10 Colo. Code Regs. § 2505-10-8.7505

Current through Register Vol. 47, No. 24, December 25, 2024

Section 10 CCR 2505-10-8.7505 - Adult Day Services

8.7505.AAdult Day Services Eligibility

1. Adult Day Services (ADS) is a covered benefit available to Members enrolled in one of the following HCBS waivers:

a. Brain Injury Waiver

b. Community Mental Health Services Waiver

c. Complementary and Integrative Health Waiver

d. Elderly, Blind, and Disabled Waiver

8.7505.BAdult Day Services Descriptions and Definitions

1. Adult Day Services (ADS) Centers are certified centers that provide Basic Adult Day Services and Specialized Adult Day Services to Members.

2. Adult Day Services (ADS) may be provided out of an Adult Day Services Center or through Non-Center-Based means including Telehealth.

3. Adult Day Services are provided on a regularly scheduled basis. Services must be delivered as specified in the Member's Provider Care Plan, and promote social, recreational, physical, and emotional well-being, and shall encompasses the supportive services needed to ensure the optimal wellness of the Member.

4. Basic Adult Day Services (ADS) Center means a community-based entity that provides basic Adult Day Services.

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

6. Licensed Medical Professional for Section 8.7505 Adult Day Services only means the primary care provider of the Member, who possesses one of the following licenses: Physician (MD/DO), Physician Assistant (PA), Advanced Practicing Nurse (APN). Registered Nurse (NR), or Licensed Practical Nurse (LPN). License Medical Professional practices shall adhere the Colorado Medical Practice Act or the Colorado Nurse Practice Act, as applicable to the professional licensure category.

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

8. Specialized Adult Day Services (SADS) Center means a community-based entity providing Adult Day Services for Members with a primary diagnosis of dementia related diseases, Multiple Sclerosis, Brain Injury, chronic mental illness, Intellectual and Developmental Disabilities, Huntington's Disease, Parkinson's, or post-stroke Members, who require extensive rehabilitative therapies. To be designated as specialized, two-thirds of an ADS Center's population must have one of any of these diagnoses. Each diagnosis must be verified by a Licensed Medical Professional either directly or through Case Management Agency documentation, in accordance with Section 8.7505.E.9.

9. Telehealth Adult Day Services are services provided through virtual means in a group or on an individual basis. Telehealth ADS allows for Members to engage in activities with their community and connect to staff and other ADS Members virtually or over the phone, only if a Member does not have access or the ability to use video chat technology. Nutrition services are not required to be included in Telehealth Services.

8.7505.CAdult Day Services Inclusions

1. Only Members whose needs may be met by the ADS Provider Agency within its Certification category and populations served may be admitted by the ADS Provider Agency.

2. A Member 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.

3. ADS for all waivers shall include, but are not limited to:

a. Assistance with Activities of Daily Living (ADL), as needed when ADS is provided in-person; monitoring of the Member's health status and personal hygiene; assistance with administering medication and medication management (administration of medication only during the in-person delivery of services); and carrying out physicians' orders as set forth in Member's individual Person-Centered Support Plan.

b. Activities that assist in the development of self-care capabilities, personal hygiene, and social support services.

4. Nutrition services including therapeutic diets and snacks in accordance with the Member's individual Provider Care Plan and hours of attendance. Nutrition services are not required during the delivery of Non-Center-Based ADS.

5. Age-appropriate social and recreational supportive services as appropriate for each Member and their needs, as documented in the Member's Provider Care Plan. Activities shall take into consideration individual differences in age, health status, sensory deficits, religious affiliation, interests, abilities, and skills by providing opportunities for a variety of types and levels of involvement.

6. Members have the right to choose not to participate in social and recreational activities.

8.7505.DSpecialized Adult Day Services

1. The Member's Person-Centered Support Plan and Provider Care Plan must include documentation of their diagnosis(es) and service goals.

2. A Specialized Adult Day Services (SADS) Provider Agency must verify all Medicaid Member's diagnosis(es) using the Professional Medical Information Page (PMIP) which shall be supplied by the Case Manager or by documentation from the Member's Licensed Medical Professional. SADS Provider Agencies must ensure documentation verifying the Member's diagnosis(es) is obtained at the time of admission and whenever there is a significant change in the Member's condition. The SADS Provider Agency shall record any significant change to the Member's condition in the Member's record

3. For Members whose services are reimbursed by a payment source other than Medicaid, diagnosis(es) must be documented in a Person-Centered Support Plan or other admission form and verified by the Member's physician or Licensed Medical Professional. This documentation must be verified at the time of admission, and whenever there is a significant change in the Member's condition.

4. Adult Day Services Exclusions and Limitations

a. The delivery of a meal, workbook, activity packet, or similar materials, does not constitute ADS and is not a covered service unless in-person ADS service is provided in addition to the delivery of food or materials.

8.7505.EAdult Day Services Provider Agency Requirements

1. General

a. Adult Day Services Provider Agencies shall be Medicaid certified by the Department in accordance with Section 8.7403.A. Proof of Medicaid Certification consists of an approved Provider Agreement by the Department and the Department's fiscal agent, and a recommendation for Certification from the Colorado Department of Public Health and Environment (CDPHE).

2. Environment

a. Adult Day Services Centers shall provide recreational areas and activities appropriate to the number and needs of the Members, at the times desired by the Members.

b. Adult Day Services Centers shall provide for a private shower and/or bathing area located on site to address the emergency hygiene needs of Members as needed.

c. To accommodate the activities and program needs of the ADS Center, the center shall provide eating and activity areas that are consistent with the number and needs of the Members being served, at a minimum of 40 square feet per Member.

d. ADS Centers shall maintain a comfortable temperature throughout the center. At no time shall the temperature fall outside the range of 68 degrees to 76 degrees Fahrenheit.

e. ADS Centers shall provide an environment free from Restraints.

f. ADS Centers shall provide a safe environment for all Members, including Members exhibiting behavioral problems, wandering behavior, or limitations in mental/cognitive functioning.

3. Food Safety Requirements

a. ADS providers shall comply with all applicable local food safety regulations. In addition, all ADS Centers shall ensure:

i. Access to a handwashing sink, soap, and disposable paper towels;

ii. Food handlers, cooks, and servers, including Members engaged in food preparation, wash their hands according to food safety hand-washing guidelines;

iii. The ADS Centers shall not allow any staff or Members who are not in good health and free of communicable disease to handle, prepare or serve food or handle utensils;

iv. Refrigerated foods opened or prepared and not used within 24 hours are marked with a "use by" or "discard by" date. The "use by" or "discard by" date may not exceed 7 days following opening or preparation, or exceed or surpass the manufacturer's expiration date for the product or its ingredients;

v. Foods provided as food service are maintained at the proper temperatures at all times. Foods that are stored cold must be held at or below 41 degrees Fahrenheit and foods that are stored hot must be held at or above 135 degrees Fahrenheit in order to control the growth of harmful bacteria;

1) Kitchen and food preparation equipment shall be maintained in working order and cleanable; and

2) Any equipment or surfaces used in the preparation and service of food shall be washed, rinsed, and sanitized before use or at least every 4 hours of continual use. Dish detergent shall be labeled for its intended purpose. Sanitizer shall be approved for use as a no-rinse food contact sanitizer. Sanitizers shall be registered with the Environmental Protection Agency (EPA) and used in accordance with labeled instructions.

4. Medication Administration and Monitoring

a. Adult Day Service Provider Agencies shall comply with Medication Administration regulations in Section 8.7414.

5. Records and Information

a. All ADS Provider Agencies shall keep records and information necessary to document the services provided to Members receiving Adult Day Services, as required in Section 8.7405. In addition to the requirements at Section 8.7405, ADS records must also include:

i. Name, address, and telephone number of primary physician;

ii. Documentation of the supervision and monitoring of services provided;

iii. Documentation that all Members and their Guardian or other Legally Authorized Representative, if authorized/if within the scope of their authority have been oriented to the ADS Center, their policies and procedures, to the services provided by the ADS provider, and delivery methods offered;

iv. A service agreement signed by the Member and/or the Guardian or other Legally Authorized Representative, if authorized/if within the scope of their authority and appropriate Adult Day Services staff;

v. For SADS providers only, a copy of the Professional Medical Information Page, or documentation of diagnosis from the Member's Licensed Medical Professional; and

vi. Documentation specifically stating the types of services and monitoring that are provided when rendered via Telehealth, ensuring the integrity of the service provided and the benefit the service provides the Member.

6. Service Plan

a. The ADS Provider Agency shall document the following information in a care plan, which shall be used to direct the Member's care.

i. Medical Information:

1) All medications prescribed for the Member, including those used by the Member while receiving Center-Based or Non-Center-Based ADS, and whether the medication is self-administered;

2) Special dietary considerations or instructions;

3) Services that are administered to the Member while receiving Center-Based and/or Non-Center-Based ADS, which may include nursing or medical interventions, speech therapy, physical therapy, or occupational therapy;

a) Any recommended restrictions on social and/or recreational activities identified by Member's Licensed Medical Professional; and

b) Any other special health or behavioral management services or supports recommended to assist the Member by the Member's Licensed Medical Professional.

4) Even if recommended by the Member's Licensed Medical Professional, staff interventions that interfere with the Member's choice of food, freedom to determine their own activities, or exercise of any other rights are Rights Modifications for which the ADS Provider Agency must comply with Section 8.7001.B.4.

ii. Provider Care Plan Planning Documentation:

1) Documentation that the Member and/or Guardian or other Legally Authorized Representative, if authorized/if within the scope of their authority, selected the ADS Provider Agency.

2) Individual choices, including location and delivery method for ADS, preferences, and needs shall be incorporated into the goals and service soutlined in a care plan;

3) All Member information and the service plan are considered Protected Health Information and shall be kept confidential; and

4) The Member and/or Guardian or other Legally Authorized Representative, must review and sign the care plan and Person-Centered Support Plan.

5) Any changes to the Person-Centered Support Plan must comply with Section 8.7001.B.4.

6) Any changes to the care plan must comply with Section 8.7410.

7) Documentation of whether the Member has executed an advance directive or other declaration regarding medical decisions.

7. Staff Requirements

a. In determining appropriate staffing levels, the Adult Day Services Provider Agency shall adjust staffing ratios based on the individual acuity and needs of the Members being served. At a minimum, staffing must be sufficient in number to provide the services described in the Provider Care Plan, considering the individual needs, level of assistance, and risks of accidents. A staff person may perform multiple functions, if those functions are consistent with the definition of Direct Care Worker, Section 8.7402.F. Staff counted in the staff-Member ratio are those who are trained and able to provide direct services to Members.

i. Center-Based and in-person, Non-Center-Based ADS shall be staffed at a minimum of 1 staff to 8 Members with continuous supervision of Members during program operation.

ii. Telehealth ADS shall be staffed at a minimum of 1 staff to 15 virtual Members with continuous virtual supervision of Members during Telehealth program operation.

b. Staff shall provide:

i. Immediate response to emergency situations to assure the safety, health, and welfare of Members;

ii. Activities that are planned to support the Person-Centered Support Plans or Provider Care Plan for the Members.

iii. Administrative, recreational, social, and supportive functions and duties.

iv. Nursing services for regular monitoring of the on-going medical needs of Members and the supervision of medications. These services must be available a minimum of two hours daily during Center-Based ADS and as needed for Non-Center-Based Adult Day Services.

v. Nursing services shall be provided by a Registered Nurse (RN) or Licensed Practical Nurse (LPN). Certified Nursing Assistants (CNA) may provide nursing services under the direction of a RN or an LPN, in conformance with delegation provisions at in § 12-38-132, C.R.S. Supervision of CNAs must include documented consultation and oversight on a weekly basis or more frequently according to the Member's needs. If the supervising RN or LPN is an ADS Staff Member with consultation and oversight of CNAs included in the Member's job description, the supervising nurse's documented attendance at the ADS center during times when nursing services are provided shall be sufficient to document consultation and oversight.

c. In addition to the above services, Specialized Adult Day Services (SADS) Centers shall have sufficient staff to provide nursing services during all hours of operation.

8. Director Qualifications

a. All Directors shall meet one of the following qualifications:

i. At least a bachelor's degree from an accredited college or university and a minimum of two years of social services or health services experience and shall have demonstrated ability to perform all aspects of the position; or

ii. An LPN or RN license issued by the state of Colorado and completion of two years of paid or volunteer experience in planning or delivering health or social services including experience in supervision and administration; or

iii. A high school diploma or GED equivalent, a minimum of four years of experience in a social services or health services setting, acquired skills in working with aging adults or adults with functional impairment, and skills required to supervise ADS Center staff persons.

9. Training Requirements

a. All staff and volunteers shall be trained in accordance with Section 8.7409.D. and in the use of Universal Precautions and infection control, as defined at Section 8.7502.Y.

b. Direct Care Workers shall complete training prior to providing services.

10. Dementia Training Requirements

a. As of October 1, 2023, each Adult Day Services Provider Agency shall ensure that its Direct Care Workers complete dementia training as required by Section 25.5-6-314, C.R.S.

b. Definitions applicable to Dementia Training Requirements: In addition to those definitions set forth at Section 25.5-6-314, C.R.S., the following definitions apply to regulations in this Section 8.7505.E:

i. "Covered Facility" means a nursing care facility or an assisted living residence licensed by the Department of Public Health and Environment pursuant to Section 25-1.5-103(1)(a).

ii. "Dementia diseases and related disabilities" is a condition in which cognitive ability declines and is severe enough to interfere with an individual's ability to perform everyday tasks. Dementia diseases and related disabilities include Alzheimer's disease, mixed dementia, Lewy Body Dementia, vascular dementia, frontotemporal dementia, and other types of dementia.

iii. "Direct Care Worker " means a Staff Member caring for the physical, emotional, or mental health needs of Members of an Adult Day Services Provider Agency and whose work involves regular contact with Members who are living with Dementia Diseases and related disabilities.

iv. "Equivalent training" means any initial training provided by a Covered Facility that meets the requirements in Section 8.7505.E.10.c. If the Equivalent Training was provided more than 24 months prior to the date of hire as allowed in the exception found in Section 8.7505.E.10.d., the individual must document participation in both the Equivalent Training and all required continuing education subsequent to the initial training.

c. Initial training: Each Adult Day Services Provider Agency is responsible for ensuring that all Direct Care Workers are trained in dementia diseases and related disabilities.

i. Initial training shall be available to Direct Care Workers at no cost to them.

ii. The training shall be competency-based and culturally competent and shall include a minimum of four hours of training in dementia topics including the following content:

1) Dementia diseases and related disabilities;

2) Person-centered care;

3) Care planning;

4) Activities of Daily Living; and

5) Dementia-related behaviors and communication.

iii. For Direct Care Workers already employed prior to October 1, 2023, the initial training must be completed as soon as practical, but no later than 120 days after October 1, 2023, unless an exception, as described in Section 8.7505.E.10.d.i. applies.

iv. For Direct Care Workers hired or providing care on or after October 1, 2023, the initial training must be completed as soon as practical, but no later than 120 days after the start of employment or the provision of direct-care services, unless an exception, as described in Section 8.7505.E.10.d.ii applies.

d. Exception to initial dementia training requirement

i. Any Direct Care Worker who is employed by or providing direct-care services prior to the October 1, 2023, may be exempted from the provider's initial training requirement if all of the following conditions are met:

1) The Direct Care Worker has completed Equivalent Training program, as defined in these rules, within the 24 months immediately preceding October 1, 2023; and

2) The Direct Care Worker may provide documentation of the satisfactory completion of the Equivalent Training program.

ii. Any Direct Care Worker who is hired or begins providing direct-care services on or after October 1, 2023, may be exempted from the provider's initial training requirement if the Direct Care Worker:

1) Has completed an equivalent initial dementia training program, as defined in these rules, either:

a) Within the 24 months immediately preceding October 1, 2023; or

b) Within the 24 months immediately preceding the date of hire or the first date the Direct Care Worker provides direct care services; and

2) Provides documentation of the satisfactory completion of the equivalent initial training program; and

3) Provides documentation of all required continuing education subsequent to the initial training.

iii. Such exceptions shall not exempt a Direct Care Worker from the requirement for dementia training continuing education as described in Section 8.7504.E.10.e.

e. Dementia Training: Continuing Education

i. After completing the required initial training, all Direct Care Workers shall have completed and documented a minimum of two hours of continuing education on dementia topics every two years.

ii. Continuing education on this topic shall be available to Direct Care Workers at no cost to them.

iii. This continuing education shall be culturally competent, include current information provided by recognized experts, agencies, or academic Institutions, and include best practices in the treatment and care of persons living with dementia diseases and related disabilities.

f. Minimum requirements for individuals conducting dementia training:

i. Specialized training from recognized experts, agencies, or academic Institutions in dementia disease, or

ii. Successful completion of other similar training which meets the minimum standards described herein; and

iii. Two or more years of experience working with persons living with dementia diseases and related disabilities.

g. Documentation of initial dementia training and continuing education for Direct Care Workers:

i. The Provider Agency shall maintain documentation that each Direct Care Worker has completed initial dementia training and continuing education. Such records shall be made available to the Department upon request.

ii. Completion shall be demonstrated by a certificate, attendance roster, or other documentation reliably demonstrating completion of training.

iii. Documentation shall include the number of hours of training, the date on which it was received, and the name of the instructor and/or training entity.

iv. Documentation of the satisfactory completion of an equivalent initial training program shall include the information required in this Section 8.7505.E.10.g.ii.and iii.

v. After the completion of training and upon request, such documentation shall be provided to the Staff Member. for their use in obtaining employment at another Covered Facility. For the purposes of dementia training documentation, Covered Facilities shall include Assisted Living Residences, and Nursing Care Facilities pursuant to § 25.5-6-314, C.R.S, and Adult Day Care Facilities as defined in §25.5-6-303(1), C.R.S.

11. Written Policies

a. In addition to the policies and procedures described in Section 8.7408, the ADS provider shall maintain written policies and procedures relevant to the operation of Adult Day Services. Such policies shall include, but not be limited to, statements describing:

i. Admission criteria for Members shall can be appropriately served by the Adult Day Services Provider Agency;

ii. Intake procedures conducted for Members and/or Guardian or other Legally Authorized Representative, if authorized/if within the scope of their authority prior to admission with the ADS provider;

iii. The meals and nourishments, including special diets, that are provided at Center-Based Adult Day Services;

iv. The hours and days that Center-Based Adult Day Services are open and available, and the days and times that Non-Center-Based Adult Day Services are available to Members, including the availability of nursing services;

v. The personal items that the Members may bring with them to the Adult Day Services Center; and

vi. The administration of Telehealth Adult Day Services, if provided. This includes Telehealth options, provision of services, and examples of services offered in a virtual setting.

b. The Adult Day Services Provider Agency shall maintain on file a current, written, signed agreement between the Member and/or Guardian or other Legally Authorized Representative, if authorized/if within the scope of their authority, and the Adult Day Services Provider Agency outlining the rules and responsibilities of the Adult Day Services Provider Agency and the Member. The Adult Day Services Provider Agency shall provide a copy of the agreement to each party to the agreement.

8.7505.FAdult Day Services Provider Agency Reimbursement Requirements

1. Claims for reimbursement for Adult Day Services provided to Members in the HCBS Elderly, Blind and Disabled (EBD), Community Mental Health Supports (CMHS), and the Complementary and Integrative Health (CIH) waivers shall be submitted in accordance with the current rate schedule:

a. ADS Provider Agencies may submit claims for 15-minute units or for 1-2 units of 3-5 hours depending on the Member's needs and how the service is delivered.

i. When submitting claims for 15-minute units, which may be delivered either in-person or via Telehealth, the total number of units may not exceed 12 units or three hours per day of Basic Adult Day Services.

ii. A Provider Agency may bill the maximum of 15-minute units for ADS in combination with no more than 1 unit of 3-5 hour ADS on the same day, only if services were rendered consecutively.

2. For persons in the HCBS waiver for Persons with a Brain Injury (BI), reimbursement for BI-AdultDay Services is to be billed in accordance with the current rate schedule.

a. Adult Day Services Provider Agencies may bill in units of 15 minutes or a unit of 2 or more hours depending on the Member's needs and how the service is delivered. When billing 15-minute units, which can be delivered either in-person or via Telehealth, the total number of units may not exceed 8 units or two (2) hours per day of services.

b. Units of 2 hours or more delivered only in-person. An Adult Day Services provider may not bill for 15-minute units of ADS if a unit of 2-hour BI ADS was provided to the same Member on the same day.

3. Adult Day Services (ADS) Centers are permitted to utilize funding from other Federal sources, such as the Child and Adult Care Food Program (CACFP), in addition to the Medicaid per diem. If such funding is utilized, a Center must acknowledge the use of multiple funding sources and demonstrate that the services funded by a federal source do not duplicate Medicaid-funded services.

4. Only providers certified as a Specialized Adult Day Services (SADS) Center are permitted to receive the SADS reimbursement rate. The SADS reimbursement rate applies to every Member at a SADS Center, even if the Member does not have a specialized diagnosis.

5. Certified SADS providers may provide Non-Center-Based Adult Day Services, including Telehealth ADS Non-Centered-Based Adult Day Services, shall be billed only as Basic Adult Day Services using the 15-minute unit, up to 3 hours per day. The SADS provider may bill the maximum of 15-minute units for Basic Adult Day Services in combination with no more than 1 unit of 3-5 hour SADS on the same day, as long as services were rendered at separate times.

6. Adult Day Services are not covered when provided on the same date as HCBS residential services, unless the following criteria have been met:

a. Adult Day Services and residential services have been authorized by the Department and are included in an approved Prior Authorization Request PAR;

b. Documentation from the Member's physician demonstrates the required specialized services in the Adult Day Services Center are necessary because of the Member's diagnosis(es), are essential to the care of the Member, and are not included in the residential per diem;

c. Documentation that the extensive rehabilitative therapies and therapeutic needs of the Member are not being met by the residential program and are not included in the residential per diem; and

d. Documentation from the Member's physician recommends Adult Day Services and describes how it will meet the Member's needs as described in subsection b, above.

10 CCR 2505-10-8.7505

47 CR 03, February 10, 2024, effective 3/16/2024

47 CR 21, November 10, 2024, effective 11/30/2024