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

UT
0247
ACCEPTED
Waiver Year:
Report Type:
$12,491 <= $38,068
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:
Adult Day Health Services
NF $164,418 177
-- Other
If Other, specify:
Homemaker Services
NF $1,458,731 469
-- Other
If Other, specify:
Respite Care Services
NF $221,707 50
-- Other
If Other, specify:
Respite Care Services LTC Facility
NF $22,538 20
-- Other
If Other, specify:
Waiver Case Management Services
NF $800,112 576
-- Other
If Other, specify:
Enhanced State Plan Supportive Maintenance Home Health Aide
NF $48,817 14
-- Other
If Other, specify:
Adult Companion Services
NF $292,242 177
-- Other
If Other, specify:
Chore Services
NF $12,840 34
-- Other
If Other, specify:
Environmental Accessibility Adaptations
NF $23,171 32
-- Other
If Other, specify:
Home Delivered Supplemental Meals
NF $244,437 266
-- Other
If Other, specify:
Medication Reminder Services
NF $18,672 38
-- Other
If Other, specify:
Personal Attendant Services Participant employed
NF $272,468 46
-- Other
If Other, specify:
Personal Attendant Services Agency employed
NF $66,517 12
-- Other
If Other, specify:
Personal Attendant Program Training
NF $0 0
-- Other
If Other, specify:
Personal Emergency Response Systems Response Center Service
NF $109,047 389
-- Other
If Other, specify:
Personal Emergency Response Systems Purchase, Rental & Repair
NF $1,070 30
-- Other
If Other, specify:
Personal Emergency Response Installation, Testing & Removal
NF $533 16
-- Other
If Other, specify:
Specialized Medical Equipment Supplies, Assistive Technology
NF $30,325 189
-- Other
If Other, specify:
Transportation Services - nonmedical
NF $120,787 115
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):