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

UT
0158
ACCEPTED
Waiver Year:
Report Type:
$40,059 <= $76,630
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:
Behavior Consultation Services I
ICF/MR $636,863 849
-- Other
If Other, specify:
Behavior Consultation Services II
ICF/MR $753,881 705
-- Other
If Other, specify:
Behavior Consultation Services III
ICF/MR $169,720 200
-- Other
If Other, specify:
Chore Services 15 minute
ICF/MR $146,352 87
-- Other
If Other, specify:
Companion Services 15 minute
ICF/MR $247,568 71
-- Other
If Other, specify:
Companion Services Daily
ICF/MR $79,525 20
-- Other
If Other, specify:
Day Supports (site/non-site)Hourly
ICF/MR $1,203,751 99
-- Other
If Other, specify:
Day Supports (site/non-site)Daily
ICF/MR $20,563,318 1,870
-- Other
If Other, specify:
Environmental Adaptations (home)
ICF/MR $109,722 67
-- Other
If Other, specify:
Environmental Adaptations (vehicle)
ICF/MR $11,456 6
-- Other
If Other, specify:
Extended Living Supports
ICF/MR $1,544,171 327
-- Other
If Other, specify:
Family Training and Preparation
ICF/MR $2,000 1
-- Other
If Other, specify:
Family and Individual Training and Preparation
ICF/MR $556 8
-- Other
If Other, specify:
Financial Management Services Low Tier
ICF/MR $424,023 1,253
-- Other
If Other, specify:
Financial Management Services High Tier
ICF/MR $198,576 177
-- Other
If Other, specify:
Homemaker Services
ICF/MR $119,007 42
-- Other
If Other, specify:
Living Start up Costs
ICF/MR $4,489 5
-- Other
If Other, specify:
Massage Therapy
ICF/MR $124,169 95
-- Other
If Other, specify:
Personal Assistance 15 minute
ICF/MR $1,032,550 286
-- Other
If Other, specify:
Personal Assistance Daily
ICF/MR $201,480 53
-- Other
If Other, specify:
Personal Budget Assistance 15 minute
ICF/MR $82,498 186
-- Other
If Other, specify:
Personal Budget Assistance Daily
ICF/MR $347,809 1,353
-- Other
If Other, specify:
Personal Emergency Response System monthly
ICF/MR $15,675 47
-- Other
If Other, specify:
Personal Emergency Response System installation
ICF/MR $300 6
-- Other
If Other, specify:
Personal Emergency Response System purchase
ICF/MR $293 2
-- Other
If Other, specify:
Professional Medication Monitoring
ICF/MR $741,742 1,017
-- Other
If Other, specify:
Residential Habilitation facility based
ICF/MR $65,386,697 1,328
-- Other
If Other, specify:
Residential Habilitation facility based-DCFS
ICF/MR $7,678,502 87
-- Other
If Other, specify:
Residential Habilitation Professional Parent/Host Home
ICF/MR $4,751,818 142
-- Other
If Other, specify:
Residential Habilitation Professional Parent DCFS
ICF/MR $5,815,089 148
-- Other
If Other, specify:
Respite Care 15 minute
ICF/MR $2,494,285 927
-- Other
If Other, specify:
Respite Care Daily
ICF/MR $1,281,724 639
-- Other
If Other, specify:
Respite Care-Group Daily
ICF/MR $114,146 126
-- Other
If Other, specify:
Respite Care-Out of home/R&B included
ICF/MR $232,758 122
-- Other
If Other, specify:
Respite Care Group/R&B included
ICF/MR $4,840 13
-- Other
If Other, specify:
Respite Care Intensive 15 minute
ICF/MR $274,278 139
-- Other
If Other, specify:
Respite Care Intensive Daily
ICF/MR $108,094 72
-- Other
If Other, specify:
Respite Care Intensive Out of home/R&B included Daily
ICF/MR $43,362 19
-- Other
If Other, specify:
Respite Care Weekly
ICF/MR $1,471,631 483
-- Other
If Other, specify:
Specialized Medical Equipment & Supplies monthly
ICF/MR $460 1
-- Other
If Other, specify:
Specialized Medical Equipment & Supplies purchase
ICF/MR $156,771 113
-- Other
If Other, specify:
Supported Employment 15 minute
ICF/MR $3,647,320 522
-- Other
If Other, specify:
Supported Employment Daily
ICF/MR $1,905,325 280
-- Other
If Other, specify:
Supported Living 15 Minute
ICF/MR $11,989,649 1,386
-- Other
If Other, specify:
Transportation Mileage
ICF/MR $45,988 65
-- Other
If Other, specify:
Transportation Daily
ICF/MR $2,827,844 1,790
-- Other
If Other, specify:
Transportation Bus pass purchase
ICF/MR $260,824 362
-- Other
If Other, specify:
Waiver Support Coordination
ICF/MR $11,968,705 4,399
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):