CMS 372 Report - OMB Control Number: 0938-0272

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

State:

Waiver Base:

0331

Report Status:

ACCEPTED

Begin Date:

End Date:

Initial Submission Date:

Report Period Year:

Waiver Year:

Report Type:

Initial Report

Lag Report

TE Report

Unduplicated Participants:

Days of Waiver Enrollment:

Average Length of Stay:

Total Waiver Expenditures:

Total Reported Expenditures:

APC Waiver Services (Factor D):

APC for State Plan Services (D'):

APC Total (D + D'):

Factor G Value:

Factor G' Value:

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

D + D' <= G + G':

$34,387 <= $53,726

Level/s of Care:

ICF/MR

Hospital

Additional Information (use if needed):

B. Factor C and D Variances:
	1.  The actual factor C value (116) is lower than the approved estimate in the Waiver (150).  Please explain the reason for the difference in the additional information box on the web-based 372 form (just below the level of care).  Does the State expect this trend to continue?

State Response: 
The number of clients served by the waiver was an estimate. The actual number of clients that are served by the waiver is directly associated with the amount of State matching dollars appropriated by the Utah State Legislature. The number served during a specific year may be lower than the estimates when the State Legislature does not appropriate additional monies for caseload growth.  In these cases, as individuals attrite, new individuals are not brought in to replace them.  As a result of limited funding, the State does not always utilize the maximum amount of capped waiver slots approved by CMS.    

2.  The actual factor D value ($17,410) is lower than the approved estimate in the Waiver ($19,568).  Please explain the reason for the difference in the additional information box on the web-based 372 form (just below the level of care).  Does the State expect this trend to continue?

State Response: 
The factor D numbers provided during the initial waiver application were estimates.  During the 2011 waiver renewal, the State will make adjustments to the factor D table estimates based off the actual utilization data for the previous waiver period.

Note: Average Per Capita (APC)

Annual Number of Section 1915c Waiver Recipients and Expenditures:

(Specify each service as in the approved waiver)

Service Name	Level of Care	Expenses	Participants
-- Other If Other, specify: 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:

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

Documentation:

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

The SMA conducted the following monitoring during FY 2010: FY 2009 Annual Review During FY 2010, the SMA conducted the FY 2009 review for the Physical Disabilities Waiver. This review addressed the assurances: 1) Plans of care are responsive to waiver participants’ needs; and 2) The health and welfare of participants. The review sample was selected June 9, 2009. As of that date, one hundred and seven (107) participants had received services through the Physical Disabilities Waiver since July, 2008. Based on this number, a Confidence Level of 95%, a Confidence Interval of 5, and a Response Distribution of 10%, sixty-one (61) participants were selected for this review. The sample was randomly selected from a list of participants who had been receiving waiver services by May 1, 2008. The operating agency had an opportunity to comment on the findings and provide relevant additional information. The final report was issued March, 2010. The review presented observations and analysis of the data for each assurance. Plans of correction were required for all deficiencies. All plans of correction have been completed. Critical Incidents/Events The SMA tracks and investigates all critical incidents/events that occur to participants receiving services from the PD Waiver. There were four critical incident investigations involving PD Waiver participants during the time period July 1, 2009 through June 30, 2010. Three of the four incidents were abuse/neglect/exploitation allegations. One of the four incidents was a medication error. All incidents have been resolved and safeguards were put in place to assure the health and safety of all participants. The Division of Services for People with Disabilities (DSPD) conducted the following monitoring during FY 2010: DSPD FY 2010 Physical Disability Waiver Report During FY 2010, DSPD conducted the FY2010 review for the Physical Disabilities Waiver. This review of the Medicaid documentation requirements addressed six areas. These areas were (1) Level of Care (2) Plans of Care/ Person Centered Support Plan (PCSP) (3) Review of Plan of Care (PCSP reviews) (4) Reviews of the Level of Care (initial certification and annual recertification of eligibility) and (5) Case Activities (documentation of activity logs) (6) Health and Welfare. A total of forty (40) files were reviewed which represented about 30% of the total number of individuals receiving service through the PD waiver in FY 10. Qualified Providers Contract Providers During FY 2010, 10 providers with contracts with DSPD provided services to PD Wavier participants. DSPD conducted reviews for all 10 providers. 6 of 10 providers (60%) met all provider contractor criteria. Corrective Action Plans were required by DSPD for providers who did not meet provider contractor criteria. 100% of compliance issues will be resolved over the next quarter.

Findings of Monitoring:

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

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

SMA FY 2009 Annual Review Assurance: Plans of Care Sub Assurance : Person Centered Service Plans (PSCPs) address all of each participant’s assessed needs, health and safety risk factors and personal goals, either by waiver services or through other means. • Performance measure: Documentation in the participant’s record contains enough information to ascertain whether they have made progress on goals identified on the PCSP and Support Strategies. Deficiency #1: 57 of 61 (93.44%) participant records reviewed contained adequate information to ascertain the progress that participants have made on the goals identified on the PCSPs and ILC Support Strategies. 4 participant records reviewed did not contain adequate information to ascertain progress on ILC Support Strategy goals. Sub Assurance: Person Centered Service Plans are developed in accordance with policies and procedures. • Performance Measure: The MDS-HC assessment was conducted at a minimum of every 12 months. Deficiency #2: 59 of the 61 participants in the sample received services from the PD Waiver for at least one year. A review of the MDS-HC assessment dates recorded on these PCSPs showed that 55 of the 59 (93.22%) participants from the sample were updated at least annually. 4 participants did not receive a re-assessment within a 12 month period. • Performance Measure: The level of case management provided is identified on the PCSP and is individualized and based on an assessment of need and risk. Deficiency # 3: 0 of 61 (0%) PCSPs accurately identified the level of case management provided, were individualized nor were based on an assessment of need and risk. 61 PCSPs did not meet these criteria. Sub Assurance: Care plans are reviewed and updated at least annually or when warranted by changes in participants’ needs. • Performance Measure: PCSPs are updated/revised when warranted by changes in the participant’s needs. Deficiency #4: Changes in the needs of 13 participants in the sample warranted that changes be made to their PCSPs. 11 of 13 (84.61%) of these participants had these changes made. 2 participants should have had changes made to their PCSPs to reflect changes in their service needs, but did not. ASSURANCE: HEALTH AND WELFARE Sub Assurance: There is continuous monitoring of the health and welfare of waiver participants and remediation actions are initiated when appropriate. • Performance Measure: Within 24 hours of any incident requiring a report, participant notified the administrative case manager by phone, email or fax. Deficiency # 5: Eight (8) participants in the sample experienced at least one incident during the review period. Incidents for two (2) participants (25%) were reported within appropriate time frames. Incidents for six (6) participants were not reported within 24 hours. • Performance Measure: An incident report was completed and submitted within 5 business days of the occurrence of an incident. Deficiency # 6: Eight (8) participants in the sample experienced at least one incident during the review period. Incident reports for all incidents were completed and submitted within appropriate time frames for three (3) participants (37.5 %). The DSPD Grievance/Incident/Event Report for all incidents was not completed and submitted within appropriate time frames for five (5) participants. DSPD FY 2010 Physical Disability Waiver Report Assurance: Level of Care Sub Assurance: The level of care of enrolled participants is re-evaluated at least annually. In addition, a participant’s level of care is screened at the time a substantial change in health status occurs to determine if the change constitutes continued nursing facility level of care, including at the conclusion of an inpatient stay at a medical institution. A full level of care is conducted whenever indicated by the screening. • Performance measure: A participant’s level of care is screened at the time a substantial change in health status occurs to determine if the change constitutes continued nursing facility level of care, including at the conclusion of an inpatient stay at a medical institution. Deficiency #1: 33 of 40 participant records reviewed identified 7 participants from the sample who had an inpatient stay at a medical institution during fiscal year 2010. 6 out of 7 of these participants were appropriately screened for level of care upon discharge from the hospital. One participant’s record did not contain an update to the MDS-HC assessment (screening) in the allotted timeframe. Assurance: Plans of Care Sub Assurance: Care plans are reviewed and updated at least annually or when warranted by changes in participants’ needs. • Performance Measure: PCSPs are updated/revised when warranted by changes in the participant’s needs. Deficiency #2: 33 of 40 participant records sampled showed care plans had been reviewed and updated appropriately. 7 participant records did not contain documentation that the participants’ needs were reviewed and documented. Assurance: Health and Welfare Sub Assurance: There is continuous monitoring of the health and welfare of waiver participants and remediation actions are initiated when appropriate. • Performance Measure: Within 24 hours of any incident requiring a report, participant notified the administrative case manager by phone, email or fax. Deficiency # 3: 4 participants in the sample experienced at least one incident during the review period. An Incident for 1 participant (25%) was reported within the appropriate time frame. Incidents for 3 participants were not reported within 24 hours. • Performance Measure: Case Managers follow up on incident reports with participants to put effective safeguards and interventions in place. Deficiency #4: Case managers and/or support coordination liaisons conducted follow up with 2 of 4 participants that had incidents reported. 2 participants did not receive follow up. • Performance Measure: The participant has a back-up plan for personal assistance. Deficiency # 5: Although all the participants in the sample had a backup plan in place, DSPD quarterly reviews showed that 12 0f 40 participant log notes did not reveal any documentation regarding a backup plan. Assurance: Qualified Providers Sub-Assurance: The State monitors non-licensed/non-certified providers to assure adherence to waiver requirements. • Performance Measure: Self administered services (SAS) providers meet all waiver requirements including accurate and updated employee files, completion of appropriate forms, appropriate training and proper billing for services. Deficiency #6: 48 of 51 participant records showed new SAS employees signed a code of conduct. 3 participant records lacked a signed code of conduct by the new SAS employee. Deficiency # 7: 48 of 51 participant records reviewed showed documentation that the SAS employees received training. 3 SAS employee records did not contain documentation that they received training. All 3 employees were able to verbally describe the type of support and method of best supporting the person.
Deficiencies have been, or are being corrected.

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

SMA FY 2009 Annual Review Deficiency #1: The following action was taken to correct the deficiency. This issue was resolved when DSPD provided documentation that the support coordinator liaisons, statewide, received training conducted by the PDW Director, to assure that documentation on monthly summaries must include adequate information to ascertain the progress participants have made on goals identified on the ILC Support Strategies/Action Plan. This issue was corrected by 2/13/10. Deficiency #2: The following action was taken to correct the deficiency. This issue was resolved when DSPD submitted documentation to indicate each administrative case manager received training from the PDW Director stressing the importance of tracking the reassessment due dates to assure that the assessments will be completed at a minimum within 12 consecutive months from the last recorded comprehensive assessment. This issue was corrected on 01/07/2010. Deficiency #3: The following action was taken to correct the deficiency. This issue was resolved when DSPD provided documentation that the support coordinator liaisons received training, conducted by the PD Director, to assure the importance of the Support Coordinator Liaisons’ observations, the type of information and the method of communicating that information to the administrative case managers. The administrative case managers also received training to assure their role of performing ongoing assessments of a person’s case management support needs and their responsibility to carefully review the information they obtain from the Support Coordinator Liaison. Spot checks of each administrative case manager’s case load were conducted and reported per the PDW FY 2010 Review. Deficiency #4: The following action was taken to correct the deficiency. This issue was resolved when DSPD submitted documentation to indicate the PDW in-service given to each administrative case manager adequately addressed the issue of directing administrative case managers to make changes to the PCSP (by writing an addendum) when there is a change in a participant’s service needs. This issue was corrected on 01/07/10 Deficiency #5: The following action was taken to correct the deficiency This issue was resolved when DSPD submitted documentation to indicate that the support coordinator liaisons, statewide, completed a training conducted by the PD Director to assure that the support coordinator liaison requirement to report critical incidents to the administrative case managers within twenty-four hours was followed. The administrative case managers’ discussions with consumers on a quarterly basis adequately address the issue that waiver participants must report critical incidents within twenty-four hours. This issue was corrected by 2/13/2010. Deficiency #6: The following action was taken to correct the deficiency This issue was resolved when DSPD submitted documentation to indicate that a PD in-service was given to each administrative case manager, the PD training given to the support coordinator liaisons statewide, and the discussion with consumers, personal attendants and families on a quarterly basis adequately address the issue that the DSPD Grievance/Incident/Event Report is completed within 5 days of the occurrence. This issue was corrected by 2/13/2010. The PDW Director conducted spot checks of incident reports compliance. Retraining was provided to address this issue per the DSPD Review submitted on 11/8/2010. DSPD FY 2010 Physical Disability Waiver Report Deficiency #1: The following action was taken to correct the deficiency. This issue was resolved when DSPD instructed the administrative nurse coordinators to follow the procedures regarding documentation procedures. Deficiency #2: The following action was taken to correct the deficiency. This issue was resolved when DSPD provided training to each administrative case manager from the PD Director to assure that the administrative case managers follow documentation requirements and specifically assess and identify participant’s needs. Deficiency #3: The following action was taken to correct the deficiency. This issue was resolved when DSPD Administrative nurse coordinators received instruction to conduct and document all follow-up interviews. Deficiency #4: The following action was taken to correct the deficiency. This issue was resolved when DSPD Administrative nurse coordinators received instruction to conduct and document all follow-up interviews. Deficiency #5: The following action was taken to correct the deficiency. This issue was resolved when DSPD instructed the administrative nurse coordinators to document participant back up plans on at least an annual basis. The Division will continue with the quarterly quality assurance reviews for implementation of plans and compliance with documentation requirements Deficiency #6: The following action was taken to correct the deficiency. This issue was resolved when DSPD provided technical assistance in each case where compliance was not met. All non-compliance issues have been resolved. Deficiency #7: The following action was taken to correct the deficiency. This issue was resolved when DSPD provided instruction to each administrative nurse coordinator to review annually SAS employee training documentation to ensure compliance.

Certification:

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

Signature:

Date:

Phone Number:

Contact Information (optional):

Contact Person:

Phone Number: