1. Request Information (2 of 3)

6. Level(s) of Care. This waiver is requested in order to provide home and community-based waiver services to individuals who, but for the provision of such services, would require the following level(s) of care, the costs of which would be reimbursed under the approved Medicaid State plan (check each that applies):
   Hospital
   Select applicable level of care

    Hospital as defined in 42 CFR §440.10

   If applicable, specify whether the State additionally limits the waiver to subcategories of the hospital level of care:

   Character Count: out of 6000

    Inpatient psychiatric facility for individuals age 21 and under as provided in42 CFR §440.160

    not selected
   Nursing Facility
   Select applicable level of care

    Nursing Facility As defined in 42 CFR §440.40 and 42 CFR §440.155

   If applicable, specify whether the State additionally limits the waiver to subcategories of the nursing facility level of care:

   Character Count: out of 6000

    Institution for Mental Disease for persons with mental illnesses aged 65 and older as provided in 42 CFR §440.140

    not selected
   Intermediate Care Facility for the Mentally Retarded (ICF/MR) (as defined in 42 CFR §440.150)
   If applicable, specify whether the State additionally limits the waiver to subcategories of the ICF/MR level of care:

   Character Count: out of 6000

1. Request Information (3 of 3)

7. Concurrent Operation with Other Programs. This waiver operates concurrently with another program (or programs) approved under the following authorities
   Select one:
    Not applicable
    Applicable
   Check the applicable authority or authorities:

   Services furnished under the provisions of §1915(a)(1)(a) of the Act and described in Appendix I

   Waiver(s) authorized under §1915(b) of the Act.

   Specify the §1915(b) waiver program and indicate whether a §1915(b) waiver application has been submitted or previously approved:

   Character Count: out of 6000

   Specify the §1915(b) authorities under which this program operates (check each that applies):

   §1915(b)(1) (mandated enrollment to managed care)

   §1915(b)(2) (central broker)

   §1915(b)(3) (employ cost savings to furnish additional services)

   §1915(b)(4) (selective contracting/limit number of providers)

   A program operated under §1932(a) of the Act.

   Specify the nature of the State Plan benefit and indicate whether the State Plan Amendment has been submitted or previously approved:

   Character Count: out of 6000

   A program authorized under §1915(i) of the Act.

   A program authorized under §1915(j) of the Act.

   A program authorized under §1115 of the Act.

   Specify the program:

   Character Count: out of 6000

   Not applicable
    not selected
8. Dual Eligiblity for Medicaid and Medicare.
   Check if applicable:
   This waiver provides services for individuals who are eligible for both Medicare and Medicaid.

2. Brief Waiver Description

3. Components of the Waiver Request

The waiver application consists of the following components. Note: Item 3-E must be completed.

1. Waiver Administration and Operation. Appendix A specifies the administrative and operational structure of this waiver.

2. Participant Access and Eligibility. Appendix B specifies the target group(s) of individuals who are served in this waiver, the number of participants that the State expects to serve during each year that the waiver is in effect, applicable Medicaid eligibility and post-eligibility (if applicable) requirements, and procedures for the evaluation and reevaluation of level of care.

3. Participant Services. Appendix C specifies the home and community-based waiver services that are furnished through the waiver, including applicable limitations on such services.

4. Participant-Centered Service Planning and Delivery. Appendix D specifies the procedures and methods that the State uses to develop, implement and monitor the participant-centered service plan (of care).

5. Participant-Direction of Services. When the State provides for participant direction of services, Appendix E specifies the participant direction opportunities that are offered in the waiver and the supports that are available to participants who direct their services. (Select one):
    Yes. This waiver provides participant direction opportunities. Appendix E is required.

    No. This waiver does not provide participant direction opportunities. Appendix E is not required.

    not selected

6. Participant Rights. Appendix F specifies how the State informs participants of their Medicaid Fair Hearing rights and other procedures to address participant grievances and complaints.

7. Participant Safeguards. Appendix G describes the safeguards that the State has established to assure the health and welfare of waiver participants in specified areas.

8. Quality Improvement Strategy. Appendix H contains the Quality Improvement Strategy for this waiver.

9. Financial Accountability. Appendix I describes the methods by which the State makes payments for waiver services, ensures the integrity of these payments, and complies with applicable federal requirements concerning payments and federal financial participation.

10. Cost-Neutrality Demonstration. Appendix J contains the State's demonstration that the waiver is cost-neutral.

4. Waiver(s) Requested

1. Comparability. The State requests a waiver of the requirements contained in §1902(a)(10)(B) of the Act in order to provide the services specified in Appendix C that are not otherwise available under the approved Medicaid State plan to individuals who: (a) require the level(s) of care specified in Item 1.F and (b) meet the target group criteria specified in Appendix B.
2. Income and Resources for the Medically Needy. Indicate whether the State requests a waiver of §1902(a)(10)(C)(i)(III) of the Act in order to use institutional income and resource rules for the medically needy (select one):
    Not Applicable

    No

    Yes

    not selected
3. Statewideness. Indicate whether the State requests a waiver of the statewideness requirements in §1902(a)(1) of the Act (select one):

   No

   Yes

   If yes, specify the waiver of statewideness that is requested (check each that applies):

   Geographic Limitation. A waiver of statewideness is requested in order to furnish services under this waiver only to individuals who reside in the following geographic areas or political subdivisions of the State.

   Specify the areas to which this waiver applies and, as applicable, the phase-in schedule of the waiver by geographic area:

   Character Count: out of 6000

   Limited Implementation of Participant-Direction. A waiver of statewideness is requested in order to make participant-direction of services as specified in Appendix E available only to individuals who reside in the following geographic areas or political subdivisions of the State. Participants who reside in these areas may elect to direct their services as provided by the State or receive comparable services through the service delivery methods that are in effect elsewhere in the State.

   Specify the areas of the State affected by this waiver and, as applicable, the phase-in schedule of the waiver by geographic area:

   Character Count: out of 6000

5. Assurances

1. Health & Welfare: The State assures that necessary safeguards have been taken to protect the health and welfare of persons receiving services under this waiver. These safeguards include:

   1. As specified in Appendix C, adequate standards for all types of providers that provide services under this waiver;

   2. Assurance that the standards of any State licensure or certification requirements specified in Appendix C are met for services or for individuals furnishing services that are provided under the waiver. The State assures that these requirements are met on the date that the services are furnished; and,

   3. Assurance that all facilities subject to §1616(e) of the Act where home and community-based waiver services are provided comply with the applicable State standards for board and care facilities as specified in Appendix C.

2. Financial Accountability. The State assures financial accountability for funds expended for home and community-based services and maintains and makes available to the Department of Health and Human Services (including the Office of the Inspector General), the Comptroller General, or other designees, appropriate financial records documenting the cost of services provided under the waiver. Methods of financial accountability are specified in Appendix I.

3. Evaluation of Need: The State assures that it provides for an initial evaluation (and periodic reevaluations, at least annually) of the need for a level of care specified for this waiver, when there is a reasonable indication that an individual might need such services in the near future (one month or less) but for the receipt of home and community based services under this waiver. The procedures for evaluation and reevaluation of level of care are specified in Appendix B.

4. Choice of Alternatives: The State assures that when an individual is determined to be likely to require the level of care specified for this waiver and is in a target group specified in Appendix B, the individual (or, legal representative, if applicable) is:

   1. Informed of any feasible alternatives under the waiver; and,

   2. Given the choice of either institutional or home and community based waiver services. Appendix B specifies the procedures that the State employs to ensure that individuals are informed of feasible alternatives under the waiver and given the choice of institutional or home and community-based waiver services.

5. Average Per Capita Expenditures: The State assures that, for any year that the waiver is in effect, the average per capita expenditures under the waiver will not exceed 100 percent of the average per capita expenditures that would have been made under the Medicaid State plan for the level(s) of care specified for this waiver had the waiver not been granted. Cost-neutrality is demonstrated in Appendix J.

6. Actual Total Expenditures: The State assures that the actual total expenditures for home and community-based waiver and other Medicaid services and its claim for FFP in expenditures for the services provided to individuals under the waiver will not, in any year of the waiver period, exceed 100 percent of the amount that would be incurred in the absence of the waiver by the State's Medicaid program for these individuals in the institutional setting(s) specified for this waiver.

7. Institutionalization Absent Waiver: The State assures that, absent the waiver, individuals served in the waiver would receive the appropriate type of Medicaid-funded institutional care for the level of care specified for this waiver.

8. Reporting: The State assures that annually it will provide CMS with information concerning the impact of the waiver on the type, amount and cost of services provided under the Medicaid State plan and on the health and welfare of waiver participants. This information will be consistent with a data collection plan designed by CMS.

9. Habilitation Services. The State assures that prevocational, educational, or supported employment services, or a combination of these services, if provided as habilitation services under the waiver are: (1) not otherwise available to the individual through a local educational agency under the Individuals with Disabilities Education Act (IDEA) or the Rehabilitation Act of 1973; and, (2) furnished as part of expanded habilitation services.

10. Services for Individuals with Chronic Mental Illness. The State assures that federal financial participation (FFP) will not be claimed in expenditures for waiver services including, but not limited to, day treatment or partial hospitalization, psychosocial rehabilitation services, and clinic services provided as home and community-based services to individuals with chronic mental illnesses if these individuals, in the absence of a waiver, would be placed in an IMD and are: (1) age 22 to 64; (2) age 65 and older and the State has not included the optional Medicaid benefit cited in 42 CFR §440.140; or (3) age 21 and under and the State has not included the optional Medicaid benefit cited in 42 CFR § 440.160.

7. Contact Person(s)

1. The Medicaid agency representative with whom CMS should communicate regarding the waiver is:

   Last Name:
   First Name:
   Title:
   Agency:
   Address:
   Address 2:
   City:
   State:	Utah
   Zip:
   Phone:	Ext: TTY
   Fax:
   E-mail:

2. If applicable, the State operating agency representative with whom CMS should communicate regarding the waiver is:

   Last Name:
   First Name:
   Title:
   Agency:
   Address:
   Address 2:
   City:
   State:	Utah
   Zip:
   Phone:	Ext: TTY
   Fax:
   E-mail:

Attachment #1: Transition Plan

Additional Needed Information (Optional)

Appendix A: Waiver Administration and Operation

7. Distribution of Waiver Operational and Administrative Functions. In the following table, specify the entity or entities that have responsibility for conducting each of the waiver operational and administrative functions listed (check each that applies):
   In accordance with 42 CFR §431.10, when the Medicaid agency does not directly conduct a function, it supervises the performance of the function and establishes and/or approves policies that affect the function. All functions not performed directly by the Medicaid agency must be delegated in writing and monitored by the Medicaid Agency. Note: More than one box may be checked per item. Ensure that Medicaid is checked when the Single State Medicaid Agency (1) conducts the function directly; (2) supervises the delegated function; and/or (3) establishes and/or approves policies related to the function.

   Function	Medicaid Agency	Other State Operating Agency
   Participant waiver enrollment
   Waiver enrollment managed against approved limits
   Waiver expenditures managed against approved levels
   Level of care evaluation
   Review of Participant service plans
   Prior authorization of waiver services
   Utilization management
   Qualified provider enrollment
   Execution of Medicaid provider agreements
   Establishment of a statewide rate methodology
   Rules, policies, procedures and information development governing the waiver program
   Quality assurance and quality improvement activities

Appendix A: Waiver Administration and Operation

Quality Improvement: Administrative Authority of the Single State Medicaid Agency

1. Methods for Discovery: Administrative Authority
   The Medicaid Agency retains ultimate administrative authority and responsibility for the operation of the waiver program by exercising oversight of the performance of waiver functions by other state and local/regional non-state agencies (if appropriate) and contracted entities.

   1. Performance Measures

      For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

      For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

      Performance Measure: Number and percentage of OA annual reports specified in the implementation plan that were submitted to the SMA on time and in the correct format. Data Source (Select one): Other If 'Other' is selected, specify: DSPD Annual reports and DSPD Annual Incident report Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      Performance Measure: Number and percentage of participants who received an annual level of care redetermination conducted at a minimum within 12 consecutive months of the last recorded level of care evaluation. Data Source (Select one): Other If 'Other' is selected, specify: DSPD records Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      Performance Measure: Number and percentage of OA documents submitted to and approved by the SMA using the Document Submittal Protocol prior to implementation. Data Source (Select one): Other If 'Other' is selected, specify: Document Approval forms and DSPD documents Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      Performance Measure: Number and percentage of maximum allowable rates (MARs) for covered waiver services approved by the SMA. Data Source (Select one): Other If 'Other' is selected, specify: Rate setting meetings minutes, Approval documentation and Correspondence Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      Performance Measure: Number and percentage of critical incidents and events of which the OA notifies the SMA on the first business day after occurrence as per SMA protocol. Data Source (Select one): Other If 'Other' is selected, specify: Critical Incident/Event findings Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

   2. If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.
      Character Count: out of 6000
      The SMA demonstrates ultimate administrative authority and responsibility for the operation of the PD waiver program through numerous activities including the issuance of policies, rules, and regulations relating to the waiver, the approval of all protocols, documents and trainings that affect any aspect of the PD waiver operations. Approvals are accomplished through a formal document approval process. The SMA also conducts quarterly meetings with DSPD (the operating agency), monitors compliance with the Interagency Agreement, conducts annual quality assurance reviews of the PD waiver program and provides technical assistance to the operating agency and other entities within the state that affect the operation of the waiver program. The SMA verifies compliance with the Administrative Authority performance measures annually. The sample size for each review will be sufficient to provide a confidence level equal to 95% and a confidence interval equal to five. A response distribution equal to 50% will be used to gather base line data for the first waiver year. The response distribution used for further reviews will reflect the findings gathered during the base line review. The SMA is the entity responsible for official communication with CMS for all issues related to the PD waiver.
2. Methods for Remediation/Fixing Individual Problems
   1. Describe the State’s method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.
      Character Count: out of 6000
      The SMA contracts with the Department of Human Services for the operation and implementation of the waiver as specified in the State Implementation Plan. The contract requires that DSPD fulfill all requirements stipulated in the implementation plan. When individual issues of non compliance occur, the SMA will require corrective action to achieve 100% compliance. Remediation will be documented in SMA Reports.
   2. Remediation Data Aggregation
      Remediation-related Data Aggregation and Analysis (including trend identification)

      Responsible Party (check each that applies):	Frequency of data aggregation and analysis (check each that applies):
      State Medicaid Agency	Weekly
      Operating Agency	Monthly
      Sub-State Entity	Quarterly
      Other Specify:	Annually
      	Continuously and Ongoing
      	Other Specify:

3. Timelines
   When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design methods for discovery and remediation related to the assurance of Administrative Authority that are currently non-operational.

    No

    Yes

    not selected
   Please provide a detailed strategy for assuring Administrative Authority, the specific timeline for implementing identified strategies, and the parties responsible for its operation.

   Character Count: out of 6000

Appendix B: Participant Access and Eligibility

B-1: Specification of the Waiver Target Group(s)

1. Target Group(s). Under the waiver of Section 1902(a)(10)(B) of the Act, the State limits waiver services to a group or subgroups of individuals. Please see the instruction manual for specifics regarding age limits. In accordance with 42 CFR §441.301(b)(6), select one waiver target group, check each of the subgroups in the selected target group that may receive services under the waiver, and specify the minimum and maximum (if any) age of individuals served in each subgroup:

   Target Group	Included	Target SubGroup	Minimum Age	Maximum Age
   				Maximum Age Limit	No Maximum Age Limit
   Aged or Disabled, or Both - General
   		Aged
   		Disabled (Physical)
   		Disabled (Other)
   Aged or Disabled, or Both - Specific Recognized Subgroups
   		Brain Injury
   		HIV/AIDS
   		Medically Fragile
   		Technology Dependent
   Mental Retardation or Developmental Disability, or Both
   		Autism
   		Developmental Disability
   		Mental Retardation
   Mental Illness
   		Mental Illness
   		Serious Emotional Disturbance
   not selected

2. Additional Criteria. The State further specifies its target group(s) as follows:

   Character Count: out of 12000
   The individual must: 1) Have established programmatic eligibility through the Utah Department of Human Services for state matching funds in accordance with Title 62A-Chapter 5-Part 1 and UAC R539-1-6 by meeting the following criteria: a)Have at least one personal attendant trained (or willing to be trained) and available to provide the authorized waiver services in a residence that is safe and can accommodate the personnel and equipment (if any) needed to adequately and safely care for the individual. The operating agency will provide information to the individual about potential community resources to assist them in recruiting an attendant. b)Be medically stable, have a physical disability and require in accordance with his/her physician’s written documentation, at least 14 hours per week of personal assistance services (as described in appendix B of this waiver) in order to remain in the community and prevent unwanted institutionalization. For purposes of this waiver, the individual’s qualifying disability and need for personal assistance services are attested to by a medically determinable physical impairment which the physician will expect to last for a continuous period of not less than 12 months and which has resulted in the individual’s functional loss of two or more limbs, to the extent that the assistance of another trained person(s) is required in order to accomplish activities of daily living/instrumental activities of daily living. c)Have decision making capability, as certified by his/her physician, of selecting, training and supervising her/his own attendant(s).* d)Have decision making capability of managing the individual’s own financial and legal affairs. 2) If a person is eligible for more than one of the waivers operated by DSPD, the Division will educate the individual about their choices and will advise the individual about which of the waivers will likely best meet their needs. * Individual’s possessing decision making capability, but having communication deficits or limited English proficiency may select a representative to communicate decisions on the individual’s behalf.

3. Transition of Individuals Affected by Maximum Age Limitation. When there is a maximum age limit that applies to individuals who may be served in the waiver, describe the transition planning procedures that are undertaken on behalf of participants affected by the age limit (select one):

   Not applicable. There is no maximum age limit

   The following transition planning procedures are employed for participants who will reach the waiver's maximum age limit.

   Specify:

   Character Count: out of 12000

   Clients age from the Disabled Physical to the Aged target group

Appendix B: Participant Access and Eligibility

B-2: Individual Cost Limit (1 of 2)

1. Individual Cost Limit. The following individual cost limit applies when determining whether to deny home and community-based services or entrance to the waiver to an otherwise eligible individual (select one) Please note that a State may have only ONE individual cost limit for the purposes of determining eligibility for the waiver:
    No Cost Limit. The State does not apply an individual cost limit. Do not complete Item B-2-b or item B-2-c.
    Cost Limit in Excess of Institutional Costs. The State refuses entrance to the waiver to any otherwise eligible individual when the State reasonably expects that the cost of the home and community-based services furnished to that individual would exceed the cost of a level of care specified for the waiver up to an amount specified by the State. Complete Items B-2-b and B-2-c.

   The limit specified by the State is (select one)

    A level higher than 100% of the institutional average.

   Specify the percentage:

    Other

   Specify:

   Character Count: out of 6000

    not selected
    Institutional Cost Limit. Pursuant to 42 CFR 441.301(a)(3), the State refuses entrance to the waiver to any otherwise eligible individual when the State reasonably expects that the cost of the home and community-based services furnished to that individual would exceed 100% of the cost of the level of care specified for the waiver. Complete Items B-2-b and B-2-c.
    Cost Limit Lower Than Institutional Costs. The State refuses entrance to the waiver to any otherwise qualified individual when the State reasonably expects that the cost of home and community-based services furnished to that individual would exceed the following amount specified by the State that is less than the cost of a level of care specified for the waiver.

   Specify the basis of the limit, including evidence that the limit is sufficient to assure the health and welfare of waiver participants. Complete Items B-2-b and B-2-c.

   Character Count: out of 6000

   The cost limit specified by the State is (select one):

    The following dollar amount:

   Specify dollar amount:

   The dollar amount (select one)

    Is adjusted each year that the waiver is in effect by applying the following formula:

   Specify the formula:

   Character Count: out of 6000

    May be adjusted during the period the waiver is in effect. The State will submit a waiver amendment to CMS to adjust the dollar amount.

    not selected

    The following percentage that is less than 100% of the institutional average:

   Specify percent:

    Other:

   Specify:

   Character Count: out of 6000

    not selected
    not selected

Appendix B: Participant Access and Eligibility

B-2: Individual Cost Limit (2 of 2)

2. Method of Implementation of the Individual Cost Limit. When an individual cost limit is specified in Item B-2-a, specify the procedures that are followed to determine in advance of waiver entrance that the individual's health and welfare can be assured within the cost limit:
   Character Count: out of 12000
3. Participant Safeguards. When the State specifies an individual cost limit in Item B-2-a and there is a change in the participant's condition or circumstances post-entrance to the waiver that requires the provision of services in an amount that exceeds the cost limit in order to assure the participant's health and welfare, the State has established the following safeguards to avoid an adverse impact on the participant (check each that applies):
   The participant is referred to another waiver that can accommodate the individual's needs.
   Additional services in excess of the individual cost limit may be authorized.

   Specify the procedures for authorizing additional services, including the amount that may be authorized:

   Character Count: out of 12000
   Other safeguard(s)

   Specify:

   Character Count: out of 12000

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served (1 of 4)

1. Unduplicated Number of Participants. The following table specifies the maximum number of unduplicated participants who are served in each year that the waiver is in effect. The State will submit a waiver amendment to CMS to modify the number of participants specified for any year(s), including when a modification is necessary due to legislative appropriation or another reason. The number of unduplicated participants specified in this table is basis for the cost-neutrality calculations in Appendix J:

   Table: B-3-a

   Waiver Year	Unduplicated Number of Participants
   Year 1
   Year 2
   Year 3
   Year 4
   Year 5

2. Limitation on the Number of Participants Served at Any Point in Time. Consistent with the unduplicated number of participants specified in Item B-3-a, the State may limit to a lesser number the number of participants who will be served at any point in time during a waiver year. Indicate whether the State limits the number of participants in this way: (select one):

   The State does not limit the number of participants that it serves at any point in time during a waiver year.

   The State limits the number of participants that it serves at any point in time during a waiver year.

   The limit that applies to each year of the waiver period is specified in the following table:

   Table: B-3-b

   Waiver Year	Maximum Number of Participants Served At Any Point During the Year
   Year 1
   Year 2
   Year 3
   Year 4
   Year 5

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served (2 of 4)

3. Reserved Waiver Capacity. The State may reserve a portion of the participant capacity of the waiver for specified purposes (e.g., provide for the community transition of institutionalized persons or furnish waiver services to individuals experiencing a crisis) subject to CMS review and approval. The State (select one):

   Not applicable. The state does not reserve capacity.

   The State reserves capacity for the following purpose(s).

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served (3 of 4)

4. Scheduled Phase-In or Phase-Out. Within a waiver year, the State may make the number of participants who are served subject to a phase-in or phase-out schedule (select one):

   The waiver is not subject to a phase-in or a phase-out schedule.

   The waiver is subject to a phase-in or phase-out schedule that is included in Attachment #1 to Appendix B-3. This schedule constitutes an intra-year limitation on the number of participants who are served in the waiver.

5. Allocation of Waiver Capacity.

   Select one:

   Waiver capacity is allocated/managed on a statewide basis.

   Waiver capacity is allocated to local/regional non-state entities.

   Specify: (a) the entities to which waiver capacity is allocated; (b) the methodology that is used to allocate capacity and how often the methodology is reevaluated; and, (c) policies for the reallocation of unused capacity among local/regional non-state entities:

   Character Count: out of 12000
6. Selection of Entrants to the Waiver. Specify the policies that apply to the selection of individuals for entrance to the waiver:
   Character Count: out of 12000
   A. Medicaid recipients who meet the programmatic eligibility requirements as defined in Appendix B-1: 1b for the Physical Disabilities waiver may choose to receive services in a NF (Nursing Facility) or through the Physical Disabilities waiver. If available capacity exists individuals are given the opportunity to choose to receive services to meet the identified needs through a NF or enter the Physical Disabilities waiver. The applicant’s choice will be documented in writing, signed by the applicant, and maintained as part of the individual record. B. If no available capacity exists in the Physical Disabilities waiver, the applicant will be advised in writing that he or she may access services through a NF or may wait for open capacity to develop in the Physical Disabilities Waiver. If the individual chooses to wait for open capacity the operating agency provides information about community resources to assist the individual. In addition, if the individual is currently Medicaid eligible, they have access to Medicaid State Plan services. The State has developed policies prioritizing access to individuals waiting for waiver services. These policies provide opportunities for access to individuals residing in the community and in institutional settings. The Division of Services for People with Disabilities has established a Critical Needs Assessment process by which individuals are ranked to prioritize access to waiver services. A significant component of the Critical Needs Assessment tool addresses the immediacy of the need for services and the individual’s risk in not gaining access to waiver services. Individuals in nursing facilities do not demonstrate an immediate need for services, nor do they present as being at high risk if waiver services are not extended to them. Individuals in institutional facilities rank extremely low on the prioritization for receipt of waiver services. The State recognized this problem and initiated a separate process in which individuals in institutional settings may gain access to waiver services. Medicaid recipients residing in nursing facilities, meeting the Physical Disabilities waiver criteria, may gain access to the waiver by having the State general funds that supported the person in the nursing facility follow the person into the Physical Disabilities waiver, the money-follows-the-person concept. The State believes the existence of these two access points of admission into the waiver is an equitable methodology to support access from both the institution and the community. This methodology is supported by the State’s Olmstead Advisory Committee and has not resulted in growth of the NF program. The State has chosen to not reserve capacity to accommodate both points of entry and will amend the waiver if necessary.

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served - Attachment #1 (4 of 4)

Appendix B: Participant Access and Eligibility

B-4: Eligibility Groups Served in the Waiver

1. 1. State Classification. The State is a (select one):
       §1634 State
       SSI Criteria State
       209(b) State
       not selected
   2. Miller Trust State.
      Indicate whether the State is a Miller Trust State (select one):
       No
       Yes
       Unknown
2. Medicaid Eligibility Groups Served in the Waiver. Individuals who receive services under this waiver are eligible under the following eligibility groups contained in the State plan. The State applies all applicable federal financial participation limits under the plan. Check all that apply:
   Eligibility Groups Served in the Waiver (excluding the special home and community-based waiver group under 42 CFR §435.217)
   Low income families with children as provided in §1931 of the Act
   SSI recipients
   Aged, blind or disabled in 209(b) states who are eligible under 42 CFR §435.121
   Optional State supplement recipients
   Optional categorically needy aged and/or disabled individuals who have income at:

   Select one:

    100% of the Federal poverty level (FPL)

    % of FPL, which is lower than 100% of FPL.

   Specify percentage:

    not selected
   Working individuals with disabilities who buy into Medicaid (BBA working disabled group as provided in §1902(a)(10)(A)(ii)(XIII)) of the Act)
   Working individuals with disabilities who buy into Medicaid (TWWIIA Basic Coverage Group as provided in §1902(a)(10)(A)(ii)(XV) of the Act)
   Working individuals with disabilities who buy into Medicaid (TWWIIA Medical Improvement Coverage Group as provided in §1902(a)(10)(A)(ii)(XVI) of the Act)
   Disabled individuals age 18 or younger who would require an institutional level of care (TEFRA 134 eligibility group as provided in §1902(e)(3) of the Act)
   Medically needy
   Medically needy in 209(b) States (42 CFR §435.330)
   Medically needy in 1634 States and SSI Criteria States (42 CFR §435.320, §435.322 and §435.324)
   Other specified groups (include only statutory/regulatory reference to reflect the additional groups in the State plan that may receive services under this waiver)

   Specify:

   Character Count: out of 6000
   Special home and community-based waiver group under 42 CFR §435.217) Note: When the special home and community-based waiver group under 42 CFR §435.217 is included, Appendix B-5 must be completed
    No. The State does not furnish waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217. Appendix B-5 is not submitted.

    Yes. The State furnishes waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217.

    not selected

   Select one and complete Appendix B-5.

    All individuals in the special home and community-based waiver group under 42 CFR §435.217

    Only the following groups of individuals in the special home and community-based waiver group under 42 CFR §435.217

    not selected

   Check each that applies:

   A special income level equal to:

   Select one:

    300% of the SSI Federal Benefit Rate (FBR)

    A percentage of FBR, which is lower than 300% (42 CFR §435.236)

   Specify percentage:

    A dollar amount which is lower than 300%.

   Specify dollar amount:

    not selected

   Aged, blind and disabled individuals who meet requirements that are more restrictive than the SSI program (42 CFR §435.121)

   Medically needy without spenddown in States which also provide Medicaid to recipients of SSI (42 CFR §435.320, §435.322 and §435.324)

   Medically needy without spend down in 209(b) States (42 CFR §435.330)

   Aged and disabled individuals who have income at:

   Select one:

    100% of FPL

    % of FPL, which is lower than 100%.

   Specify percentage amount:

    not selected

   Other specified groups (include only statutory/regulatory reference to reflect the additional groups in the State plan that may receive services under this waiver)

   Specify:

   Character Count: out of 6000

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (1 of 4)

In accordance with 42 CFR §441.303(e), Appendix B-5 must be completed when the State furnishes waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217, as indicated in Appendix B-4. Post-eligibility applies only to the 42 CFR §435.217 group. A State that uses spousal impoverishment rules under §1924 of the Act to determine the eligibility of individuals with a community spouse may elect to use spousal post-eligibility rules under §1924 of the Act to protect a personal needs allowance for a participant with a community spouse.

1. Use of Spousal Impoverishment Rules. Indicate whether spousal impoverishment rules are used to determine eligibility for the special home and community-based waiver group under 42 CFR §435.217 (select one):

    Spousal impoverishment rules under §1924 of the Act are used to determine the eligibility of individuals with a community spouse for the special home and community-based waiver group.

   In the case of a participant with a community spouse, the State elects to (select one):

    Use spousal post-eligibility rules under §1924 of the Act.

   (Complete Item B-5-b (SSI State) and Item B-5-d)

    Use regular post-eligibility rules under 42 CFR §435.726 (SSI State) or under §435.735 (209b State)

   (Complete Item B-5-b (SSI State) . Do not complete Item B-5-d)

    not selected

    Spousal impoverishment rules under §1924 of the Act are not used to determine eligibility of individuals with a community spouse for the special home and community-based waiver group. The State uses regular post-eligibility rules for individuals with a community spouse.

   (Complete Item B-5-b (SSI State) . Do not complete Item B-5-d)

    not selected

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (2 of 4)

2. Regular Post-Eligibility Treatment of Income: SSI State.

   The State uses the post-eligibility rules at 42 CFR 435.726. Payment for home and community-based waiver services is reduced by the amount remaining after deducting the following allowances and expenses from the waiver participant's income:

   1. Allowance for the needs of the waiver participant (select one):

       The following standard included under the State plan

      Select one:

       SSI standard

       Optional State supplement standard

       Medically needy income standard

       The special income level for institutionalized persons

      (select one):

       300% of the SSI Federal Benefit Rate (FBR)

       A percentage of the FBR, which is less than 300%

      Specify the percentage:

       A dollar amount which is less than 300%.

      Specify dollar amount:

       not selected

       A percentage of the Federal poverty level

      Specify percentage:

       Other standard included under the State Plan

      Specify:

      Character Count: out of 36000

       not selected
       The following dollar amount

      Specify dollar amount: If this amount changes, this item will be revised.
       The following formula is used to determine the needs allowance:

      Specify:

      Character Count: out of 6000
       Other

      Specify:

      Character Count: out of 6000
       not selected

   2. Allowance for the spouse only (select one):

       Not Applicable (see instructions)
       SSI standard
       Optional State supplement standard
       Medically needy income standard
       The following dollar amount:

      Specify dollar amount: If this amount changes, this item will be revised.
       The amount is determined using the following formula:

      Specify:

      Character Count: out of 6000
       not selected

   3. Allowance for the family (select one):

       Not Applicable (see instructions)
       AFDC need standard
       Medically needy income standard
       The following dollar amount:

      Specify dollar amount: The amount specified cannot exceed the higher of the need standard for a family of the same size used to determine eligibility under the State's approved AFDC plan or the medically needy income standard established under 42 CFR §435.811 for a family of the same size. If this amount changes, this item will be revised.
       The amount is determined using the following formula:

      Specify:

      Character Count: out of 6000
       Other

      Specify:

      Character Count: out of 6000
       not selected

   4. Amounts for incurred medical or remedial care expenses not subject to payment by a third party, specified in 42 §CFR 435.726:

      1. Health insurance premiums, deductibles and co-insurance charges
      2. Necessary medical or remedial care expenses recognized under State law but not covered under the State's Medicaid plan, subject to reasonable limits that the State may establish on the amounts of these expenses.

      Select one:

       Not Applicable (see instructions) Note: If the State protects the maximum amount for the waiver participant, not applicable must be selected.
       The State does not establish reasonable limits.
       The State establishes the following reasonable limits

      Specify:

      Character Count: out of 6000
       not selected

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (3 of 4)

3. Regular Post-Eligibility Treatment of Income: 209(B) State.

   Answers provided in Appendix B-4 indicate that you do not need to complete this section and therefore this section is not visible.

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (4 of 4)

4. Post-Eligibility Treatment of Income Using Spousal Impoverishment Rules

   The State uses the post-eligibility rules of §1924(d) of the Act (spousal impoverishment protection) to determine the contribution of a participant with a community spouse toward the cost of home and community-based care if it determines the individual's eligibility under §1924 of the Act. There is deducted from the participant’s monthly income a personal needs allowance (as specified below), a community spouse's allowance and a family allowance as specified in the State Medicaid Plan.. The State must also protect amounts for incurred expenses for medical or remedial care (as specified below).

   Answers provided in Appendix B-5-a indicate that you do not need to complete this section and therefore this section is not visible.

Appendix B: Participant Access and Eligibility

B-6: Evaluation/Reevaluation of Level of Care

1. Reasonable Indication of Need for Services. In order for an individual to be determined to need waiver services, an individual must require: (a) the provision of at least one waiver service, as documented in the service plan, and (b) the provision of waiver services at least monthly or, if the need for services is less than monthly, the participant requires regular monthly monitoring which must be documented in the service plan. Specify the State's policies concerning the reasonable indication of the need for services:

   1. Minimum number of services.

      The minimum number of waiver services (one or more) that an individual must require in order to be determined to need waiver services is:
   2. Frequency of services. The State requires (select one):
       The provision of waiver services at least monthly
       Monthly monitoring of the individual when services are furnished on a less than monthly basis

      If the State also requires a minimum frequency for the provision of waiver services other than monthly (e.g., quarterly), specify the frequency:

      Character Count: out of 4000
       not selected
2. Responsibility for Performing Evaluations and Reevaluations. Level of care evaluations and reevaluations are performed (select one):
    Directly by the Medicaid agency
    By the operating agency specified in Appendix A
    By an entity under contract with the Medicaid agency.

   Specify the entity:

   Character Count: out of 4000
    Other
   Specify:

   Character Count: out of 4000
    not selected
3. Qualifications of Individuals Performing Initial Evaluation: Per 42 CFR §441.303(c)(1), specify the educational/professional qualifications of individuals who perform the initial evaluation of level of care for waiver applicants:

   Character Count: out of 6000
   Individuals performing initial level of care evaluations will be Utah licensed registered nurses employed by the operating agency.
4. Level of Care Criteria. Fully specify the level of care criteria that are used to evaluate and reevaluate whether an individual needs services through the waiver and that serve as the basis of the State's level of care instrument/tool. Specify the level of care instrument/tool that is employed. State laws, regulations, and policies concerning level of care criteria and the level of care instrument/tool are available to CMS upon request through the Medicaid agency or the operating agency (if applicable), including the instrument/tool utilized.

   Character Count: out of 12000
   Utah State administrative rule R414-502 delineates the nursing facility level of care criteria that must be met to qualify for Medicaid reimbursement under the State Plan nursing facility benefit. In accordance with R414-502, in determining whether an applicant has mental or physical conditions that can only be cared for in a nursing facility, or equivalent alternative Medicaid health care delivery programs, must document that at least two of the following factors exist: a) Due to diagnosed medical conditions, the applicant requires substantial physical maintenance with activities of daily living above the level of verbal prompting, supervision, or setting up; b) The attending physician has determined that the applicant’s level of dysfunction in orientation to person, place or time requires nursing facility care; or equivalent care provided through an alternative Medicaid health delivery program; or c) The medical condition and intensity of services indicate that the care needs of the applicant cannot be safely met in a less structured setting; or without the services and supports of an alternative Medicaid health care delivery program. The Operating Agency will provide for an evaluation (and periodic reevaluations) assessment using the standard waiver instrument, InterRAI MINIMUM DATA SET – HOME CARE (MDS-HC), described in Appendix B-6(e), to assess the level of care specified in item 1-F of this request, when there is a reasonable indication that individuals might need such services in the near future, but for the availability of home and community-based services.
5. Level of Care Instrument(s). Per 42 CFR §441.303(c)(2), indicate whether the instrument/tool used to evaluate level of care for the waiver differs from the instrument/tool used to evaluate institutional level of care (select one):
    The same instrument is used in determining the level of care for the waiver and for institutional care under the State Plan.
    A different instrument is used to determine the level of care for the waiver than for institutional care under the State plan.

   Describe how and why this instrument differs from the form used to evaluate institutional level of care and explain how the outcome of the determination is reliable, valid, and fully comparable.

   Character Count: out of 12000

   The InterRAI MINIMUM DATA SET - HOME CARE (MDS-HC) is the instrument used to determine the level of care for this waiver. Persons responsible for collecting the needed information and for making level of care determinations are trained by staff, of the Division of Services for People with Disabilities (DSPD), in the proper application of the MDS-HC instrument and the proper analysis of the MDS-HC data to perform level of care evaluations. The MDS-HC is a comprehensive, standardized instrument for evaluating the needs, strengths and preferences of clients of home care agencies. The MDS-HC also acts as a screening component that enables a home care provider to assess multiple key domains of function, health, social support and service use. Particular MDS-HC items identify clients who could benefit from further evaluation of specific problems and risk for functional decline. The MDS-HC has been designed to be compatible with the family of InterRAI assessment and problem identification tools, which includes the MDS (InterRAI Minimum Data Set) nursing home assessment instrument. Such compatibility promotes continuity of care through a seamless geriatric assessment system across multiple health care settings, and promotes a person-centered evaluation in contradiction to a site-specific assessment. Accordingly, the main differences between the MDS-HC and the MDS is that the MDS includes assessment information more pertinent to a residential facility setting, addressing structural problems related to performance of ADLs (Activities of Daily Living) in a facility, activity pursuit patterns, discharge potential and overall status and therapy supplement. Whereas the MDS-HC includes assessment information more pertinent to community living by addressing social functioning, informal support services, preventative health measures, environmental assessment, service utilization of home care services, medications (prescription, non-prescription and herbal), resource/support and services assessment and information, social resource assessment, caregiver assessment, social support information, additional medical problems and nurse summary sections. Despite these differences, both the MDS-HC and MDS assessments help to determine level of care by including basic assessment data related to the individual. This information includes: identification and background information, cognitive patterns, communication/hearing patterns, vision patterns, mood and behavior patterns, physical functioning [IADL (Instrumental Activities of Daily Living) and ADL performance], continence, disease diagnoses, health conditions, nutrition/hydration status, skin condition, special treatments and therapies and programs.
    not selected
6. Process for Level of Care Evaluation/Reevaluation: Per 42 CFR §441.303(c)(1), describe the process for evaluating waiver applicants for their need for the level of care under the waiver. If the reevaluation process differs from the evaluation process, describe the differences:

   Character Count: out of 12000
   The State Operating Agency utilizes the following process to make level of care determinations as follows: The registered nurse employed by the Operating Agency will conduct a face to face level of care assessment using the standard waiver instrument described in Appendix B-6(e). This assessment is conducted at the individual’s current living environment.
7. Reevaluation Schedule. Per 42 CFR §441.303(c)(4), reevaluations of the level of care required by a participant are conducted no less frequently than annually according to the following schedule (select one):
    Every three months
    Every six months
    Every twelve months
    Other schedule
   Specify the other schedule:

   Character Count: out of 4000

   A full level of care reevaluation is conducted at a minimum within 12 consecutive months of the last recorded full level of care evaluation, or more frequently, whenever indicated by a significant change in the individual’s health status. The individual’s level of care is screened at the time a substantial change in the individual’s health status occurs, including at the conclusion of an inpatient stay in a medical institution, to determine whether the individual’s resultant health status constitutes an ongoing nursing facility level of care. The screening date and determination are documented in the individual’s activity log.
    not selected
8. Qualifications of Individuals Who Perform Reevaluations. Specify the qualifications of individuals who perform reevaluations (select one):
    The qualifications of individuals who perform reevaluations are the same as individuals who perform initial evaluations.
    The qualifications are different.
   Specify the qualifications:

   Character Count: out of 6000
    not selected
9. Procedures to Ensure Timely Reevaluations. Per 42 CFR §441.303(c)(4), specify the procedures that the State employs to ensure timely reevaluations of level of care (specify):

   Character Count: out of 6000
   The Utah Systems for Tracking Eligibility, Planning and Services (USTEPS), developed and maintained by the Division of Services for People with Disabilities, creates an automated tickler “to do” message that is sent at the beginning of the month in which a re-evaluation is due.
10. Maintenance of Evaluation/Reevaluation Records. Per 42 CFR §441.303(c)(3), the State assures that written and/or electronically retrievable documentation of all evaluations and reevaluations are maintained for a minimum period of 3 years as required in 45 CFR §92.42. Specify the location(s) where records of evaluations and reevaluations of level of care are maintained:

    Character Count: out of 6000
    Electronically retrievable documentation of all evaluations and re-evaluations are maintained within the Utah Systems for Tracking Eligibility, Planning and Services (USTEPS) system. To assure documents are retrievable, standard data back-up procedures employed with the UTSTEPS database include: • The DSPD_USTEPS_PROD_DB is backed up from Sybase database to a disk dump at 10:30 PM every night. The Uniplexed Information and Computing System (UNIX) backup occurs on the following schedule (these are backups to tape): • Monthly Full on 1st of each month – copies are retained on and off site for 3 years

Appendix B: Evaluation/Reevaluation of Level of Care

Quality Improvement: Level of Care

1. Methods for Discovery: Level of Care Assurance/Sub-assurances
   1. Sub-Assurances:

      1. Sub-assurance: An evaluation for LOC is provided to all applicants for whom there is reasonable indication that services may be needed in the future.

         Performance Measures

         For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

         For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

         Performance Measure: Number and percentage of new enrollees who met level of care prior to receiving PD waiver services. Data Source (Select one): Other If 'Other' is selected, specify: DSPD records Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      2. Sub-assurance: The levels of care of enrolled participants are reevaluated at least annually or as specified in the approved waiver.

         Performance Measures

         For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

         For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

         Performance Measure: Number and percentage of participants who received an annual level of care redetermination conducted at a minimum within 12 consecutive months of the last recorded level of care evaluation. Data Source (Select one): Other If 'Other' is selected, specify: Waiver participant records Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

         Performance Measure: Number and percentage of health status change screenings conducted when a substantial change in health status occurs and/or at the conclusion of an inpatient stay in a medical institution to determine an ongoing need for nursing facility level of care. Data Source (Select one): Other If 'Other' is selected, specify: Waiver participant records Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

         Performance Measure: Number and percentage of level of care reevaluations conducted when indicated by a health status change screening. Data Source (Select one): Other If 'Other' is selected, specify: Waiver participant records Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      3. Sub-assurance: The processes and instruments described in the approved waiver are applied appropriately and according to the approved description to determine participant level of care.

         Performance Measures

         For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

         For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

         Performance Measure: Number and percentage of individuals who conduct level of care evaluations and reevaluations and have a current Utah Registered Nurse license and are employed by the OA. Data Source (Select one): Other If 'Other' is selected, specify: Waiver Participant records and DSPD records Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

         Performance Measure: Number and percentage of individuals whose level of care reevaluation was conducted during a face to face visit. Data Source (Select one): Other If 'Other' is selected, specify: Waiver participant records and USTEPS Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

   2. If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.
      Character Count: out of 6000
      Individuals who request services from DSPD are screened for level of care for all waivers, ranked according to a critical needs assessment process and placed on the waiting list. When the individual is taken off the waiting list, the PD Administrative Case Manager determines if the individual needs services from the PD waiver program. For all individuals who have been taken off the waiting list and require services, an evaluation for level of care is conducted by the Administrative Case Manager. DSPD is the entity that will conduct level of care reviews. Findings from the reviews will be submitted to the SMA. The sample size for each review will be sufficient to provide a confidence level equal to 95% and a confidence interval equal to five. A response distribution equal to 50% will be used to gather base line data for the first waiver year. Base line data will be collected over a two year period with 50% of the total sample size collected each year. The response distribution used for further reviews will reflect the findings gathered during the base line review.
2. Methods for Remediation/Fixing Individual Problems
   1. Describe the State’s method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.
      Character Count: out of 6000
      Individual issues regarding the accuracy of level of care determination are addressed and corrected immediately by DSPD to assure that all participants meet nursing facility level of care. Plans of correction (such as training) may be required to assure future compliance. To assure all issues have been addressed entities assigned the responsibility of review and remediation are required to report back to the OA or SMA on the results of their interventions within designated time frames. Results of the reviews will be documented in DSPD and SMA Final Reports.
   2. Remediation Data Aggregation
      Remediation-related Data Aggregation and Analysis (including trend identification)

      Responsible Party (check each that applies):	Frequency of data aggregation and analysis (check each that applies):
      State Medicaid Agency	Weekly
      Operating Agency	Monthly
      Sub-State Entity	Quarterly
      Other Specify:	Annually
      	Continuously and Ongoing
      	Other Specify:

3. Timelines
   When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design methods for discovery and remediation related to the assurance of Level of Care that are currently non-operational.

    No

    Yes

    not selected
   Please provide a detailed strategy for assuring Level of Care, the specific timeline for implementing identified strategies, and the parties responsible for its operation.

   Character Count: out of 6000

Appendix B: Participant Access and Eligibility

B-7: Freedom of Choice

1. Procedures. Specify the State's procedures for informing eligible individuals (or their legal representatives) of the feasible alternatives available under the waiver and allowing these individuals to choose either institutional or waiver services. Identify the form(s) that are employed to document freedom of choice. The form or forms are available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
   Character Count: out of 12000
   Freedom of Choice is documented in the Care Plan. Freedom of choice procedures: 1. When an individual is determined eligible for waiver services, the individual and the individual’s representative, if applicable, will be informed of the alternatives available under the waiver and offered the choice of institutional care (NF) or home and community-based care. A copy of the Division of Services for People with Disabilities (DSPD) publication AN INTRODUCTORY GUIDE—Division of Services for People with Disabilities (hereafter referred to as the Guide), which describes the array of services and supports available in Utah including nursing facilities and the Home and Community Based Services Waiver program, is given to each individual applying for waiver services. 2. The administrative case manager will offer the choice of waiver services only if: a. The individual's needs assessment indicates the services the individual requires, including waiver services, are available in the community. b. The individual support plan has been agreed to by all parties. c. The health and safety of the individual can be adequately protected in relation to the delivery of waiver services and supports. 3. Once the individual has chosen home and community-based waiver services, the choice has been documented by the administrative case manger and the individual has received a copy of the Guide, subsequent review of choice of program will only be required at the time a substantial change in the enrollee’s condition results in a change in the individual support plan. It is, however, the individual’s option to choose institutional (NF) care at any time during the period they are in the waiver. 4. The waiver enrollee, and the individual’s legal representative if applicable, will be given the opportunity to choose the providers of waiver services identified on the individual support plan if more than one qualified provider is available to render the services. The individual’s choice of providers will be documented in the individual’s support plan. 5. The agency will provide an opportunity for a fair hearing, under 42 CFR Part 431, subpart E, to beneficiaries who are not given the choice of home or community-based services as an alternative to the institutional care specified for this request, or who are denied the waiver service(s) of their choice or the waiver provider(s) of their choice.
2. Maintenance of Forms. Per 45 CFR §92.42, written copies or electronically retrievable facsimiles of Freedom of Choice forms are maintained for a minimum of three years. Specify the locations where copies of these forms are maintained.
   Character Count: out of 4000
   The Freedom of Choice, documented in the Care Plan as part of the person centered support planning process, is maintained in the individual’s case record maintained by the Operating Agency in hard copy format.

Appendix B: Participant Access and Eligibility

B-8: Access to Services by Limited English Proficiency Persons

Appendix C: Participant Services

C-1: Summary of Services Covered (1 of 2)

1. Waiver Services Summary. List the services that are furnished under the waiver in the following table. If case management is not a service under the waiver, complete items C-1-b and C-1-c:

   Service Type	Service
   Statutory Service	Personal Attendant Services
   Supports for Participant Direction	Consumer Preparation Services
   Supports for Participant Direction	Financial Management Services
   Other Service	Local Area Support Coordination Liaison
   Other Service	Personal Emergency Response Systems (PERS)

Appendix C: Participant Services

C-1: Summary of Services Covered (2 of 2)

2. Provision of Case Management Services to Waiver Participants. Indicate how case management is furnished to waiver participants (select one):
    not selected
    Not applicable - Case management is not furnished as a distinct activity to waiver participants.
    Applicable - Case management is furnished as a distinct activity to waiver participants.
   Check each that applies:

   As a waiver service defined in Appendix C-3. Do not complete item C-1-c.

   As a Medicaid State plan service under §1915(i) of the Act (HCBS as a State Plan Option). Complete item C-1-c.

   As a Medicaid State plan service under §1915(g)(1) of the Act (Targeted Case Management). Complete item C-1-c.

   As an administrative activity. Complete item C-1-c. NOTE: Pursuant to CMS-2237-IFC this selection is no longer available for 1915(c) waivers.

   Not applicable - Case management is not furnished as a distinct activity to waiver participants. Do not complete item C-1-c.
    None of the above apply - Case management is furnished as a waiver service (Do not complete item C-1-c).

3. Delivery of Case Management Services. Specify the entity or entities that conduct case management functions on behalf of waiver participants:

   Character Count: out of 4000
   Administrative Case Management Services are provided by the Utah licensed registered nurses employed by the Operating Agency (DSPD).

Appendix C: Participant Services

C-2: General Service Specifications (1 of 3)

1. Criminal History and/or Background Investigations. Specify the State's policies concerning the conduct of criminal history and/or background investigations of individuals who provide waiver services (select one):

   No. Criminal history and/or background investigations are not required.

   Yes. Criminal history and/or background investigations are required.

   Specify: (a) the types of positions (e.g., personal assistants, attendants) for which such investigations must be conducted; (b) the scope of such investigations (e.g., state, national); and, (c) the process for ensuring that mandatory investigations have been conducted. State laws, regulations and policies referenced in this description are available to CMS upon request through the Medicaid or the operating agency (if applicable):

   Character Count: out of 12000

   UCA 62A-2-120 through 122 and R501-14, of the Utah Human Services Administration, require all persons having direct access to children or vulnerable adults to undergo a criminal history/background investigation except in the case where the waiver enrollee has chosen to self-employ a family member as part of their self directed program. The Office of Licensing, an agency within the Utah Department of Human Services, has the responsibility of conducting background checks on all direct care workers who provide waiver services. The scope of the investigation includes a check of the State’s child and adult abuse registries (maintained by The Utah Division of Child and Family Services and The Utah Division of Aging and Adult Services respectively), and a Criminal History check through the Criminal Investigations and Technical Services Division of the Department of Public Safety. If a person has lived outside the State of Utah or in any foreign countries for six or more consecutive weeks within the last five years, the FBI National Criminal History Records and National Criminal History will be accessed to conduct a check in those states and countries where the person resided. The Division of Services for People with Disabilities (DSPD) maintains a database on all approved employees. DSPD will not approve payments if the required screenings have not been completed. For providers under the Self Administered Service Model, the state will withhold payments for services for anyone who has not completed a background check within the first 30 days of being hired. The Division of Services for People with Disabilities (DSPD) has the ability to view the database of the Office of Licensing in regards to the status of employees hired under the self-administered model. All employees are required to renew their background checks on an annual basis. A client has the option of having a criminal background check completed on a family member if they chose to do that, but it is not required. The health and safety of clients are ensured by routinely scheduled face-to-face visits by support coordinators, and by quality monitoring reviews by both the operating agency and the State Medicaid Agency.

2. Abuse Registry Screening. Specify whether the State requires the screening of individuals who provide waiver services through a State-maintained abuse registry (select one):

   No. The State does not conduct abuse registry screening.

   Yes. The State maintains an abuse registry and requires the screening of individuals through this registry.

   Specify: (a) the entity (entities) responsible for maintaining the abuse registry; (b) the types of positions for which abuse registry screenings must be conducted; and, (c) the process for ensuring that mandatory screenings have been conducted. State laws, regulations and policies referenced in this description are available to CMS upon request through the Medicaid agency or the operating agency (if applicable):

   Character Count: out of 12000

   UCA 62A-2-120 through 122 and R501-14, of the Utah Human Services Administration, require all persons having direct access to children or vulnerable adults to undergo an abuse screening except in the case where the waiver enrollee has chosen to self-employ a family member as part of their self directed program. The Utah Division of Aging and Adult Services and The Utah Division of Child and Family Services maintain these abuse registries. A designated staff person within the Department of Human Services, Office of Licensing, completes all screenings. The Division of Services for People with Disabilities (DSPD) maintains a database on all approved employees. DSPD will not approve payments if the required screenings have not been completed.

Appendix C: Participant Services

C-2: General Service Specifications (2 of 3)

3. Services in Facilities Subject to §1616(e) of the Social Security Act. Select one:

   No. Home and community-based services under this waiver are not provided in facilities subject to §1616(e) of the Act.

   Yes. Home and community-based services are provided in facilities subject to §1616(e) of the Act. The standards that apply to each type of facility where waiver services are provided are available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Appendix C: Participant Services

C-2: General Service Specifications (3 of 3)

4. Provision of Personal Care or Similar Services by Legally Responsible Individuals. A legally responsible individual is any person who has a duty under State law to care for another person and typically includes: (a) the parent (biological or adoptive) of a minor child or the guardian of a minor child who must provide care to the child or (b) a spouse of a waiver participant. Except at the option of the State and under extraordinary circumstances specified by the State, payment may not be made to a legally responsible individual for the provision of personal care or similar services that the legally responsible individual would ordinarily perform or be responsible to perform on behalf of a waiver participant. Select one:

    No. The State does not make payment to legally responsible individuals for furnishing personal care or similar services.
    Yes. The State makes payment to legally responsible individuals for furnishing personal care or similar services when they are qualified to provide the services.

   Specify: (a) the legally responsible individuals who may be paid to furnish such services and the services they may provide; (b) State policies that specify the circumstances when payment may be authorized for the provision of extraordinary care by a legally responsible individual and how the State ensures that the provision of services by a legally responsible individual is in the best interest of the participant; and, (c) the controls that are employed to ensure that payments are made only for services rendered. Also, specify in Appendix C-1/C-3 the personal care or similar services for which payment may be made to legally responsible individuals under the State policies specified here.

   Character Count: out of 12000
    not selected

5. Other State Policies Concerning Payment for Waiver Services Furnished by Relatives/Legal Guardians. Specify State policies concerning making payment to relatives/legal guardians for the provision of waiver services over and above the policies addressed in Item C-2-d. Select one:

    The State does not make payment to relatives/legal guardians for furnishing waiver services.
    The State makes payment to relatives/legal guardians under specific circumstances and only when the relative/guardian is qualified to furnish services.

   Specify the specific circumstances under which payment is made, the types of relatives/legal guardians to whom payment may be made, and the services for which payment may be made. Specify the controls that are employed to ensure that payments are made only for services rendered. Also, specify in Appendix C-1/C-3 each waiver service for which payment may be made to relatives/legal guardians.

   Character Count: out of 12000

   The types of relatives to who payment is made: With the exception of parents of adult children who are only allowed to be paid under specific circumstances, there are no restrictions to payments made to relatives of the person. Specific circumstances under which payment is made to a parent, step-parent of the person: 1. When a person lives in a rural area within five miles of a population center of less than 2,500 when there are no other resources to provide supports within a reasonable geographic area (15 miles) from the person and the person conducts on ongoing recruitment of resources other than a parent. 2. For the time when the parent who has specialized training for safely operating health related technology for the Person including but not limited to the operation of a ventilator, G peg tube feeding, home dialyses infusion, and wound care performs those tasks because the person can demonstrate they have no other dependable or qualified resources available to do so. 3. If the person is functionally quadriplegic and is dependent on others to perform health and safety related supports and other routine activities of daily living. 4. If the person needs supports critical to their health and safety during non-traditional work hours such as during the night. Parents, Step-parents, may be paid to provide services under this waiver under the service of personal attendant. Please also see the full service description in appendix C-3. Controls that are employed to ensure that payments are made only for services rendered: In order for a parent, step parent to be paid under this waiver, he/she must meet all of the following authorization criteria and monitoring provisions; - meet the criteria as outlined in the Personal Attendant Service - the service must be specified in the consumers Person Centered Support Plan (PCSP) - service must be paid at a rate that does not exceed that which would otherwise be paid to an employee - a parent, step-parent may not be paid for more than 40 hours of services in a seven day period - time sheets and other required documentation must be submitted for hours paid. Other monitoring requirements/provisions: The below listed requirements apply to consumers electing to use parents, step-parents to be paid during specific circumstances; - monthly reviews by the FMS of hours billed for parents, step-parents care. These reviews will be overseen by the administrative nurse coordinators to ensure the appropriate usage and compliance with the billing process. -the administrative nurse coordinators will contact the person by phone or e-mail on at least a quarterly basis to identify the proper usage of and compliance with the program and to also ensure the persons health and safety as well as the status of the person and if the specific circumstance still applies. - the administrative nurse coordinator will conduct annual Self-Administered-Services Method (SAS) reviews and will review all of the required documentation that goes along with this method.
    Relatives/legal guardians may be paid for providing waiver services whenever the relative/legal guardian is qualified to provide services as specified in Appendix C-1/C-3.

   Specify the controls that are employed to ensure that payments are made only for services rendered.

   Character Count: out of 12000
    Other policy.

   Specify:

   Character Count: out of 12000
    not selected

6. Open Enrollment of Providers. Specify the processes that are employed to assure that all willing and qualified providers have the opportunity to enroll as waiver service providers as provided in 42 CFR §431.51:

   Character Count: out of 12000
   All Participants in the Physical Disability Program operated by DSPD are allowed to hire, train, and supervise employees to provide direct services. Persons with physical disabilities hire staff ("Employee") in accordance with Federal Internal Revenue Service ("IRS") and Federal and State Department of Labor ("DOL") rules and regulations (IRS Revenue Ruling 87-41; IRS Publication 15-A: Employer's Supplemental Tax Guide; Federal DOL Publication WH 1409, Title 29 CFR Part 552, Subpart A, Section 3: Application of the Fair Labor Standards Act to Domestic Service; and states = ABC Test). The Utah Department of Health will enter into a provider agreement with all willing providers who are selected by the participant and meet licensure, certification and/or other competency requirements. DHS/DSPD provides a participant with choices for a fiscal agent. The fiscal agent is a private or public entity that is approved by the IRS (under IRS Revenue Procedure 70-6) to act as the client's intermediary for the purpose of managing employment taxes, including income tax withholding, FICA, FUTA/SUTA, and brokering/managing benefits, including worker's compensation and state disability insurance premiums (if applicable). The fiscal agent collects employment documents and verifies signatures from participants prior to distributing paychecks to the participant's employees. The participant remains the employer of record, retaining control over the hiring, training, management, and supervision of employees hired by the participant who provide direct care services.

Appendix C: Participant Services

Quality Improvement: Qualified Providers

1. Methods for Discovery: Qualified Providers
   1. Sub-Assurances:

      1. Sub-Assurance: The State verifies that providers initially and continually meet required licensure and/or certification standards and adhere to other standards prior to their furnishing waiver services.

         Performance Measures

         For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

         For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

         Performance Measure: Number and percentage of PD waiver providers that meet OA provider contract criteria. Data Source (Select one): Other If 'Other' is selected, specify: Provider records and Provider staff interviews Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      2. Sub-Assurance: The State monitors non-licensed/non-certified providers to assure adherence to waiver requirements.

         For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

         For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

         Performance Measure: Number and percentage of participants who maintain accurate and updated personal attendant employee files. Data Source (Select one): Other If 'Other' is selected, specify: Employee files, 2-9C, 2-9EA, 2-9SA, Provider Code of Conduct and Background Check Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      3. Sub-Assurance: The State implements its policies and procedures for verifying that provider training is conducted in accordance with state requirements and the approved waiver.

         For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

         For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

         Performance Measure: Number and percentage of participants who provided individual training to personal attendants. Data Source (Select one): Other If 'Other' is selected, specify: Employee files and 2-9C Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = 5 Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

   2. If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.
      Character Count: out of 6000
      DSPD contract analysts conduct annual provider reviews of all programs that provide services to PD waiver participants. Monitoring includes all criteria specified in the provider contract. Administrative case managers monitor a sample of SAS employees on a monthly basis. The administrative case managers also complete a review checklist, which covers employee files, forms, and appropriate training for staff. Time sheets are reviewed to ensure proper billing for services. Administrative case managers meet in person with the participant to confirm the employees have received appropriate training. Both the administrative case managers and the USTEPS system track the expenditures for each participant and ensure that services remain within the allotted budget. When not 100%, the sample size for each review will be sufficient to provide a confidence level equal to 95% and a confidence interval equal to five. A response distribution equal to 50% will be used to gather base line data for the first waiver year. Base line data will be collected over a two year period with 50% of the total sample size collected each year. The response distribution used for further reviews will reflect the findings gathered during the base line review.
2. Methods for Remediation/Fixing Individual Problems
   1. Describe the State’s method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.
      Character Count: out of 6000
      Individual provider issues identified during contract reviews are corrected immediately by the provider or, at a minimum within designated time frames. To assure the issue has been addressed, entities assigned the responsibility of review and remediation are required to report back to the OA or SMA on the results of their interventions within designated time frames. Findings and corrections are documented in DSPD Final Reports.
   2. Remediation Data Aggregation
      Remediation-related Data Aggregation and Analysis (including trend identification)

      Responsible Party (check each that applies):	Frequency of data aggregation and analysis (check each that applies):
      State Medicaid Agency	Weekly
      Operating Agency	Monthly
      Sub-State Entity	Quarterly
      Other Specify:	Annually
      	Continuously and Ongoing
      	Other Specify:

3. Timelines
   When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design methods for discovery and remediation related to the assurance of Qualified Providers that are currently non-operational.

    No

    Yes

    not selected
   Please provide a detailed strategy for assuring Qualified Providers, the specific timeline for implementing identified strategies, and the parties responsible for its operation.

   Character Count: out of 6000