372 - Annual Report on Home and Community-Based Services Waivers

UT
0292
ACCEPTED
Waiver Year:
Report Type:
$30,661 <= $41,020
Level/s of Care:
Note: Average Per Capita (APC)
Annual Number of Section 1915c Waiver Recipients and Expenditures:
(Specify each service as in the approved waiver)
Service Name Level of Care Expenses Participants
-- Other
If Other, specify:
ABI SUPPORT COORDINATION
NF $242,665 97
-- Other
If Other, specify:
CHORE SERVICES
NF $0 0
-- Other
If Other, specify:
COMMUNITY LIVING SUPPORTS congregate residential service
NF $726,649 16
-- Other
If Other, specify:
COMMUNITY SUPPORTED LIVING host home service
NF $63,966 1
-- Other
If Other, specify:
COMMUNITY SUPPORTED LIVING extended living supports in congregate setting
NF $3,566 1
-- Other
If Other, specify:
COMMUNITY SUPPORTED LIVING supported living in home setting
NF $766,002 66
-- Other
If Other, specify:
COMMUNITY SUPPORTED LIVING supported living in home setting, self directed employee model
NF $144,253 17
-- Other
If Other, specify:
COMPANION SERVICES DAY
NF $2,170 1
-- Other
If Other, specify:
COMPANION SERVICES 15 MIN
NF $76,171 11
-- Other
If Other, specify:
FAMILY ASSISTANCE AND SUPPORT agency based provider model
NF $0 0
-- Other
If Other, specify:
FAMILY ASSISTANCE AND SUPPORT self directed employee model
NF $0 0
-- Other
If Other, specify:
HABILITATION, DAY (STRUCTURE DAY PROGRAM) routine service
NF $18,197 3
-- Other
If Other, specify:
HABILITATION DAY (STRUCTURED DAY PROGRAM) individualized service
NF $182,781 17
-- Other
If Other, specify:
HOMEMAKER SERVICES
NF $1,544 1
-- Other
If Other, specify:
PERSONAL EMERGENCY RESPONSE SYSTEM purchase
NF $0 0
-- Other
If Other, specify:
PERSONAL EMERGENCY RESPONSE SYSTEM installation & testing
NF $50 1
-- Other
If Other, specify:
PERSONAL EMERGENCY RESPONSE SYSTEM service fee
NF $2,167 7
-- Other
If Other, specify:
RESPITE CARE (UNSKILLED) agency based provider model
NF $42,162 5
-- Other
If Other, specify:
RESPITE CARE (UNSKILLED) self directed employee model
NF $20,222 8
-- Other
If Other, specify:
SPECIALIZED MEDICAL EQUIPMENT & SUPPLIES purchase
NF $68 1
-- Other
If Other, specify:
SPECIALIZED MEDICAL EQUIPMENT & SUPPLIES service fee
NF $600 1
-- Other
If Other, specify:
SUPPORTED EMPLOYMENT routine model
NF $114,266 19
-- Other
If Other, specify:
SUPPORTED EMPLOYMENT enclave model
NF $46,787 8
-- Other
If Other, specify:
TRANSPORTATION, NON MEDICAL personal/family arrangements
NF $901 2
-- Other
If Other, specify:
TRANSPORTATION, NON MEDICAL agency based provider
NF $26,696 18
-- Other
If Other, specify:
TRANSPORATION, NON MEDICAL multi pass, public transit system
NF $14,663 22
Assurances:
Documentation:
Findings of Monitoring:
Certification:
I, do certify that the information shown on the Form CMS-372(S) is correct to the best of my knowledge and belief:
Contact Information (optional):