1920.1The purpose of this section is to establish standards governing Medicaid eligibility for day habilitation for persons enrolled in the Home and CommunityBased Services (HCBS) Waiver for Individuals with Intellectual and Developmental Disabilities (Waiver), and to establish conditions of participation for providers of day habilitation services.
1920.2Day habilitation services are aimed at developing meaningful adult activities and skills acquisition to: support or further community integration, inclusion, and exploration, improve communication skills; improve or maintain physical, occupational and/or speech and language functional skills; foster independence, self-determination and self-advocacy and autonomy; support persons to build and maintain relationships; facilitate the exploration of employment and/or integrated retirement opportunities; help a person achieve valued social roles; and to foster and encourage persons on their pathway to community integration, employment and the development of a full life in the person's community.
1920.3Day habilitation services are intended to be different and separate from residential services. These services are delivered in group settings or can be provided as day habilitation one-to-one services.
1920.4Medicaid reimbursable day habilitation services may also be delivered in small group settings at a ratio of 1:3 for persons who are medically and/or behaviorally complex, as verified by the DDA Level of Need (LON) Assessment and Screening Tool, or its successor tool, and/or the person's Behavior Support Plan, and who would benefit from day habilitation services in a smaller setting. Small group day habilitation settings must include integrated skills building in the community and support access to the greater community. In order to be Medicaid reimbursable, small group day habilitation:
(a) Cannot be provided in the same building as a large day habilitation facility setting;(b) Must be located in places that facilitate community integration and inclusion;(c) Must full comply with the requirements of the HCBS Settings Rule; and(d) May not be delivered in settings that have a daily census larger than fifteen (15) persons.1920.5To be eligible for day habilitation services:
(a) The service shall be requested by the person and recommended by the person's Support Team and included in the ISP and Plan of Care;(b) A person shall have a demonstrated personal and/or social adjustment need that can be addressed through participation in a habilitation program that is individualized to meet their goals, preferences, and needs; and(c) Day habilitation services may be delivered through remote supports to the extent the recommended service delivery is through remote supports services, and the person is able to utilize equipment/technology needed for remote supports services as assessed and determined by the support team.1920.6Day habilitation one-to-one services shall consist of:
(a) Intense behavioral supports that require a behavioral support plan; or(b) Services for a person who has medical needs that require intensive staffing and supports.1920.7To be eligible for day habilitation one-to-one services, a person shall meet at least one of the following requirements:
(a) Exhibit elopement which places the health, safety, or well-being of the person at risk;(b) Exhibit behavior that poses serious bodily harm to self or others;(c) Exhibit destructive behavior that poses serious property damage, including fire-setting;(d) Have any other intense behavioral problem that has been deemed to require one-to-one supervision;(e) Exhibit sexually predatory behavior; or(f) Have a medical history of, or high risk for, falls with injury, be physically fragile or have physical needs that do not require professional nursing but require intensive staffing, and have a physician's order for one-to-one staffing support.1920.9Day habilitation services shall be provided pursuant to the following service delivery criteria:
(a) The service may be provided in a group setting. However, persons within the group must also receive individualized services to meet their goals, preferences and needs;(b) The services provided in a community-based venue shall offer skillbuilding activities to enhance the person's habilitation needs; and(c) The service shall be provided in the most integrated setting appropriate to the needs of the person.1920.10In order to be reimbursed by Medicaid, day habilitation services shall consist of the following age-appropriate learning and/or habilitative activities that are based on what is important to and for the person as documented in his or her Individualized Support Plan and reflected in his or her Person-Centered Thinking and Discovery tools:
(a) Training and skills development that increase participation in community activities, enhance community inclusion, and foster greater independence, self-determination and self-advocacy;(b) A diversity of activities that allow the person the opportunity to choose and identify his or her own areas of interest and preferences;(c) Activities that provide opportunities for socialization and leisure activities in the community, community explorations, and activities that support the person to build and maintain relationships;(d) Training in the safe and effective use of one or more modes of accessible public transportation;(e) Coordination of transportation to enable the person to participate in community activities;(f) Activities to support community integration and inclusion: (1) These must occur in the community in groups not to exceed four (4) participants for regular day habilitation or three (3) participants for persons in small group day habilitation;(2) The activities, frequency and duration of these activities must be based on a person's interests and preferences as reflected in his or her Individualized Support Plan and Person-Centered Thinking and Discovery tools;(3) There shall be a system to match persons together in community outings based on common interests, goals, and/ or friendships, including that a person is given a choice as to whom he or she would like to spend time with during these activities;(4) Except when a person's ISP indicates a lower frequency, each person must be offered the opportunity to engage in community integration and inclusion activities at least once per week, and more if indicated by the ISP;(5) The Department on Disability Services (DDS) encourages the use of learning logs for documentation of community integration and inclusion activities;(6) At least quarterly, there must be a community integration activity for each person in which a Day Habilitation Program Coordinator, Assistant Director, and/or a Qualified Intellectual and Developmental Disabilities Professional participates to ensure: proper matching of participants; that the community outings reflect each person's interests, goals, or friendships; that each person receiving supports has opportunities to engage with people while in the community and to coach Direct Support Professionals (DSPs) on the skills needed to successfully connect persons receiving supports with the broader community, and this must be fully documented in the quarterly report; and(7) Each day habilitation provider must have, and must train their DSP staff on, written protocols regarding how DSPs are expected to support persons in the community and requirements for documenting progress notes regarding community engagement activities; and(g) Individualized or group services that enable the person to attain his/her maximum functional level based on the ISP and Plan of Care.1920.11Day habilitation services shall include a Registered Nurse for the purposes of:
(a) Medication administration;(b) Staff training in components of the Health Care Management Plan (regardless of the author of the plan); and(c) Oversight of Health Care Management Plans (regardless of the author of the plan).1920.12Day habilitation services shall include a nutritionally adequate meal for participants who live independently or in the family home and who select to receive a meal. The meal shall be provided during lunch hours, meet one-third of a person's daily Recommended Dietary Allowance, be based on the person's preferences, and not be medically contraindicated.
1920.13Each day habilitation provider shall develop a day habilitation plan for each person that corresponds with the person's ISP and Plan of Care that supports the interests, choices, goals and prioritized needs of the person. In order to develop this plan, the provider must first develop a Positive Personal Profile (PPP) and Job Search and Community Participation Plan; the initial PPP and Job Search and Community Participation Plan shall be developed within thirty (30) days of the initiation of services and shall be updated at least annually. Activities set forth in the day habilitation plan shall be functional, chosen by the person, correspond with habilitation needs and provide a pattern of life experiences common to other persons of similar age and the community-at-large. To develop the plan, the provider shall:
(a) Use observation, conversation, and other interactions, including assessments such as a vocational assessment, as necessary, to develop a functional analysis of the person's capabilities within the first month of participation and annually thereafter;(b) Use the functional analysis, the ISP and Plan of Care, Person-Centered Thinking and Discovery tools, and other information available to identify what is important to and for the person and to develop a plan with measurable outcomes that develops to the extent possible the skills necessary to allow the person to reside and work in the community while maintaining the person's health and safety; and(c) Focus on enabling each person to attain his or her maximum functional level by coordinating Waiver services with other services provided by any licensed professionals listed in the person's ISP and Plan of Care.1920.14Each provider of Medicaid reimbursable day habilitation services shall develop, with the person, an individualized schedule of daily activities that meets all requirements in the DDS guidance on daily schedules, including that it is based upon the person's goals and activities as identified in his or her ISP, and consistent with what is in his or her Person-Centered Thinking and Discovery tools, of meaningful adult activities that support the person on his or her pathway to employment and community integration and inclusion.
1920.15Day habilitation providers may not pay a stipend to a person for attendance or participation in activities at the day habilitation program.
1920.16Each day habilitation provider shall meet the following provider qualification and enrollment requirements:
(a) Comply with the requirements described under Section 1904 (Provider Qualifications) and Section 1905 (Provider Enrollment Process) of Chapter 19 of Title 29 DCMR;(b) Maintain the required staff-to-person ratio, indicated on the person's ISP and Plan of Care, to a maximum staffing ratio of 1:4 for regular day habilitation or 1:3 for persons in small group day habilitation;(c) Shall have at least one individual on staff as a full-time employee or consultant basis that has experience developing adult education programs for a person with intellectual disabilities, to ensure outcome-based learning is taking place; and(d) Shall have one individual on staff as a full-time employee or consultant basis that has experience developing adult senior curriculums for persons with intellectual disabilities, to ensure outcome-based learning is taking place.1920.17In addition to the requirements at Subsection 1920.16, each small group day habilitation provider shall meet the following provider qualifications and enrollment requirements:
(a) Fully comply with all requirements of the HCBS Settings Rule as that phrase is defined in Section 1999 (Definitions); and(b) Provide documentation that the program manager of the HCBS Waiver provider agency has at least three (3) years of experience working with persons with intellectual and developmental disabilities who have complex medical and/or behavioral needs.1920.18Each DSP providing day habilitation services for a provider shall comply with Section 1906 (Requirements of Direct Support Professionals) of Chapter 19 of Title 29 DCMR.
1920.19To receive Medicaid reimbursement, day habilitation services shall be provided in the community or in a facility-based setting that provides opportunities for community engagement, inclusion and integration. There shall be no increase in the number of facility-based settings authorized for current providers. No facilitybased settings will be authorized for newly enrolling providers, with the exception of small group day habilitation.
1920.20Each provider of Medicaid reimbursable day habilitation services shall comply with the requirements under Section 1938 (Home and Community-Based Settings Requirements) of Chapter 19 of Title 29 DCMR.
1920.21All day habilitation services shall be authorized in accordance with the following requirements:
(a) DDS shall provide a written service authorization before the commencement of services;(b) The day habilitation DSP providing one-to-one services shall be trained in physical management techniques, positive behavioral support practices and other training required to implement the person's health care management plan and behavioral support plan, as applicable;(c) The service name and provider entity delivering services shall be identified in the ISP and Plan of Care;(d) The ISP, Plan of Care and Summary of Supports and Services shall document the amount and frequency of services to be received;(e) Completion of the person's day habilitation plan;(f) Approval of the behavioral support plan or the physician's order for one-to-one staffing support for persons receiving day habilitation one-to-one services; and(g) When required by a person's BSP, accurate completion by the DSP of the behavioral data sheets for persons receiving day habilitation one-to-one services.1920.22Each provider shall comply with the requirements described under Section 1908 (Reporting Requirements) of Chapter 19 of Title 29 DCMR and Section 1911 (Individual Rights) of Chapter 19 of Title 29 DCMR. Additionally, quarterly reports shall include a description of the person's activities in the community that support community integration and inclusion using the Person-Centered Thinking Learning Log, available on-line at: https://dds.dc.gov/publication/person-centered-thinking-tools-procedure.
1920.23Each provider shall comply with the requirements described under Section 1909 (Records and Confidentiality of Information) of Chapter 19 of Title 29 DCMR.
1920.24There shall be a Medicaid reimbursement rate for regular day habilitation services. Services shall be provided for a maximum of eight (8) hours per day. The billable unit of service for regular day habilitation services shall be fifteen (15) minutes. A provider shall provide at least eight (8) minutes of service in a span of fifteen (15) continuous minutes to be able to bill a unit of service.
1920.25There shall be a Medicaid reimbursement rate for day habilitation one-to-one services. The billable unit of service for day habilitation one-to-one services shall be fifteen (15) minutes. A provider shall provide at least eight (8) minutes of service in a span of fifteen (15) continuous minutes to be able to bill a unit of service.
1920.26There shall be a Medicaid reimbursement rate for small group day habilitation services. The billable unit of service for small group day habilitation shall be fifteen (15) minutes. A provider shall provide at least eight (8) minutes of service in a span of fifteen (15) continuous minutes to be able to bill a unit of service.
1920.27For persons who live independently or with family and select to receive a meal, the rate is increased by a dollar amount per day that the person receives a meal, and an additional dollar amount per day that the person receives a meal, if that meal is delivered by a third-party vendor.
1920.28Small group day habilitation 1:1 shall be provided for a maximum of eight (8) hours a day, not to exceed forty (40) hours per week and two thousand eighty (2,080) hours annually. Small group day habilitation delivered through remote supports services shall be provided for a maximum of four (4) hours a day consecutively or in increments, not to exceed twenty (20) hours per week.
1920.29Day habilitation services shall not be provided concurrently with Individualized Day Supports, Companion, Supported Employment or Employment Readiness services.
1920.30No payment shall be made for care and supervision normally provided by the family or natural caregivers, residential provider, or employer.
1920.31Provisions shall be made by the day habilitation provider for persons who arrive early and depart late.
1920.32Time spent in transportation to and from the program shall not be included in the total amount of services provided per day.
1920.33Any day habilitation setting that is established after the effective date of these regulations must fully comply with the requirements of the HCBS Settings Rule. The daily census of any new setting may not exceed fifty (50) people. The daily census includes people who receive support through the ID/DD HCBS Waiver and people who receive ICF/IID supports and are engaged in active treatment at the setting. However, the daily census does not include people who are in the setting only for morning arrival and afternoon departure and who spend the remainder of their day in the community.
1920.34Non-small group day habilitation settings established prior to the effective date of these regulations that have a daily census under fifty (50) people may only receive authorizations for services for new participants up to a daily census of fifty (50) people in the setting. Current non-small group day habilitation settings that have a daily census of fifty (50) people or more in the setting will not be eligible for authorizations for services for new participants until their daily census is less than fifty (50) people in the setting.
(a) The daily census includes people who receive support through the ID/DD HCBS Waiver and people who receive ICF/IID supports and are engaged in active treatment at the setting; and(b) The daily census does not include people who are in the setting only for morning arrival and afternoon departure and who spend the remainder of their day in the community.1920.35The following service limitations apply to new enrollees in non-small group day habilitation services:
(a) No new enrollee may attend non-small group day habilitation for more than twenty-four (24) hours per week;(b) People who are sixty-four (64) years old and younger and have a level of need (LON) Day Composite score of two (2) or less would not be eligible to attend day habilitation services, unless approved by DDA due to extenuating circumstances or barriers that are expected to be resolved within six (6) months:(1) This limitation is applicable to small group day habilitation services;(2) Exceptions may only be granted by DDA for six (6) month periods and must be accompanied by an Individual Support Plan goal aimed at addressing the barrier to participation in other day or employment Waiver supports; and(3) Alternative services, including Employment Readiness, Small Group Supported Employment, Individualized Day Supports, and Companion services that are offered during regular day service hours, would be available, in combination, for up to forty (40) hours per week.(c) People who are sixty-four (64) years old and younger and have a LON Day Composite score of three (3) or higher would not be eligible to attend day habilitation services, unless they already have tried other day and employment options for at least one year: (1) This limitation is not applicable to small group day habilitation services;(2) DDS may approve an exception to this prohibition due to extenuating circumstances or barriers that are expected to be resolved within six (6) months. Any exceptions must be accompanied by an ISP goal aimed at addressing the barrier to participation in other day or employment Waiver supports;(3) Alternative services including Supported Employment, Individualized Day Supports, Employment Readiness and Companion would be available, in combination, for up to forty (40) hours per week.1920.36The following service limitations apply to people who are currently attending non-small group day habilitation services:
(a) Within one (1) year from the Waiver renewal effective date, any person with a LON Day Composite score of one (1) or two (2) would no longer be eligible for day habilitation services and services may no longer be authorized:(1) For any person with a LON Day Composite score of one (1) or two (2), the person should be offered employment services, either through the Waiver, the Rehabilitation Services Administration, or other community-based options;(2) The transition from day habilitation services would be implemented on a rolling basis over the course of the year, with the new service limitation discussed and choice of alternative options offered at the person's next ISP meeting, subject to the exception described in subparagraph (3) of this subsection; and(3) For a person with an ISP meeting that is scheduled within ninety (90) days of the Waiver effective date, DDA may authorize day habilitation services for up to ninety (90) days following the ISP meeting to ensure a smooth transition.(b) Within one (1) year from the effective date of the Waiver renewal, nonsmall group day habilitation services may not be authorized for any Waiver participant with a LON Day Composite score above two (2) for more than twenty-four (24) hours per week, subject to the exception described below: (1) Wrap around services are available, including Supported Employment, Individualized Day Supports, Employment Readiness and Companion, in combination, for up to forty (40) hours per week;(2) For people with an ISP meeting that is scheduled within ninety (90) days of the Waiver renewal effective date, DDA may authorize up to forty (40) hours of day habilitation services per week for up to ninety (90) days following the ISP meeting to ensure a smooth transition; and(3) This limitation is not applicable to small group day habilitation services.(c) For any person who is currently receiving non-small group day habilitation services who will be subject to a reduction in authorized service hours due to the service limitations identified in these provisions, DDA will provide timely and adequate due process notice of the change in services and the person's appeal rights, using the process described in the DDS Person-Centered Planning Process and Individual Support Plans policy and procedures, or the successor documents.1920.37Each provider of remote day habilitation services shall comply with the requirements under Section 1943 (Remote Supports Services) of Chapter 19 of Title 29 of DCMR.
1920.38Remote day habilitation services shall be issued as a separate service authorization indicating the frequency of usage. A hybrid model may be used for in-person and remote supports services day habilitation hours where two (2) service authorizations are issued to cover the in-person service hours and the remote supports service hours.
1920.39Remote day habilitation 1:1, day habilitation, and small group day habilitation services staffing ratio are 1:6 and must have active, continuous engagement and contact with the remote supports platform. Staff shall be available during the service hours and document that they are continuously engaged with the person or the remote supports responder platform to bill for hourly services.
1920.40HCBS waiver providers providing day habilitation through remote supports services must meet the criteria, as specified at §§ 1943.
D.C. Mun. Regs. tit. 29, r. 29-1920
Final Rulemaking published at 60 DCR 15530 (November 8, 2013); amended by Final Rulemaking published at 63 DCR 11876 (9/30/2016); amended by Final Rulemaking published at 69 DCR 10218 (8/12/2022); amended by Final Rulemaking published at 71 DCR 10372 (8/16/2024)Authority: An Act to enable the District of Columbia to receive federal financial assistance under Title XIX of the Social Security Act for a medical assistance program, and for other purposes, approved December 27, 1967 (81 Stat. 774; D.C. Official Code § 1-307.02 (2012 Repl. & 2013 Supp.)) and Section 6(6) of the Department of Health Care Finance Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code § 7-771.05(6) (2012 Repl.)).