. Clients shall have all rights stated in § 8.515.85.F.1.

2. Any provider that chooses to handle Client funds and property must maintain policies and practices for management of Client funds and property that are consistent with those at 6 CCR 1011-1, Ch. 7, Section 11.10.

3. Upon Client request, a Client shall be entitled to receive, and the provider shall promptly deliver, available money or funds held in trust.

8.515.85.I FIRE SAFETY AND EMERGENCY PROCEDURES

1. Applicants for initial provider Certification shall meet the applicable standards of the rules for building, fire, and life safety code enforcement as adopted by DFPC.

a. The Department may grant an exception to this provision for a provider qualified under § 8.515.85.D.1.c, if the provider holds a current certificate of compliance from the local fire authority.

3. Providers shall develop written emergency plans and procedures for fire, serious illness, severe weather, disruption of essential utility services, and missing persons for each Client. Emergency and evacuation procedures shall be consistent with any relevant local and state fire and life safety codes and the provisions set forth in 6 CCR 1011-1 Ch. 7, § 10.

4. Within three (3) days of scheduled work or commencement of volunteer service, the program shall provide adequate training for staff in emergency and fire escape plan procedures.

5. SLP providers must train all staff and Clients on emergency plans and procedures at intervals throughout the year. Providers shall conduct fire drills at least once every six (6) months, during the evening and overnight hours while Clients are sleeping. All such practices and training shall be documented and reviewed every six (6) months. Such documentation shall include any difficulties encountered and any needed adaptations to the plan. Such adaptations shall be implemented immediately upon identification.

8.515.85.J ENVIRONMENTAL AND MAINTENANCE REQUIREMENTS

1. The SLP provider shall adhere to regulations at 6 CCR 1011-1, Ch. 7, Sections 15,16, 17, and 19, (2018) which are hereby incorporated by reference. The incorporation of this regulation excludes later amendments to, or editions of the referenced material. Pursuant to Section 24-4-103 (12.5), C.R.S. the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 1570 Grant Street, Denver, CO, 80203. Certified copies of incorporated materials are provided at cost upon request. Copies are also available from CDPHE at 4300 Cherry Creek Drive South, Denver, CO 80246.

2. The interior and exterior environment of the SLP residence shall adhere to regulations at 6 CCR 1011-1, Ch. 7, Sections 20, 21, 22, 23, and 24, (2018) which are hereby incorporated by reference. The incorporation of this regulation excludes later amendments to, or editions of the referenced material. Pursuant to Section 24-4-103 (12.5), C.R.S. the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 1570 Grant Street, Denver, CO, 80203. Certified copies of incorporated materials are provided at cost upon request. Copies are also available from CDPHE at 4300 Cherry Creek Drive South, Denver, CO 80246.

3. Clients shall be allowed free use of all common living areas within the residence, with due regard for privacy, personal possessions, and safety of Clients.

4. SLP providers shall develop and implement procedures for the following:

a. Handling of soiled linen and clothing;

b. Storing personal care items;

c. General cleaning to minimize the spread of pathogenic organisms; and

d. Keeping the home free from offensive odors and accumulations of dirt and garbage.

5. The SLP provider shall ensure that each Client is furnished with his or her own personal hygiene and care items. These items are to be considered basic in meeting an individual's needs for hygiene and remaining healthy. Any additional items may be selected and purchased by the Client at their discretion.

6. There shall be adequate bathroom facilities for individuals to access without undue waiting or burden.

7. Each Client shall have access to telephones, both to make and to receive calls in privacy.

8.515.85.K COMPLAINTS AND GRIEVANCES

Each Client will have the right to voice grievances and recommend changes in policies and services to both the Department and/or the SLP provider. Complaints and grievances made to the Department shall be made in accordance with the grievance and appeal process in § 8.209.

8.515.85.M RECORDS

1. The SLP provider shall adhere to regulations at 6 CCR 1011-1, Ch. 7, Section 18, (2018) which are hereby incorporated by reference. The incorporation of this regulation excludes later amendments to, or editions of the referenced material. Pursuant to Section 24-4-103 (12.5), C.R.S. the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 1570 Grant Street, Denver, CO, 80203. Certified copies of incorporated materials are provided at cost upon request. Copies are also available from CDPHE at 4300 Cherry Creek Drive South, Denver, CO 80246.

2. Supportive Living Providers shall develop policies and procedures to secure Client information against potential identity theft. Confidentiality of medical records shall be maintained in compliance with 45 C.F.R. § 160.101, et seq.

3. All medical records for adults (persons eighteen (18) years of age or older) shall be retained for no less than six (6) years after the last date of service or discharge from the SLP. All medical records for minors shall be retained after the last date of service or discharge from the SLP for the period of minority plus six (6) years.

8.515.85.N REIMBURSEMENT

1. SLP services shall be reimbursed according to a per diem rate, using a methodology determined by the Department.

2. The methodology for calculating the per diem rate shall be based on a weighted average of Client acuity scores.

3. The Department shall establish a maximum allowable room and board charge for Clients in the SLP. Increases in payment shall be permitted in a dollar-for-dollar relationship to any increase in the Supplemental Security Income grant standard if the Colorado Department of Human Services also raises grant amounts.

a. Room and board shall not be a benefit of HCBS-BI residential services. Clients shall be responsible for room and board in an amount not to exceed the Department-established rate.

8.515.85.O POST-ELIGIBILITY TREATMENT OF INCOME (PETI)

1. Definition a. Post Eligibility Treatment of Income (PETI) means the calculation used to determine the member's obligation (payment) for the payment of services.

2. Post-Eligibility Treatment of Income Application

a. When a member has been determined eligible for Home and Community Based Services (HCBS) under the 300% income standard, according to Section 8.100, the Department may reduce Medicaid payment for Supported Living Program services according to the procedures at Section 8.515.85.C

b. PETI is required for Medicaid members residing in Supported Living Programs under the Home and Community Based Services (HCBS) Brain Injury (BI) waiver

3. Case Management Responsibilities

a. For 300% eligible members who reside in a Supported Living Program (SLP), the case manager shall complete a State-prescribed form which calculates the member payment according to the following procedures:

i. The member's Total Gross Monthly Income is determined by adding the Gross Monthly Income to the Gross Monthly Long-Term Care (LTC) Insurance amount.

ii. The member's Room and Board amount shall be deducted from the gross income and paid to the provider

iii. The member's Personal Needs Allowance (PNA) amount is based upon a members gross income, up to the maximum amount set by the Department. For an individual with financial responsibility for only a spouse, the amount protected under Spousal Protection as defined in Section 8.100.7 K shall be deducted from the member's gross income.

iv. If the individual is financially responsible for a spouse plus other dependents, or with financial responsibility for other dependents only, an amount equal to the appropriate Temporary Assistance to Needy Families (TANF) grant level less any income of the spouse and/or dependents (excluding income from part-time employment earnings of a dependent child, as defined at Section 8.100.1, who is either a full-time student or a part-time student§) shall be deducted from the member's gross income.

v. Amounts for incurred expenses for medical or remedial care for the member that are not covered by Medicare, Medicaid, or other third party shall be deducted from the member's gross income as follows:

a) Health insurance premiums, deductibles and co-insurance charges if health insurance coverage is documented.

b) Necessary dental care not to exceed amounts equal to actual expenses incurred.

c) Vision and auditory care expenses not to exceed amounts equal to actual expenses incurred.

d) Medications, with the following limitations:

1) The member has a prescription for the medication

2) Medications which may be purchased through regular Medicaid prior authorization procedures shall not be allowed.

3) The full cost of brand-name medications shall not be allowed if a generic form is available at a lower price.

vii. Other necessary medical or remedial care shall be deducted from the member's gross income, with the following limitations:

a) The need for such care shall be documented in writing by the attending physician. The documentation shall list the service, supply, or equipment; state why it is medically necessary; be signed by the physician; and, shall be renewed at least annually or whenever there is a change.

b) Any service, supply or equipment that is available under regular Medicaid, with or without prior authorization, shall not be allowed as a deduction.

c) Deductions for medical and remedial care may be allowed up to the end of the next full month while the physician's prescription is being obtained. If the physician's prescription cannot be obtained by the end of the next full month, the deduction shall be discontinued.

d) When the case manager cannot immediately determine whether a particular medical or remedial service, supply, equipment or medication is a benefit of Medicaid, the deduction may be allowed up to the end of the next full month while the case manager determines whether such deduction is a benefit of the Medicaid program. If it is determined that the service, supply, equipment or medication is a benefit of Medicaid, the deduction shall be discontinued.

viii. Verifiable Federal and State tax liabilities shall be an allowable deduction up to $300 per month from the member's gross income.

xi. Any remaining income shall be applied to the cost of the SLP services, as described at Section 8.515.85.C, and shall be paid by the member directly to the provider.

x. If there is still income remaining after the entire cost of Supported Living Program services are paid from the member's income, the remaining income shall be kept by the member and may be used at the member's discretion.

b. Case managers shall inform HCBSSLP service members of their payment obligations in a manner prescribed by the Department at the beginning of each support plan year and whenever there is a significant change to their payment obligation.

i. Significant change is defined as fifty dollars ($50) or more.

c. Copies of member payment forms shall be kept in the member files at the case management agency. A copy of the form may be requested by the Department for monitoring purposes.

10 CCR 2505-10-8.515

46 CR 13, July 10, 2023, effective 7/30/2023

46 CR 21, November 10, 2023, effective 11/30/2023

47 CR 16, August 25, 2024, effective 9/14/2024