D.C. Mun. Regs. tit. 29, r. 29-979
Effective March 8, 2003 in addition to the facility-specific per diem rate calculated in accordance with section 970, the Medicaid Program shall pay an additional amount to an ICF/MR for each resident receiving one-to-one services pursuant to the requirements set forth in subsections 979.1 through 979.36.
One-to-one services constitute an altered staffing pattern that allows for one person to provide services to one resident exclusively, for a pre-authorized length of time. Services shall be provided by a paraprofessional, a registered nurse or practical nurse, as appropriate.
One-to-one services shall be provided both within an ICF/MR and outside the facility, including day treatment, to the extent that the services do not duplicate those provided by other agencies.
The additional amount paid to an ICF/MR for one to one services is resident specific. If the resident moves to another facility, the additional amount of reimbursement attributable for one-to-one services shall be transferred to the new facility and discontinued from the resident's former facility. If the resident dies or no longer requires one to-one services, payment shall be discontinued.
The Department of Health, Medical Assistance Administration (MAA) shall authorize all requests for reimbursement for one-to-one services.
One-to-one services shall be ordered by and provided under the direction of the individual resident's interdisciplinary team.
The client's physician shall approve each request for professional one-to one services prior to submission to MAA.
Interventions for managing the resident's care shall be employed with sufficient safeguards and supervision to ensure that the safety, welfare, civil and human rights of the resident are adequately protected.
Techniques for managing inappropriate resident behavior or excessive restrictive measures shall never be used for disciplinary purposes, or the convenience of staff, or as a substitute for an active treatment program.
The use of clinically appropriate systematic interventions for managing maladaptive resident behavior, physical fragility or medical fragility shall be incorporated into the resident's individual habilitation plan (IHP) or individual support plan (ISP).
Services provided pursuant to standing orders or as needed programs to control inappropriate behavior, medical or physical fragility shall not be reimbursed.
To be eligible for reimbursement for paraprofessional one-to-one services, the resident shall be required to have a behavior support plan and meet at least one of the following characteristics:
To be eligible for reimbursement for professional one-to-one services, the resident shall meet at least one of the following characteristics:
The provider shall submit to the resident's case manager a written request for paraprofessional or professional one-to-one services.
The request for paraprofessional one-to-one services shall include all of the following information, if applicable:
The request for professional one-to-one services shall include all of the following information, if applicable:
The request by the provider to the resident's case manager for one-to-one services shall be an indication that the ICF/MR is unable to adequately support the care of the section with the existing staffing configuration.
Upon receipt of the request, the resident's case manager shall immediately convene a conference with the provider and the interdisciplinary team to re-evaluate the resident and, if necessary, update the IHP or ISP.
If the resident's individual interdisciplinary team determines that the facility is unable to support the care of the client who requires professional one-to-one services with the existing staff configuration, they shall recommend professional one-to-one services as an alternative to a new residential placement.
The addendum to the ISP shall reflect the interdisciplinary team's determination that there is a need for one-to-one services and include a statement that sets forth the reason for the one-to-one services, and the duties and responsibilities of the person who shall provide the service.
The case manager shall review the request for one-to-one services, including supporting documentation within two (2) business days of receipt to ensure that the provider has submitted all required documentation.
Upon completion of the review required in Section 979.21, the case manager shall submit the interdisciplinary team's recommendation for services, the provider's request and supporting documentation to MAA for approval.
MAA shall review the submission from the case manager and approve or disapprove the request for one-to-one services within two (2) business days of receipt. If necessary, MAA may call the provider, case manager, or other interdisciplinary team member or perform an on-site visit to obtain additional information regarding the request for one-to-one services.
In an emergency, the case manager shall initiate a telephone conference call with MAA and core interdisciplinary team members to re-evaluate the resident's needs and make recommendations for one-to-one services. A full meeting of the interdisciplinary team shall be convened within five (5) business days after the telephone conference call. MAA may authorize one-to-one services for a period not to exceed (10) business days pending receipt of all required documents.
MAA shall send written notification of the approval or denial for any request for services to the resident's or resident's representative, the provider, and the resident's case manager.
If services are denied, the resident or his or her representative may submit to MAA a written request for reconsideration, including additional documentation in support of the request.
If the request for reconsideration is denied, MAA shall send written notification of the denial to the client or client's representative, the provider, and the client's case manager. The written denial letter shall comply with the requirements set forth in 42 CFR 431.200 et seq and include information informing the client or client's representative of the right to appeal the determination by contacting the Department of Human Services, Office of Fair Hearings orally or in writing.
Following the initiation of paraprofessional one-to-one services, the provider shall submit, on a quarterly basis, a status report to the case manager for review. Each status report shall indicate the resident's current condition, changes in the resident's condition since the last reporting period, interventions used and the resident's response to the interventions. The provider also shall submit documentation that reflects the need for continued one-to-one services and efforts made by the provider to eliminate the need for one-to-one services. Documentation may include progress reports from the resident's monitoring psychologist or other clinical staff.
Following the initiation of professional one-to-one services, the provider shall submit, on a monthly basis, a status report to the case manager for review. Each status report shall indicate the resident's current condition, changes in the resident's condition since the last reporting period, interventions used and the resident's response to the interventions. The provider also shall submit documentation that reflects the need for continued one-to-one services and discussions regarding the appropriateness of alternatives to one-to-one services, such as temporary hospitalization or nursing facility placement.
Each provider shall submit to the case manager, on a monthly basis, a summary of the total number of hours one-to-one services provided by each staff person. The summary shall be signed and dated by the provider.
Following the initiation of services, the case manager shall report to MAA, at least once every six months, the appropriateness and need for continued one-to-one services. The case manager shall also report any efforts that were undertaken to eliminate the need for services.
The case manager shall immediately notify MAA when services are no longer needed or if the provider fails to submit the required status report or monthly summary of services provided.
MAA may terminate payment for one-to-one services if the provider fails to submit the status report as required pursuant to sections 979.28 and 979.29.
The reimbursement rate for paraprofessional one-to-one services shall be $11.50 per hour, which includes 15% benefits.
The reimbursement rate for professional one-to-one services shall be as follows:
Registered Nurse- $22.00 per hour; or
Practical Nurse- $20.00 per hour.
Each ICF/MR that has previously received an adjustment to the facility-specific rate for one-to-one services, prior to the effective date of these rules, shall comply with the requirements set forth in these rules. The facility-specific rate shall be adjusted in conformity with these rules.
DEFINITIONS
For the purposes of this section, the following terms and phrases shall have the meanings ascribed:
Case Manager - Shall have the same meaning as set forth in Section 940 of Chapter 9 of Title 29 DCMR.
Individual Habilitation Plan (IHP) -That plan as set forth in Section 403 of the Mentally Retarded Citizens Constitutional Rights and Dignity Act of 1978, effective March 3, 1979 (D.C. Law 2-137; D.C. Official Code § 7-1304.03) .
Individual Support Plan (ISP) -The successor to the Individual Habilitation Plan (IHP) as defined in the court-approved Joy Evans Exit Plan.
Interdisciplinary Team - A group of persons with special training and experience In the diagnosis and habilitation of mentally retarded persons which has the responsibility of performing a comprehensive evaluation of each resident and participating in the development, implementation and monitoring of the resident's individual habilitation plan. The "core team" shall include the resident and resident's representative, the case manager, and relevant clinical staff.
Medical Fragility - A weakened medical state in which an individual is susceptible to disruptions in one's physical, emotional, and functional wellbeing.
Paraprofessional One-to-One Services - Services provided by persons such as nurse's aides, counselors, and those qualified to provide personal care attendant services.
Practical Nurse - A person who is licensed or authorized to provide practical nursing pursuant to the District of Columbia Health Occupations Revision Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code §§ 3-1201et seq.) or licensed as a practical nurse in the jurisdiction where services are provided.
Professional One-to-One Services - Services provided by a registered nurse or practical nurse.
Registered Nurse - A person who is licensed or authorized to provide registered nursing pursuant to the District of Columbia Health Occupations Revision Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code §§ 3-1201et seq.) or licensed as a registered nurse in the jurisdiction where services are provided.
D.C. Mun. Regs. tit. 29, r. 29-979