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

UT
0331
ACCEPTED
Waiver Year:
Report Type:
$34,387 <= $53,726
Level/s of Care:
Note: Average Per Capita (APC)
Annual Number of Section 1915c Waiver Recipients and Expenditures:
(Specify each service as in the approved waiver)
Service Name Level of Care Expenses Participants
-- Other
If Other, specify:
Home Care Training to Client (Per 15 Min)
NF $101 6
-- Other
If Other, specify:
Emergency Response System (Purchase)
NF $0 0
-- Other
If Other, specify:
Emergency Response System (Per Month)
NF $27,849 72
-- Other
If Other, specify:
Supports Brokerage Self Directed (Per 15 Min)
NF $34,022 92
-- Other
If Other, specify:
Attendant Care Services (Per 15 Min)
NF $1,866,301 115
-- Other
If Other, specify:
Attendant Care Services (Daily)
NF $26,817 3
-- Other
If Other, specify:
Financial Management Services Low (Per Month)
NF $27,972 89
-- Other
If Other, specify:
Financial Management Services High (Per Month)
NF $35,974 35
-- Other
If Other, specify:
Personal Emergency Response Systems, Installation & Testing
NF $510 11
Assurances:
Documentation:
Findings of Monitoring:
Certification:
I, do certify that the information shown on the Form CMS-372(S) is correct to the best of my knowledge and belief:
Contact Information (optional):