10 Colo. Code Regs. § 2505-10-8.612

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

Section 10 CCR 2505-10-8.612 - SUPPORTS INTENSITY SCALE ASSESSMENT AND SUPPORT LEVELS

8.612.1Supports Intensity Scale (SIS) Assessment [Eff. 2/1/12]

A. Completion of a Supports Intensity Scale (SIS) Assessment is a requirement for a Client to participate in the Home and Community Based Services-Supported Living Services (HCBS-SLS) or the Home and Community Based Services for Persons with Developmental Disabilities (HCBS-DD) waiver. A Client or his or her guardian refusing to have a SIS assessment shall not be enrolled in the HCBS-SLS or HCBS-DD waivers.

B. Specific scores from the Client's SIS assessment shall be used in addition to other factors to obtain the Client's Support Level in the HCBS-DD and HCBS-SLS waivers.

C. The Community Centered Board (CCB) shall conduct a SIS assessment for a Client at the time of enrollment. Additional assessments will be conducted at a frequency determined by the Department.

D. The CCB shall:

1. Notify the Client, his or her legal guardian, authorized representative, or family member, as appropriate, of the requirement for and the right to participate in the SIS assessment.

2. Support and encourage the Client to participate in the SIS assessment. If the Client chooses not to participate in the SIS assessment, the CMA shall document his or her choice in the Client record on the Department required data system.

3. Schedule a SIS Interviewer to conduct the assessment. If the Client, his or her legal guardian, authorized representative, or family member, as appropriate, objects to the assigned SIS Interviewer, he or she shall be offered a choice of a different SIS Interviewer.

4. Assist the Client or other interdisciplinary team (IDT) members to identify at least two people who know the Client well enough to act as respondents for the SIS assessment. If at least two respondents cannot be identified, the CMA shall document the efforts to find two respondents and the reasons this could not be done and proceed with the assessment using the information available.

5. Upon Department approval, SIS assessment may be completed by the case manager at an alternate location, via the telephone or using virtual technology methods. Such approval may be granted for situations in which face-to-face meetings would pose a documented safety risk to the case manager or client (e.g. natural disaster, pandemic, etc.).

E. A qualified SIS Interviewer shall conduct the assessment. A SIS Interviewer shall not act as the respondent for a SIS assessment.

F. The CCB shall inform the Client, his or her legal guardian, authorized representative, or family member, as appropriate, of the purpose of the SIS, the SIS Complaint Process, the Support Level Review Process, and that he or she may receive a copy of the completed SIS assessment upon request. The CCB shall document that this information was provided and received on the SIS and Support Level disclosure form.

G. After the initial SIS assessment has been completed, the CMA shall conduct another SIS assessment for the Client only when approved by the Department through the following process:

1. Prior to a subsequent SIS assessment being conducted, the CMA shall submit a request to the Department for approval in the format prescribed by the Department.

2. The Department shall provide the CMA with a written decision regarding the request to conduct another SIS assessment within fifteen (15) business days after the date the request was received.

3. Upon receiving approval to conduct a subsequent SIS the CMA shall contact the designated CCB to request a SIS reassessment.

4. If the Client, his or her legal guardian, authorized representative or family member, as appropriate, disagrees with the decision, then a request for review of the decision may be submitted to the Executive Director of the Department within fifteen (15) business days after the date the decision was received.

5. The Executive Director or his or her designee shall review the request for conducting a SIS reassessment and provide a written decision within fifteen (15) business days.

6. The decision of the Executive Director or his or her designee shall constitute the final agency decision and will be subject to judicial review pursuant to Section 24-4-106, C.R.S.

H. A subsequent SIS assessment shall be conducted only when approved by the Department and when:

1. There has been a change in the Client's life circumstances or condition resulting in a significant change to the amount of services and supports needed to keep the Client safe;

2. The Client or his or her legal guardian, authorized representative, family member or case manager as appropriate, has reason to believe that the results of the most recent SIS assessment do not accurately reflect his or her current support needs; or,

3. The Department deems it necessary to complete a new assessment in order to ensure its accuracy.

I. Administration of the SIS assessments shall be reviewed by the Department for the purpose of quality assurance.

J. When the Department identifies SIS Interviewer practices that result in inaccurate SIS assessments:

1. Remediation efforts may occur to ensure that the SIS Interviewer performs assessments according to Department standards. The SIS Interviewer(s) who conducted the inaccurate SIS assessment(s) may be deemed no longer qualified to conduct SIS assessments.

2. Payments made for the administration of the inaccurate SIS assessments may be recovered through a repayment agreement; by offsetting the amount owed against current and future SIS determination payments; or, by any other appropriate action within the Department's legal authority.

3. The Client shall receive another SIS assessment conducted by a SIS Interviewer designated by the Department.

4. The Client's Support Level and Service Plan Authorization Limit will be adjusted as necessary and effective on the date determined by the Department.

8.612.2SIS Complaint Process [Eff. 2/1/12]

A. The Client, his or her legal guardian, authorized representative, or family member as appropriate, may file a complaint regarding the administration of the SIS assessment up to thirty (30) calendar days after the SIS assessment is conducted.

B. The complaint shall be filed verbally or in writing with the Client's CCB. Additional information to support the complaint may be submitted at that time. If the complaint has been filed verbally the CMA shall document in the Client's record on the Department required data system the time, date and details surrounding the complaint.

C. When the complaint requests that another SIS assessment be completed, the CCB shall submit a request for approval to conduct another SIS assessment, pursuant to the process identified in Section 8.612.1.G.

D. The CCB shall make efforts to resolve the complaint and provide the complainant with a written response within ten (10) business days after receipt of the complaint.

E. When a resolution cannot be reached, the CCB shall inform the complainant that he or she may submit the complaint to the Department within fifteen (15) business days after receipt of the CCB response.

F. The Department shall provide a written response to the complainant within fifteen (15) business days after receipt of the complaint.

8.612.3Support Levels [Eff. 2/1/12]

A. A Client is assigned into one of six Support Levels according to his or her overall support needs and based upon the standardized algorithm for the HCBS-DD or HCBS-SLS waivers. The SIS-A Assessment converts subscale raw scores for each section into standard scores for each section, which are used in the algorithm for support levels. Additional information can be found on the Department's webpage or can be obtained in writing by requesting from the Department.

B. The structure of the algorithm, defined at Section 8.600.4 definitions, includes the following:

1. Algorithm factors:

a. Standard scores from Section 2: Parts A (Home Living Activities), B (Community Living Activities), and E (Health and Safety Activities) (ABE) from the SIS assessment;

b. Total scores from Section 1A: Exceptional medial support needs score from the SIS assessment;

c. Total scores from Section 1B: exceptional behavioral support needs score from the SIS assessment; and,

d. Whether the Client presents as a safety risk, defined at Section 8.600.4 definitions, as follows:

1) In the HCBS-SLS waiver, Public Safety Risk-Convicted.

2) In the HCBS-DD waiver, Public Safety Risk-Convicted/Not Convicted or Extreme Safety Risk to Self.

2. The subgroups in the algorithm table under each support level reflect variations of the intensity of the Client's basic support, medical support and behavioral support needs; no matter which subgroup a Client falls into, he or she is eligible for that support level. The subgroups cluster individuals with similar behavioral and medical support needs within each major group. Additional information can be found on the Department's website or can be obtained in writing by requesting from the Department.

3. Following an assessment of the factors defined above, standard scores for each factor are applied to the algorithm.

The Support Level is determined when the scores for each factor meet all of the criteria of a support level subgroup

4. The results of the algorithm are used to assign Clients to support levels one through six; with a support level one indicating a minimal need for supports and a support level six indicating a significantly higher need for supports.

5. For the HCBS-SLS waiver, the support level determines the Service Plan Authorization Limit (SPAL), which is defined at Section 8.600.4 definitions. The SPALs are posted annually by the Department on the Department's webpage or available in writing by contacting the Department.

For the HCBS-DD waiver, the support level determines the rate of reimbursement for the provider(s).

C. The formula for the algorithm is:

Support Level/Subgroup

Support Level 1

Subgroup 1A: ABE < 25; 1A<1 AND 1B< 2

Subgroup 1B: ABE < 25; 1A< 2 AND 1B< 5

Subgroup 1C: ABE < 25; 1A<4 and 1B< 5

Support Level 2

Subgroup 2A: ABE 26-30; 1A<1 AND 1B<2

Subgroup 2B: ABE 26-30; 1A< 2 AND 1B< 5

Subgroup 2C: ABE 26-30; 1A<4 AND 1B< 5

Subgroup 1D: ABE < 25; 1A<6

Subgroup 1G: ABE < 25; 1B<9

Subgroup 2D: ABE 26-30; 1A<6

Subgroup 2G: ABE 26-30; 1B<9

Subgroup 3A: ABE 31-33; 1A< 1 AND 1B< 2

Subgroup 3B: ABE 31-33 1A< 2 AND 1B< 5

Support Level 3

Subgroup 1H: ABE < 25; 1B<13

Subgroup 2H: ABE 26-30; 1B<13

Subgroup 3C: ABE 31-33; 1A<4 AND 1B< 5

Subgroup 3D: ABE 31-33; 1A<6

Subgroup 3G: ABE 31-33; 1B<9

Subgroup 4A: ABE > 34; 1A< 1 AND 1B< 2

Subgroup 4B: ABE >34 1A< 2 AND 1B< 5

Support Level 4

Subgroup 1E: ABE < 25; 1A<8

Subgroup 1F: ABE < 25; 1A>9

Subgroup 1I: ABE < 25; 1B<15

Subgroup 1J: ABE < 25; 1B>16

Subgroup 2E: ABE 26-30; 1A<8

Subgroup 2I: ABE 26-30; 1B<15

Subgroup 2J: ABE 26-30; 1B>16

Subgroup 3E: ABE 31-33; 1A<8

Subgroup 3H: ABE 31-33; 1B<13

Subgroup 4C: ABE > 34; 1A<4 AND 1B< 5

Subgroup 4G: ABE > 34; 1B<9

Support Level 5

Subgroup 2F: ABE 26-30; 1A>9

Subgroup 3I: ABE 31-33; 1B<15

Subgroup 3J: ABE 31-33; 1B>16

Subgroup 4D: ABE >34; 1A<6

Subgroup 4E: ABE > 34; 1A<8

Subgroup 4H: ABE > 34; 1B<13

Subgroup 4I: ABE > 34; 1B<15

Group 5A: Community Safety (either status) AND 1b<11

Support Level 6

Subgroup 4J: ABE > 34; 1B>16

Group 6A: Community Safety (either status) AND 1b>12

Subgroup 3F: ABE 31-33; 1A>9

Subgroup 4F: ABE > 34; 1A>9

Level 7

Group 7: Individuals with Tier 7 Rates

Extreme Safety Risk to Self (as defined at Section 8.600.4 definitions) - This factor acts to increase the level otherwise determined by the above criteria. Level 1 increases to level 3, level 2 increases to level 4, level 3 increases to level 4, level 4 increases to level 5. No change to levels 5 or 6, as this factor is already considered in the algorithm. Public Safety Risk (as defined at Section 8.600.4 definitions) - this factor acts to increase the level otherwise determined by the above criteria. Level 1 increases to level 5, level 2 increases to level 5, level 3 increases to level 5, and level 4 increases to level 6. No change to levels 5 or 6 as this factor is already considered in the algorithm.

D. The CMA in conjunction with the IDT shall make a determination whether a Client meets the definition of Public Safety Risk or Extreme Safety Risk to Self through the following process:

1. The decision shall be made by a case management supervisor . He or she shall:

a. Document the rationale to support the decision which shall be kept in the Client's record;

b. Document that the Client meets the definition in the Department required data system; and,

c. Review the Client at least annually or when significant changes occur to assure that the Client continues to meet the definition.

2. At the point when a Client no longer meets the definition, his or her status must be changed in the Department-required data system and his or her Support Level must be re-calculated.

E. The CMA shall inform each Client, his or her legal guardian, authorized representative, or family member, as appropriate, of his or her Support Level at the time of the Service Plan development or when the Support Level changes for any reason.

F. Notification of a Support Level change shall occur within ten (10) business days of the date after the Service Plan development or Support Level change.

G. Each Support Level corresponds with the standardized reimbursement rates for individual waiver services and the Service Plan Authorization Limits (SPAL) in HCBS-SLS.

H. In HCBS-DD, the Department may assign a reimbursement rate for day habilitation services and residential habilitation services provided to a Client with exceptional overall needs in accordance with the Support Level Review Process.

8.612.4Support Level Review Process [Eff. 2/1/12]

A. The client, his or her legal guardian, authorized representative, family member, or CMA, as appropriate, may request a review regarding the Support Level assigned to meet the client's needs.

B. The CMA shall complete the information required by the Department to request that the client's assigned Support Level be reviewed. Prior to submitting the request, the CMA shall provide an opportunity for the client, his or her legal guardian, authorized representative, or family member, as appropriate, to review and provide additional information that will be submitted to the Department.

C. The Department shall convene a review panel to examine Support Level review requests monthly or as needed.

1. The review panel shall be comprised of the following:

a. A minimum of three (3) members designated by the Department.

b. Members shall include staff from the Department, staff from a CMA that does not provide services to the client, or an additional party with extensive knowledge and experience with the SIS assessment, the Support Levels, case management, and HCBS waiver services.

2. The review panel:

a. Shall examine all of the information submitted by the CMA and seek to identify any significant factors not included in the Support Level calculation, which cause the client to have substantially higher support needs than those in the established Support Level.

b. In cases where the panel finds that the client does have substantially higher support needs than those in the initial Support Level, the panel may assign the client to a Support Level that is a closer representation of the client's overall support needs.

3. A client who has been assigned to a higher Support Level shall have this assignment re-examined by the review panel annually or as determined by the Department, unless the panel determines that the client's condition necessitating a higher Support Level is unlikely to improve.

D. The Department shall provide the CMA and the client, his or her legal guardian, authorized representative, or family member, as appropriate, with the written decision regarding the requested review of the client's Support Level within fifteen (15) business days after the panel meeting.

1. The results of the panel review for a client enrolled in the HCBS-DD waiver are conclusive.

2. If a client enrolled in the HCBS-SLS waiver, his or her legal guardian, authorized representative, or family member, as appropriate, disagrees with the decision provided by the panel, the client may request a review by the Executive Director or his or her designee, within fifteen (15) business days after the receipt of the decision.

a. The Executive Director or his or her designee shall review the request and provide a written decision within fifteen (15) business days.

b. The decision of the Executive Director or his or her designee shall constitute the final agency decision and will be subject to judicial review pursuant to Section 24-4-106, C.R.S.

E. The client shall be notified, pursuant to the Department of Health Care Policy and Financing rules in Section 8.057.2.A when a waiver service is terminated, reduced, or denied. At any time, the client may pursue a Medicaid Fair Hearing in accordance with Section 8.057.3.A.

10 CCR 2505-10-8.612