CMS 372 Report - OMB Control Number: 0938-0272

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

State:

Waiver Base:

0292

Report Status:

ACCEPTED

Begin Date:

End Date:

Initial Submission Date:

Report Period Year:

Waiver Year:

Report Type:

Initial Report

Lag Report

TE Report

Unduplicated Participants:

Days of Waiver Enrollment:

Average Length of Stay:

Total Waiver Expenditures:

Total Reported Expenditures:

APC Waiver Services (Factor D):

APC for State Plan Services (D'):

APC Total (D + D'):

Factor G Value:

Factor G' Value:

APC Total if no waiver (G + G'):

D + D' <= G + G':

$30,661 <= $41,020

Level/s of Care:

ICF/MR

Hospital

Additional Information (use if needed):

The number of clients served by the waiver was an estimate. The actual number of clients that are served by the waiver is directly associated with the amount of State matching dollars appropriated by the Utah State Legislature. The number served during a specific year may be lower than the estimates when the State Legislature does not appropriate additional monies for caseload growth.  In these cases, as individuals attrite, new individuals are not brought in to replace them.  As a result of limited funding, the State does not always utilize the maximum amount of capped waiver slots approved by CMS.      
The factor D and D' table numbers provided during the initial waiver application were estimates.  During the 2009 waiver renewal, the State made adjustments to the factor D and D' table estimates based off the actual utilization data for the previous waiver period.

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:

Assurances were submitted with the initial report. (If you are submitting a lag report this item must be checked.)
All provider standards and health and welfare safeguards have been met and corrective actions have been taken where appropriate
All providers of waiver services were properly trained, supervised, and certified and/or licensed, and corrective actions have been taken where appropriate.

Documentation:

Provide a brief description of the process for monitoring the safeguards and standards under the waiver:

The SMA conducted the following monitoring during FY 2010: FY 2008 Annual Review During FY 2010, the SMA concluded the FY 2008 review for the ABI Waiver. This review addressed the assurances: 1) The State conducts level of care determinations consistent with the need for nursing facility level of care, 2) Individual Service Plans are responsive to waiver participants’ needs, 3) The health and welfare of participants, 4) The State provides financial accountability for the waiver. The review sample was selected February 26, 2009. As of that date, one hundred four (104) individuals had received services through the Acquired Brain Injury Waiver since July, 2007. Based on this number, a Confidence Level of 95% and a Confidence Interval of 8.69, and a response distribution of 10%, thirty-two (32) individuals were selected for this review. The sample was randomly selected from a list of participants that had started receiving waiver services by July 1, 2007. The operating agency had an opportunity to comment on the findings and provide relevant additional information. The final report was issued June, 2010. The review presented observations and analysis of the data for each assurance. Plans of correction were required for all deficiencies. All plans of correction have been completed. Critical Incidents/Events The SMA tracks and investigates all critical incidents/events that occur to participants receiving services from the ABI Waiver. There were twelve critical incident investigations involving ABI Waiver participants during the time period July 1, 2009 through June 30, 2010. Seven of the twelve incidents (58%) were participants who were involved in criminal activity and faced law enforcement charges. Three of the twelve incidents (25%) involved participants who had been missing for at least 2 hours. One of the twelve incidents (8%) was a participant who experienced a human rights violation. One of the twelve incidents (8%) was a participant who experienced an accidental fall. One incident remains open with the investigation continuing. Eleven incidents were resolved and safeguards were put in place to assure the health and safety of all participants. Qualified Providers Contract Providers During FY 2010, 61 providers with contracts with DSPD provided services to ABI participants. 36 of 61 ABI providers (59%) met all provider contractor criteria. Corrective Action Plans were required by DSPD for providers who did not meet provider contract criteria. 88% of providers are currently in 100% compliance with provider contract criteria. 7 of 61 providers are in the process of resolving compliance issues to the satisfaction of DSPD. Provider Sites are Safe and in Good Repair The Division of Services for People with Disabilities (DSPD) ensures all provider sites are safe and in good repair. There are 74 licensed providers and 592 certified apartments which provide Residential Supports for ABI consumers. • Licensed Providers The Department of Human Services (DHS) Office of Licensing, licenses Residential Supports providers. These include, Group Homes that serve 4 or more individuals, Professional Parent Homes for child placement and Day Supports. DSPD works closely with the Office of Licensing to ensure all providers are meet licensing criteria including provider sites are safe and in good repair. Payments are only made to providers who have a current license issued by the Office of Licensing. During FY 2010, The Office of Licensing reviewed 74 of 74 licensed providers (100%). All compliance issues were corrected and 74 of 74 licensed providers (100%) are currently in compliance with licsinsing criteria including providing a safe site which is in good repair. • Certified Providers DSPD certifies Supervised Apartments that serve three or fewer individuals. DSPD reviews 100% of these supervised apartments annually to ensure they meet all certification criteria including provider sites are safe and in good repair. Payments are only made to supervised apartment providers who have a current certification issued by DSPD. During FY 2010 592 of 592 supervised apartments were reviewed. All compliance issues were corrected and 592 of 592 (100%) are currently in compliance with certification criteria including providing a safe site which is in good repair.

Findings of Monitoring:

No deficiencies were detected during the monitoring process;
Deficiencies were detected.

Provide a summary of the significant areas where deficiencies were detected, (Note: Individual reports or assessment forms for waiver individuals and/or providers disclosing deficiencies and which document the summary are not necessary):

The SMA identified the following significant deficiencies: Assurance: Level of Care Sub Assurance: The level of care of enrolled participants is re-evaluated at least annually and whenever a substantial change in health status occurs to determine if change constitutes continued nursing facility level of care. • Performance measure: Level of Care is re-evaluated at least annually using the Comprehensive Brain Injury Assessment Instrument (CBIA). Deficiency #1: 28 of 32 (88%) participants who required an annual re-evaluation were screened for level of care. 4 participants were not re-evaluated within twelve months from the date the previous level of care assessment was conducted. Assurance: Plans of Care Sub Assurance: Person Centered Service Plans are developed in accordance with policies and procedures. • Performance measure: The Comprehensive Brain Injury Assessment is administered at a minimum every 12 months. Deficiency #2: 26 of 32 (81.25%) participants received an annual re-assessment. 6 participants did not receive a re-assessment within a 12 month period. Sub Assurance: Services are delivered in accordance with the Person Centered Service Plan, including the type, scope, amount, and frequency specified in the Person Centered Service Plan. • Performance measure: All services provided, including the amount, frequency and duration for each service are clearly identified on the Person Centered Service Plan. Deficiency #3: 27 of 31 (87.09%) of the PCSPs reviewed identified all the services provided to the participant and included the amount, frequency and duration for each service that was authorized. 4 PCSPs either did not identify the services provided to the participant on a valid PCSP or the amount of services provided to the participant exceeded the amount authorized on the budget. Assurance: Health and Welfare Sub Assurance: There is continuous monitoring of the health and welfare of waiver participants and remediation actions are initiated when appropriate. • Performance measure: Health and welfare needs are addressed and steps are taken to resolve concerns in a timely manner and documented in the record. Deficiency #4: 27 of 32 (84%) participants had health and welfare needs addressed and steps were taken to resolve concerns in a timely manner. 5 participants had health and safety issues that warranted follow up but little or no documentation in the activity logs verified the issues were addressed. • Performance Measure: Critical Incident Management: Within 24 hours of any incident requiring a report the provider notified the Support Coordinator by phone, email or fax. Deficiency #5: The incidents for 9 of 15 (60%) participants were reported within the required time frames. Incidents experienced by 6 participants were not reported within the required time frames. • Performance Measure: Critical Incident Management: Within 5 business days of the occurrence of an incident, the provider completes Form I-8 Incident Report and files it with the Support Coordinator. Deficiency #6: 10 of 15 (66.66%) records showed providers completed and submitted Form I-8 within 5 business days of the occurrence of an incident. Providers did not complete and submit Form I-8 to the support coordinator within 5 business days for 5 participants. • Performance Measure: Support coordinator follows up on incident reports with providers to put effective safeguards and interventions in place. Deficiency #7: 11 of 15 (73.33%) participants who experienced an incident received follow up with providers to develop safeguards and interventions. Safeguards and interventions were not put in place for 4 participants who experienced an incident.
Deficiencies have been, or are being corrected.

Provide an explaination of how these deficiencies have been, or are being corrected as well as an explanation of what steps have been taken to ensure the deficiencies do not recur:

Deficiency #1: The following action was taken to correct the deficiency. This issue was resolved when DSPD provided documentation that ABISC division staff received training stressing the importance of the timeliness of the re-determination of the level of care and that the Level of Care re-determinations need to be based on the findings in the CBIA. In addition, the ABI newsletter reminded staff that the level of care re-determinations cannot be completed without the completion of the CBIA. Finally, DSPD implemented an online tracking system in USTEPS that ensures a Level of Care determination cannot be completed without the completion of the CBIA. Deficiency #2: The following action was taken to correct the deficiency. This issue was resolved when DSPD submitted documentation to indicate support coordinators received retraining by DSPD Area Program Managers (APMs) reviewing the requirements of the CBIA assessment, including meeting the required score (40-120) and performing the assessment within 12 months of the previous assessment. In addition, the ABI newsletter reminded staff that the CBIA has to be administered at a minimum within 12 months from the completion of the previous CBIA assessment. Finally, DSPD provided documentation that training for ABISC division staff was conducted stressing the importance of the time frame in which the CBIA needs to be administered. Deficiency #3: The following action was taken to correct the deficiency. This issue was resolved when DSPD developed a “Support Coordinator External (SCE) Contract Compliance Review Instrument” to be used by the APM to review cases that are assigned to SCE’s. One of the areas of compliance requirements is the proper completion of the PCSP to ensure that the listed amount, duration, and frequency for each listed service is clearly identified. In addition, DSPD implemented the online tracking system in USTEPS which does not allow a service to be paid if it is not authorized on the PCSP. Finally, DSPD Program Director annually reviewed 20 cases to ensure amount, duration and frequency is appropriately and clearly identified for each listed service. Deficiency #4: The following action was taken to correct the deficiency. This issue was resolved when DSPD instructed the support coordinators that health and welfare/safety needs are addressed promptly and that necessary steps are taken to resolve concerns. In addition, DSPD developed a “Support Coordinator External (SCE) Contract Compliance Review Instrument” to be used by the APM to review cases that are assigned to SCE’s. One of the areas of compliance requirements is the health and safety to ensure support coordinators appropriately monitor and provide appropriate follow-up. Finally, The ABI Newsletter dated 5/1/10, reminded the staff that health and welfare/safety needs are to be addressed promptly and steps taken to resolve concerns. Deficiency #5: The following action was taken to correct the deficiency. This issue was resolved when DSPD Program Managers reviewed a sample of Activity Logs monthly to determine if Incident Reports were reported in a timely manner. The ABI Program Director re-trained support coordinators regarding the importance of meeting the timelines of incidents in four trainings across the State of Utah between 5/6/10 and 6/3/10. Deficiency #6: The following action was taken to correct the deficiency. This issue was resolved when DSPD Program Managers reviewed a sample of Activity Logs monthly to determine if Incident Reports were submitted in a timely manner. The ABI Program Director re-trained support coordinators regarding the importance of meeting the timelines of incidents in four trainings across the State of Utah between 5/6/10 and 6/3/10. Deficiency #7: The following action was taken to correct the deficiency. This issue was resolved when DSPD developed a memorandum for support coordinators, which was placed onto DSPD’s website, clarifying the expectation that they follow up on incident reports and document that follow-up and resolution in their activity logs. In addition, DSPD APM’s reviewed a sample of support coordinator files to include assessing if the incident was followed-up on by the support coordinator and resolved. The ABI Program Director re-trained support coordinators regarding the importance of Incident Report follow-ups with providers and consumers and log in any activities in the consumers log in four trainings across the State of Utah between 5/6/100 and 6/3/10.

Certification:

I, do certify that the information shown on the Form CMS-372(S) is correct to the best of my knowledge and belief:

Signature:

Date:

Phone Number:

Contact Information (optional):

Contact Person:

Phone Number: