RELATES TO:
KRS
205.5605,
205.5606,
205.5607,
205.8451,
205.8477,
42 C.F.R.
441.300-
310,
42 C.F.R.
455.100-
106,
42 U.S.C.
1396a, b, d, n
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
Family Services, Department for Medicaid Services, has responsibility to
administer the Medicaid Program.
KRS
205.520(3) authorizes the
cabinet, by administrative regulation, to comply with any requirement that may
be imposed, or opportunity presented, by federal law to qualify for federal
Medicaid funds. KRS
205.5606(1) requires the
cabinet to promulgate administrative regulations to establish a
participant-directed services program to provide an option for the home and
community-based services waivers. This administrative regulation establishes
the coverage provisions relating to home- and community-based waiver services
provided to an individual with an acquired brain injury as an alternative to
nursing facility services and including a participant-directed services program
pursuant to KRS
205.5606.
Section
1. Definitions.
(1) "1915(c) home
and community based services waiver program" means a Kentucky Medicaid program
established pursuant to and in accordance with
42 U.S.C.
1396n(c).
(2) "ABI" means an acquired brain
injury.
(3) "ABI provider" means an
entity that meets the criteria established in Section 2 of this administrative
regulation.
(4) "Acquired Brain
Injury Branch" or "ABIB" means the Acquired Brain Injury Branch of the
Department for Medicaid Services, Division of Community Alternatives.
(5) "Acquired brain injury waiver service" or
"ABI waiver service" means a home and community based waiver service provided
to a Medicaid eligible individual who has acquired a brain injury.
(6) "Advanced practice registered nurse" is
defined by KRS
314.l011(7).
(7) "Assessment" or "reassessment" means a
comprehensive evaluation of abilities, needs, and services that:
(a) Serves as the basis for a level of care
determination;
(b) Is completed on
a MAP 351, Medicaid Waiver Assessment that is uploaded into the MWMA;
and
(c) Occurs at least once every
twelve (12) months thereafter.
(8) "Behavior intervention committee" or
"BIC" means a group of individuals established to evaluate the technical
adequacy of a proposed behavior intervention for an ABI recipient.
(9) "Blended services" means a nonduplicative
combination of ABI waiver services identified in Section 4 of this
administrative regulation and participant directed services identified in
Section 10 of this administrative regulation provided pursuant to a recipient's
approved person-centered service plan.
(10) "Board certified behavior analyst" means
an independent practitioner who is certified by the Behavior Analyst
Certification Board, Inc.
(11)
"Budget allowance" is defined by
KRS
205.5605(1).
(12) "Case manager" means an individual who
manages the overall development and monitoring of a recipient's person-centered
service plan.
(13) "Covered
services and supports" is defined by
KRS
205.5605(3).
(14) "Crisis prevention and response plan"
means a plan developed by the person centered team to identify any potential
risk to a recipient and to detail a strategy to minimize the risk.
(15) "DCBS" means the Department for
Community Based Services.
(16)
"Department" means the Department for Medicaid Services or its
designee.
(17) "Good cause" means a
circumstance beyond the control of an individual that affects the individual's
ability to access funding or services, including:
(a) Illness or hospitalization of the
individual which is expected to last sixty (60) days or less;
(b) Death or incapacitation of the primary
caregiver;
(c) Required paperwork
and documentation for processing in accordance with Section 3 of this
administrative regulation that has not been completed but is expected to be
completed in two (2) weeks or less; or
(d) The individual or his or her legal
representative has made diligent contact with a potential provider to secure
placement or access services but has not been accepted within the sixty (60)
day time period.
(18)
"Human rights committee" or "HRC" means a group of individuals established to
protect the rights and welfare of an ABI recipient.
(19) "Level of care certification" means
verification, by the department, of ABI program eligibility for:
(a) An individual; and
(b) A specific period of time.
(20) "Licensed marriage and family
therapist" or "LMFT" is defined by
KRS
335.300(2).
(21) "Licensed medical professional" means:
(a) A physician;
(b) An advanced practice registered
nurse;
(c) A physician
assistant;
(d) A registered
nurse;
(e) A licensed practical
nurse; or
(f) A
pharmacist.
(22)
"Licensed professional clinical counselor" is defined by
KRS
335.500(3).
(23) "Medically necessary" or "medical
necessity" means that a covered benefit is determined to be needed in
accordance with
907 KAR 3:130.
(25) "Occupational therapist" is defined by
KRS
319A.010(3).
(26) "Occupational therapy assistant" is
defined by KRS
319A.010(4).
(27) "Participant directed services" or "PDS"
means an option established by
KRS
205.5606 within the 1915(c) home and
community based service waiver programs that allows recipients to receive
non-medical services in which the individual:
(a) Assists with the design of the
program;
(b) Chooses the providers
of services; and
(c) Directs the
delivery of services to meet their needs.
(28) "Patient liability" means the financial
amount, determined by the department, that an individual is required to
contribute towards cost of care in order to maintain Medicaid
eligibility.
(29) "Person-centered
service plan" means a written individualized plan of services for a participant
that meets the requirements established in Section 4 of this administrative
regulation.
(30) "Person centered
team" means a participant, the participant's guardian or representative, and
other individuals who are natural or paid supports and who:
(a) Recognize that evidenced based decisions
are determined within the basic frame-work of what is important for the
participant and within the context of what is important to the participant
based on informed choice;
(b) Work
together to identify what roles they will assume to assist the participant in
becoming as independent as possible in meeting the participant's needs;
and
(c) Include providers who
receive payment for services who shall:
1. Be
active contributing members of the person centered team meetings;
2. Base their input upon evidence-based
information; and
3. Not request
reimbursement for person-centered team meetings.
(31) "Personal services agency" is
defined by KRS
216.710(8).
(32) "Psychologist" is defined by
KRS
319.010(9).
(33) "Psychologist with autonomous
functioning" means an individual who is licensed in accordance with
KRS
319.056.
(34) "Qualified mental health professional"
is defined by KRS
202A.011(12).
(35) "Representative" is defined by
KRS
205.5605(6).
(36) "Speech-language pathologist" is defined
by KRS
334A.020(3).
(37) "Support broker" means an individual
designated by the department to:
(a) Provide
training, technical assistance, and support to a participant; and
(b) Assist a participant in any other aspects
of PDS.
(38) "Support
spending plan" means a plan for a participant that identifies the:
(a) PDS requested;
(b) Employee name;
(c) Hourly wage;
(d) Hours per month;
(e) Monthly pay;
(f) Taxes; and
(g) Budget allowance.
(39) "Transition plan" means a plan that is
developed by the person centered team to aid an ABI recipient in exiting from
the ABI program into the community.
Section 2. Non-PDS Provider Participation
Requirements.
(1) In order to provide an ABI
waiver service in accordance with Section 4 of this administrative regulation,
excluding a participant-directed service, an ABI provider shall:
(a) Be enrolled as a Medicaid provider in
accordance with
907 KAR 1:671;
(b) Be certified by the department prior to
the initiation of the service;
(c)
Be recertified at least annually by the department;
(d) Have an office within the Commonwealth of
Kentucky; and
(e) Complete and
submit a MAP-4100a to the department.
(2) An ABI provider shall comply with:
(e) The Health Insurance Portability and
Accountability Act, 42
U.S.C.
1320d-2, and
45 C.F.R. Parts
160,
162, and
164; and
(3) An ABI provider shall have a governing
body that shall be:
(a) A legally-constituted
entity within the Commonwealth of Kentucky; and
(b) Responsible for the overall operation of
the organization including establishing policy that complies with this
administrative regulation concerning the operation of the agency and the
health, safety and welfare of an ABI recipient served by the agency.
(4) An ABI provider shall:
(a) Unless providing PDS, ensure that an ABI
waiver service is not provided to a participant by a staff member of the ABI
provider who has one (1) of the following blood relationships to the
participant:
1. Child;
2. Parent;
3. Sibling; or
4. Spouse;
(b) Not enroll a participant for whom the ABI
provider cannot meet the service needs; and
(c) Have and follow written criteria that
complies with this administrative regulation for determining the eligibility of
an individual for admission to services.
(5) An ABI provider shall meet the following
requirements if responsible for the management of a participant's funds:
(a) Separate accounting shall be maintained
for each participant or for his or her interest in a common trust or special
account;
(b) Account balance and
records of transactions shall be provided to the participant or legal
representative on a quarterly basis; and
(c) The participant or legal representative
shall be notified when a large balance is accrued that may affect Medicaid
eligibility.
(6) An ABI
provider shall have a written statement of its mission and values.
(7) An ABI provider shall have written policy
and procedures for communication and interaction with a family and legal
representative of a participant, which shall:
(a) Require a timely response to an
inquiry;
(b) Require the
opportunity for interaction with direct care staff;
(c) Require prompt notification of any
unusual incident;
(d) Permit
visitation with the participant at a reasonable time and with due regard for
the participant's right of privacy;
(e) Require involvement of the legal
representative in decision-making regarding the selection and direction of the
service provided; and
(f) Consider
the cultural, educational, language, and socioeconomic characteristics of the
participant.
(8)
(a) An ABI provider shall have written
policies and procedures for all settings that assure the participant has:
1. Rights of privacy, dignity, respect, and
freedom from coercion and restraint;
2. Freedom of choice:
a. As defined by the experience of
independence, individual initiative, or autonomy in making life choices, both
in small everyday matters (what to eat or what to wear), and in large,
life-defining matters (where and with whom to live and work); and
b. Including the freedom to choose:
(i) Services;
(ii) Providers;
(iii) Settings from among setting options
including non-disability specific settings; and
(iv) Where to live with as much independence
as possible and in the most community-integrated environment.
(b) The
setting options and choices shall be:
1.
Identified and documented in the person-centered service plan; and
2. Based on the participant's needs and
preferences.
(c) For a
residential setting, the resources available for room and board shall be
documented in the person-centered service plan.
(9) An ABI provider shall have written
policies and procedures for residential settings that assure the participant
has:
(a) Privacy in the sleeping unit and
living unit in a residential setting;
(b) An option for a private unit in a
residential setting;
(c) A unit
with lockable entrance doors and with only the participant and appropriate
staff having keys to those doors;
(d) A choice of roommate or
housemate;
(e) The freedom to
furnish or decorate their sleeping or living units within the lease or other
agreement;
(f) Visitors of the
participant's choosing at any time and access to a private area for visitors;
and
(g) Physical accessibility,
defined as being easy to approach, enter, operate, or participate in a safe
manner and with dignity by a person with or without a disability.
1. Settings considered to be physically
accessible shall also meet the Americans with Disabilities Act standards of
accessibility for all participants served in the setting.
2. All communal areas shall be accessible to
all participants as well as have a means to enter the building (i.e. keys,
security codes, etc.).
3. Bedrooms
shall be accessible to the appropriate persons.
4.
a. Any
modification of an additional residential condition except for the setting
being physically accessible requirement shall be supported by a specific
assessed need and justified in the participant's person-centered service
plan.
b. Regarding a modification,
the following shall be documented in a participant's person-centered service
plan:
(i) That the modification is the result
of an identified specific and individualized assessed need;
(ii) Any positive intervention or support
used prior to the modification;
(iii) Any less intrusive method of meeting
the participant's need that was tried but failed;
(iv) A clear description of the condition
that is directly proportionate to the specific assessed need;
(v) Regular collection and review of data
used to measure the ongoing effectiveness of the modification;
(vi) Time limits established for periodic
reviews to determine if the modification remains necessary or should be
terminated;
(vii) Informed consent
by the participant or participant's representative for the modification;
and
(viii) An assurance that
interventions and supports will cause no harm to the participant.
(10) An ABI provider shall cooperate with
monitoring visits from monitoring agents.
(11) An ABI provider shall maintain a record
for each participant served that shall:
(a) Be
recorded in permanent ink;
(b) Be
free from correction fluid;
(c)
Have a strike through each error which is initialed and dated; and
(d) Contain no blank lines between each
entry.
(12) A record of
each participant who is served shall:
(a) Be
cumulative;
(b) Be readily
available;
(c) Contain a legend
that identifies any symbol or abbreviation used in making a record entry;
and
(d) Contain the following
specific information:
1. The participant's
name and Medical Assistance Identification Number (MAID);
2. An assessment summary relevant to the
service area;
3. The
person-centered service plan;
4.
The crisis prevention and response plan that shall include:
a. A list containing emergency contact
telephone numbers; and
b. The
participant's history of any allergies with appropriate allergy alerts for
severe allergies;
5. The
transition plan that shall include:
a. Skills
to be obtained from the ABI waiver program;
b. A listing of the on-going formal and
informal community services available to be accessed;
c. A listing of additional resources needed;
and
d. Expected date of transition
from the ABI waiver program;
6. The training objective for any service
that provides skills training to the participant;
7. The participant's medication record,
including a copy of the prescription or the signed physician's order and the
medication log if medication is administered at the service site;
8. Legally-adequate consent for the provision
of services or other treatment including a consent for emergency attention,
which shall be located at each service site;
9. The MAP-350, Long Term Care Facilities and
Home and Community Based Program Certification form updated at recertification;
and
10. Current level of care
certification;
(e) Be
maintained by the provider in a manner to ensure the confidentiality of the
participant's record and other personal information and to allow the
participant or legal representative to determine when to share the information
as provided by law;
(f) Be secured
against loss, destruction, or use by an unauthorized person ensured by the
provider; and
(g) Be available to
the participant or legal representative according to the provider's written
policy and procedures, which shall address the availability of the
record.
(13) An ABI
provider:
(a) Shall:
1. Ensure that each new staff person or
volunteer performing direct care or a supervisory function has had a
tuberculosis (TB) risk assessment performed by a licensed medical professional
and, if indicated, a TB skin test with a negative result within the past twelve
(12) months as documented on test results received by the provider;
2. Maintain, for existing staff,
documentation of each staff person's or, if a volunteer performs direct care or
a supervisory function, the volunteer's annual TB risk assessment or negative
tuberculosis test required by subparagraph 1 of this paragraph;
3. Ensure that an employee or volunteer who
tests positive for TB or has a history of a positive TB skin test shall be
assessed annually by a licensed medical professional for signs or symptoms of
active disease;
4. Before allowing
a staff person or volunteer determined to have signs or symptoms of active
disease to work, ensure that follow-up testing is administered by a physician
with the test results indicating the person does not have active TB disease;
and
5. Maintain annual
documentation for an employee or volunteer with a positive TB test to ensure no
active disease symptoms are present;
(b)
1. Shall
for each potential employee or volunteer expected to perform direct care or a
supervisory function, obtain:
a. Prior to the
date of hire or date of service as a volunteer, the results of:
(i) A criminal record check from the
Administrative Office of the Courts or equivalent out-of-state agency if the
individual resided, worked, or volunteered outside Kentucky during the year
prior to employment or volunteer service;
(ii) A Nurse Aide Abuse Registry check as
described in
906 KAR 1:100; and
(iii) A Caregiver Misconduct Registry check
as described in
922 KAR 5:120; and
b. Within thirty (30) days of the
date of hire or date of service as a volunteer, the results of a Central
Registry check as described in
922 KAR 1:470; or
2. May use Kentucky's national
background check program established by
906 KAR 1:190 to satisfy the
background check requirements of subparagraph 1 of this paragraph;
(c) Shall annually, for
twenty-five (25) percent of employees randomly selected, obtain the results of
a criminal record check from the Kentucky Administrative Office of the Courts
or equivalent out-of-state agency if the individual resided or worked outside
of Kentucky during the year prior to employment;
(d) Shall not employ or permit an individual
to serve as a volunteer performing direct care or a supervisory function if the
individual has a prior conviction of an offense delineated in
KRS
17.165(1) through (3) or
prior felony conviction;
(e) Shall
not permit an employee or volunteer to transport an ABI recipient if the
employee or volunteer:
1. Does not possess a
valid operator's license issued pursuant to
KRS
186.410; or
2. Has a conviction of Driving Under the
Influence (DUI) during the past year;
(f) Shall not employ or permit an individual
to serve as a volunteer performing direct care or a supervisory function if the
individual has a conviction of trafficking, manufacturing, or possession of an
illegal drug during the past five (5) years;
(g) Shall not employ or permit an individual
to serve as a volunteer performing direct care or a supervisory function if the
individual has a conviction of abuse, neglect or exploitation;
(h) Shall not employ or permit an individual
to serve as a volunteer performing direct care or a supervisory function if the
individual has a Cabinet for Health and Family Services finding of:
1. Child abuse or neglect pursuant to the
Central Registry; or
2. Adult
abuse, neglect, or exploitation pursuant to the Caregiver Misconduct
Registry;
(i) Shall not
employ or permit an individual to serve as a volunteer performing direct care
or a supervisory function if the individual is listed on the:
(j) Shall evaluate and document
the performance of each employee upon completion of the agency's designated
probationary period and at a minimum of annually thereafter; and
(k) Shall conduct and document periodic and
regularly-scheduled supervisory visits of all professional and paraprofessional
direct-service staff at the service site in order to ensure that high quality,
appropriate services are provided to the participant.
(14) An ABI provider shall:
(a) Have an executive director who:
1. Is qualified with a bachelor's degree from
an accredited institution in administration or a human services field;
and
2. Has a minimum of one (1)
year of administrative responsibility in an organization which served an
individual with a disability; and
(b) Have adequate direct-contact staff who:
1. Is eighteen (18) years of age or
older;
2. Has a high school diploma
or GED; and
3.
a. Has a minimum of two (2) years' experience
in providing a service to an individual with a disability; or
b. Has successfully completed a formalized
training program such as nursing facility nurse aide training.
(15) An ABI
provider shall establish written guidelines that address the health, safety and
welfare of a participant, which shall include:
(a) Ensuring the health, safety and welfare
of the participant;
(b) Maintenance
of sanitary conditions;
(c)
Ensuring each site operated by the provider is equipped with:
1. Operational smoke detectors placed in
strategic locations; and
2. A
minimum of two (2) correctly-charged fire extinguishers placed in strategic
locations, one (1) of which shall be capable of extinguishing a grease fire and
have a rating of 1A10BC;
(d) For a supervised residential care or
adult day training provider, ensuring the availability of an ample supply of
hot and cold running water with the water temperature at a tap used by the
participant not exceeding 120 degrees Fahrenheit;
(e) Ensuring that the nutritional needs of
the participant are met in accordance with the current recommended dietary
allowance of the Food and Nutrition Board of the National Research Council or
as specified by a physician;
(f)
Ensuring that staff who supervise medication administration:
1. Unless the employee is a licensed or
registered nurse, have specific training provided by a licensed medical
professional and documented competency on cause and effect and proper
administration and storage of medication; and
2. Document all medication administered,
including self-administered, over-the-counter drugs, on a medication log, with
the date, time, and initials of the person who administered the medication and
ensure that the medication shall:
a. Be kept
in a locked container;
b. If a
controlled substance, be kept under double lock;
c. Be carried in a proper container labeled
with medication, dosage, time of administration, and the recipient's name if
administered to the participant or self-administered at a program site other
than his or her residence; and
d.
Be documented on a medication administration form and properly disposed of if
discontinued; and
(g) Establish policies and procedures for
on-going monitoring of medication administration as approved by the
department.
(16) An ABI
provider shall establish and follow written guidelines for handling an
emergency or a disaster which shall:
(a) Be
readily accessible on site;
(b)
Include an evacuation drill:
1. To be
conducted and documented at least quarterly; and
2. For a residential setting, scheduled to
include a time overnight when a participant is typically asleep;
(c) Mandate that:
1. The result of an evacuation drill be
evaluated and modified as needed; and
2. Results of the prior year's evacuation
drill be maintained on site.
(17) An ABI provider shall:
(a) Provide orientation for each new employee
which shall include the mission, goals, organization and policy of the
agency;
(b) Require documentation
of all training which shall include:
1. The
type of training provided;
2. The
name and title of the trainer;
3.
The length of the training;
4. The
date of completion; and
5. The
signature of the trainee verifying completion;
(c) Ensure that each employee complete ABI
training consistent with the curriculum that has been approved by the
department prior to working independently with a participant, which shall
include:
1. Required orientation in brain
injury;
2. Identifying and
reporting abuse, neglect and exploitation;
3. Unless the employee is a licensed or
registered nurse, first aid, which shall be provided by an individual certified
as a trainer by the American Red Cross or other nationally-accredited
organization; and
4. Coronary
pulmonary resuscitation, which shall be provided by an individual certified as
a trainer by the American Red Cross or other nationally-accredited
organization;
(d) Ensure
that each employee completes at least six (6) hours of continuing education in
brain injury annually;
(e) Not be
required to receive the training specified in paragraph (c)1 of this subsection
if the provider is a professional who has, within the prior five (5) years,
2,000 hours of experience in serving a person with a primary diagnosis of a
brain injury including:
1. An occupational
therapist or occupational therapy assistant providing occupational
therapy;
2. A psychologist or
psychologist with autonomous functioning providing psychological
services;
3. A speech-language
pathologist providing speech-language pathology services; or
4. A board certified behavior analyst;
and
(f) Ensure that
prior to the date of service as a volunteer, an individual receives training
which shall include:
1. Required orientation
in brain injury as specified in paragraph (c)1, 2, 3, and 4 of this
subsection;
2. Orientation to the
agency;
3. A confidentiality
statement; and
4. Individualized
instruction on the needs of the participant to whom the volunteer will provide
services.
(18) An ABI provider shall provide
information to a case manager necessary for completion of a Mayo-Portland
Adaptability Inventory-4 for each participant served by the provider.
(19) A case management provider shall meet
the requirements established in Section 5 of this administrative
regulation.
Section 3.
Participant Eligibility, Enrollment and Termination.
(1) To be eligible to receive a service in
the ABI program:
(a) An individual shall:
1. Be at least eighteen (18) years of
age;
2. Have acquired a brain
injury of the following nature, to the central nervous system:
a. An injury from physical trauma;
b. Damage from anoxia or from a hypoxic
episode; or
c. Damage from an
allergic condition, toxic substance, or another acute medical
incident;
3. Apply to be
placed on the ABI waiting list in accordance with Section 9 of this
administrative regulation; and
4.
Be screened by the department for the purpose of making a preliminary
determination of whether the individual might qualify for ABI waiver
services;
(b) An
individual or the individual's representative shall:
1. Apply for 1915(c) home and community based
waiver services via the MWMA; and
2. Complete and upload to the MWMA a MAP -
115 Application Intake - Participant Authorization;
(c) A case manager or support broker, on
behalf of an applicant, shall enter into the MWMA a certification packet
containing the following:
1. A copy of the
allocation letter;
2. A MAP 351,
Medicaid Waiver Assessment;
3. A
statement for the need for ABI waiver services which shall be signed and dated
by a physician on a MAP-10, Waiver Services - Physician's
Recommendation;
4. A MAP 350, Long
Term Care Facilities and Home and Community Based Program Certification form;
and
5. A person-centered service
plan;
(d) An individual
shall receive notification of potential funding allocated for ABI services for
the individual;
(e) An individual
shall meet the patient status criteria for nursing facility services
established in
907 KAR 1:022 including nursing
facility services for a brain injury;
(f) An individual shall meet the following
conditions:
1. Have a primary diagnosis that
indicates an ABI with structural, nondegenerative brain injury;
2. Be medically stable;
3. Meet Medicaid eligibility requirements
established in
907 KAR 20:010;
4. Exhibit cognitive, behavioral, motor or
sensory damage with an indication for rehabilitation and retraining potential;
and
5. Have a rating of at least
four (4) on the Family Guide to the Rancho Levels of Cognitive Functioning;
and
(g) An individual
shall receive notification of approval from the department.
(2) An individual shall not remain
in the ABI waiver program for an indefinite period of time.
(3) The basis of an eligibility determination
for participation in the ABI waiver program shall be:
(a) The presenting problem;
(b) The person-centered service plan
goal;
(c) The expected benefit of
the admission;
(d) The expected
outcome;
(e) The service required;
and
(f) The cost effectiveness of
service delivery as an alternative to nursing facility and nursing facility
brain injury services.
(4) An ABI waiver service shall not be
furnished to an individual if the individual is:
(a) An inpatient of a hospital, nursing
facility or an intermediate care facility for individuals with an intellectual
disability; or
(b) Receiving a
service in another 1915(c) home and community based services waiver
program.
(5) The
department shall make:
(a) An initial
evaluation to determine if an individual meets the nursing facility patient
status criteria established in
907 KAR 1:022; and
(b) A determination of whether to admit an
individual into the ABI waiver program.
(6) To maintain eligibility as a participant:
(a) An individual shall maintain Medicaid
eligibility requirements established in
907 KAR 20:010; and
(b) A reevaluation shall be conducted at
least once every twelve (12) months to determine if the individual continues to
meet the patient status criteria for nursing facility services established in
907 KAR 1:022.
(7) The department may exclude an
individual from receiving ABI waiver services if the projected cost of ABI
waiver services for the individual is reasonably expected to exceed the cost of
nursing facility services for the individual.
(8) Involuntary termination or loss of an ABI
waiver program placement shall be in accordance with
907 KAR 1:563 and shall be
initiated if:
(a) An individual fails to
initiate an ABI waiver service within sixty (60) days of notification of
potential funding without good cause shown. The individual or legal
representative shall have the burden of providing documentation of good cause,
including:
1. A statement signed by the
participant or legal representative;
2. Copies of letters to providers;
and
3. Copies of letters from
providers;
(b) A
participant or legal representative fails to access the required service as
outlined in the person-centered service plan for a period greater than sixty
(60) consecutive days without good cause shown.
1. The participant or legal representative
shall have the burden of providing documentation of good cause including:
a. A statement signed by the participant or
legal representative;
b. Copies of
letters to providers; and
c. Copies
of letters from providers; and
2. Upon receipt of documentation of good
cause, the department shall grant one (1) extension in writing which shall be:
a. Sixty (60) days for an individual who does
not reside in a facility; and
b.
For an individual who resides in a facility, the length of the transition plan
and contingent upon continued active participation in the transition
plan;
(c) A
participant changes residence outside the Commonwealth of Kentucky;
(d) A participant does not meet the patient
status criteria for nursing facility services established in
907 KAR 1:022;
(e) A participant is no longer able to be
safely served in the community;
(f)
The participant has reached maximum rehabilitation potential; or
(g) The participant is no longer actively
participating in services within the approved person-centered service plan as
determined by the person-centered team.
(9) Involuntary termination of a service to a
participant by an ABI provider shall require:
(a) Simultaneous notice to the department,
the participant or legal representative and the case manager at least thirty
(30) days prior to the effective date of the action, which shall include:
1. A statement of the intended
action;
2. The basis for the
intended action;
3. The authority
by which the action is taken; and
4. The participant's right to appeal the
intended action through the provider's appeal or grievance process;
and
(b) The case manager
in conjunction with the provider to:
1.
Provide the participant with the name, address and telephone number of each
current ABI provider in the state;
2. Provide assistance to the participant in
making contact with another ABI provider;
3. Arrange transportation for a requested
visit to an ABI provider site;
4.
Provide a copy of pertinent information to the participant or legal
representative;
5. Ensure the
health, safety and welfare of the participant until an appropriate placement is
secured;
6. Continue to provide
supports until alternative services or another placement is secured;
and
7. Provide assistance to ensure
a safe and effective service transition.
(10) Voluntary termination and loss of an ABI
waiver program placement shall be initiated if a participant or legal
representative submits a written notice of intent to discontinue services to
the service provider and to the department.
(a) An action to terminate services shall not
be initiated until thirty (30) calendar days from the date of the notice;
and
(b) The participant or legal
representative may reconsider and revoke the notice in writing during the
thirty (30) calendar day period.
Section 4. Person-centered Service Plan
Requirements.
(1) A person-centered service
plan shall be established:
(a) For each
participant; and
(b) By the
participant's person-centered service plan team.
(2) A participant's person-centered service
plan shall:
(a) Be developed by:
1. The participant, the participant's
guardian, or the participant's representative;
2. The participant's case manager;
3. The participant's person-centered team;
and
4. Any other individual chosen
by the participant if the participant chooses any other individual to
participate in developing the person-centered service plan;
(b) Use a process that:
1. Provides the necessary information and
support to empower the participant, the participant's guardian, or
participant's legal representative to direct the planning process in a way that
empowers the participant to have the freedom and support to control the
recipient's schedules and activities without coercion or restraint;
2. Is timely and occurs at times and
locations convenient for the participant;
3. Reflects cultural considerations of the
participant;
4. Provides
information:
a. Using plain language in
accordance with 42 C.F.R.
435.905(b); and
b. In a way that is accessible to an
individual with a disability or who has limited English proficiency;
5. Offers an informed choice
defined as a choice from options based on accurate and thorough knowledge and
understanding to the participant regarding the services and supports to be
received and from whom;
6. Includes
a method for the participant to request updates to the person-centered service
plan as needed;
7. Enables all
parties to understand how the participant:
a.
Learns;
b. Makes decisions;
and
c. Chooses to live and work in
the participant's community;
8. Discovers the participant's needs, likes,
and dislikes;
9. Empowers the
participant's person-centered team to create a person-centered service plan
that:
a. Is based on the participant's:
(i) Assessed clinical and support
needs;
(ii) Strengths;
(iii) Preferences; and
(iv) Ideas;
b. Encourages and supports the participant's:
(i) Rehabilitative needs;
(ii) Habilitative needs; and
(iii) Long term satisfaction;
c. Is based on reasonable costs
given the participant's support needs;
d. Includes:
(i) The participant's goals;
(ii) The participant's desired outcomes;
and
(iii) Matters important to the
participant;
e. Includes
a range of supports including funded, community, and natural supports that
shall assist the participant in achieving identified goals;
f. Includes:
(i) Information necessary to support the
participant during times of crisis; and
(ii) Risk factors and measures in place to
prevent crises from occurring;
g. Assists the participant in making informed
choices by facilitating knowledge of and access to services and
supports;
h. Records the
alternative home and community-based settings that were considered by the
participant;
i. Reflects that the
setting in which the participant resides was chosen by the recipient;
j. Is understandable to the participant and
to the individuals who are important in supporting the participant;
k. Identifies the individual or entity
responsible for monitoring the person-centered service plan;
l. Is finalized and agreed to with the
informed consent of the participant or recipient's legal representative in
writing with signatures by each individual who will be involved in implementing
the person-centered service plan;
m. Shall be distributed to the individual and
other people involved in implementing the person-centered service
plan;
n. Includes those services
that the individual elects to self-direct; and
o. Prevents the provision of unnecessary or
inappropriate services and supports; and
(c) Includes in all settings the ability for
the participant to:
1. Have access to make
private phone calls, texts, or emails at the participant's preference or
convenience; and
2.
a. Choose when and what to eat;
b. Have access to food at any time;
c. Choose with whom to eat or whether to eat
alone; and
d. Choose appropriating
clothing according to the:
(i) Participant's
preference;
(ii) Weather;
and
(iii) Activities to be
performed.
(3) If a participant's person-centered
service plan includes ADHC services, the ADHC services plan of treatment shall
be addressed in the person-centered service plan.
(4)
(a) A
participant's person-centered service plan shall be:
1. Entered into the MWMA by the participant's
case manager; and
2. Updated in the
MWMA by the participant's case manager.
(b) A participant or participant's authorized
representative shall complete and upload into the MWMA a MAP - 116 Service Plan
- Participant Authorization prior to or at the time the person-centered service
plan is uploaded into the MWMA.
Section 5. Case Management Requirements.
(1) A case manager shall:
(a)
1. Be a
registered nurse;
2. Be a licensed
practical nurse; or
3. Be an
individual with a bachelor's degree or master's degree in a human services
field who meets all applicable requirements of his or her particular field
including a degree in:
a.
Psychology;
b. Sociology;
c. Social work;
d. Rehabilitation counseling; or
e. Occupational therapy;
(b)
1. Be independent as defined as not being
employed by an agency that is providing ABI waiver services to the participant;
or
2. Be employed by or work under
contract with a free-standing case management agency; and
(c) Have completed case management training
that is consistent with the curriculum that has been approved by the department
prior to providing case management services.
(2) A case manager shall:
(a) Communicate in a way that ensures the
best interest of the participant;
(b) Be able to identify and meet the needs of
the participant;
(c)
1. Be competent in the participant's language
either through personal knowledge of the language or through interpretation;
and
2. Demonstrate a heightened
awareness of the unique way in which the participant interacts with the world
around the participant;
(d) Ensure that:
1. The participant is educated in a way that
addresses the participant's:
a. Need for
knowledge of the case management process;
b. Personal rights; and
c. Risks and responsibilities as well as
awareness of available services; and
2. All individuals involved in implementing
the participant's person-centered service plan are informed of changes in the
scope of work related to the person-centered service plan as
applicable;
(e) Have a
code of ethics to guide the case manager in providing case management, which
shall address:
1. Advocating for standards
that promote outcomes of quality;
2. Ensuring that no harm is done;
3. Respecting the rights of others to make
their own decisions;
4. Treating
others fairly; and
5. Being
faithful and following through on promises and commitments;
(f)
1. Lead the person-centered service planning
team;
2. Take charge of
coordinating services through team meetings with representatives of all
agencies involved in implementing a participant's person-centered service
plan;
(g)
1. Include the participant's participation or
legal representative's participation in the case management process;
and
2. Make the participant's
preferences and participation in decision making a priority;
(h) Document:
1. A participant's interactions and
communications with other agencies involved in implementing the participant's
person-centered service plan; and
2. Personal observations;
(i) Advocate for a participant
with service providers to ensure that services are delivered as established in
the participant's person-centered service plan;
(j) Be accountable to:
1. A participant to whom the case manager
providers case management in ensuring that the participant's needs are
met;
2. A participant's
person-centered service plan team and provide leadership to the team and follow
through on commitments made; and
3.
The case manager's employer by following the employer's policies and
procedures;
(k) Stay
current regarding the practice of case management and case management
research;
(l) Assess the quality of
services, safety of services, and cost effectiveness of services being provided
to a participant in order to ensure that implementation of the participant's
person-centered service plan is successful and done so in a way that is
efficient regarding the participant's financial assets and benefits;
(m) Document services provided to a
participant by entering the following into the MWMA:
1. A monthly department-approved person
centered monitoring tool; and
2. A
monthly entry, which shall include:
a. The
month and year for the time period the note covers;
b. An analysis of progress toward the
participant's outcome or outcomes;
c. Identification of barriers to achievement
of outcomes;
d. A projected plan to
achieve the next step in achievement of outcomes;
e. The signature and title of the case
manager completing the note; and
f.
The date the note was generated;
(n) Document via an entry into the MWMA if a
participant is:
1. Admitted to the ABI long
term care waiver program;
2.
Terminated from the ABI long-term care waiver program;
3. Temporarily discharged from the ABI long
term care waiver program;
4.
Admitted to a hospital;
5. Admitted
to a nursing facility;
6. Changing
the primary ABI provider;
7.
Changing the case management agency;
8. Transferred to another Medicaid 1915(c)
home and community based waiver service program; or
9. Relocated to a different address;
and
(o) Provide
information about participant-directed services to the participant or the
participant's guardian:
1. At the time the
initial person-centered service plan is developed;
2. At least annually thereafter;
and
3. Upon inquiry from the
participant or participant's guardian.
(3) A case management provider shall:
(a) Establish a human rights committee which
shall:
1. Include an:
a. Individual with a brain injury or a family
member of an individual with a brain injury;
b. Individual not affiliated with the ABI
provider; and
c. Individual who has
knowledge and experience in human rights issues;
2. Review and approve each person-centered
service plan with human rights restrictions at a minimum of every six (6)
months;
3. Review and approve, in
conjunction with the participant's team, behavior intervention plans that
contain human rights restrictions; and
4. Review the use of a psychotropic
medication by a participant without an Axis I diagnosis;
(b) Establish a behavior intervention
committee which shall:
1. Include one (1)
individual who has expertise in behavior intervention and is not the behavior
specialist who wrote the behavior intervention plan;
2. Be separate from the human rights
committee; and
3. Review and
approve, prior to implementation and at a minimum of every six (6) months in
conjunction with the participant's team, an intervention plan that includes
highly restrictive procedures or contain human rights restrictions;
and
(c) Complete and
submit a Mayo-Portland Adaptability Inventory-4 to the department for each
participant:
1. Within thirty (30) days of the
participant's admission into the ABI program;
2. Annually thereafter; and
3. Upon discharge from the ABI waiver
program.
(4)
(a) Case management for any participant who
begins receiving ABI waiver services after the effective date of this
administrative regulation shall be conflict free.
(b)
1.
Conflict free case management shall be a scenario in which a provider including
any subsidiary, partnership, not-for-profit, or for-profit business entity that
has a business interest in the provider who renders case management to a
participant shall not also provide another 1915(c) home and community based
waiver service to that same participant unless the provider is the only willing
and qualified ABI waiver services provider within thirty (30) miles of the
participant's residence.
2. An
exemption to the conflict free case management requirement shall be granted if:
a. A participant requests the
exemption;
b. The participant's
case manager provides documentation of evidence to the department that there is
a lack of a qualified case manager within thirty (30) miles of the
participant's residence;
c. The
participant or participant's representative and case manager signs a completed
MAP - 531 Conflict-Free Case Management Exemption; and
d. The participant, participant's
representative, or case manager uploads the completed MAP - 531 Conflict-Free
Case Management Exemption into the MWMA.
3. If a case management service is approved
to be provided despite not being conflict free, the case management provider
shall document conflict of interest protections, separating case management and
service provision functions within the provider entity, and demonstrate that
the participant is provided with a clear and accessible alternative dispute
resolution process.
4. An exemption
to the conflict free case management requirement shall be requested upon
reassessment or at least annually.
(c) A participant who receives ABI waiver
services prior to the effective date of this administrative regulation shall
transition to conflict free case management when the participant's next level
of care determination occurs.
(d)
During the transition to conflict free case management, any case manager
providing case management to a participant shall educate the participant and
members of the participant's person-centered team of the conflict free case
management requirement in order to prepare the participant to decide, if
necessary, to change the participant's:
1.
Case manager; or
2. Provider of
non-case management ABI waiver services.
(5) Case management shall:
(a) Include initiation, coordination,
implementation, and monitoring of the assessment or reassessment, evaluation,
intake, and eligibility process;
(b) Assist a participant in the
identification, coordination, and facilitation of the person centered team and
person centered team meetings;
(c)
Assist a participant and the person-centered team to develop an individualized
person-centered service plan and update it as necessary based on changes in the
participant's medical condition and supports;
(d) Include monitoring of the delivery of
services and the effectiveness of the person-centered service plan, which
shall:
1. Be initially developed with the
participant and legal representative if appointed prior to the level of care
determination;
2. Be updated within
the first thirty (30) days of service and as changes or recertification occurs;
and
3. Include the person-centered
service plan being sent to the department or its designee prior to the
implementation of the effective date the change occurs with the
participant;
(e) Include
a transition plan that shall be developed within the first thirty (30) days of
service, updated as changes or recertification occurs, and updated thirty (30)
days prior to discharge, and shall include:
1.
The skills or service obtained from the ABI waiver program upon transition into
the community;
2. A listing of the
community supports available upon the transition; and
3. The expected date of transition from the
ABI waiver program;
(f)
Assist a participant in obtaining a needed service outside those available by
the ABI waiver;
(g) Be provided by
a case manager who:
1.
a. Is a registered nurse;
b. Is a licensed practical nurse;
c. Is an individual who has a bachelor's or
master's degree in a human services field who meets all applicable requirements
of his or her particular field including a degree in psychology, sociology,
social work, rehabilitation counseling, or occupational therapy;
d. Is an independent case manager;
or
e. Is employed by a
free-standing case management agency;
2. Has completed case management training
that is consistent with the curriculum that has been approved by the department
prior to providing case management services;
3. Shall provide a participant and legal
representative with a listing of each available ABI provider in the service
area;
4. Shall maintain
documentation signed by a participant or legal representative of informed
choice of an ABI provider and of any change to the selection of an ABI provider
and the reason for the change;
5.
Shall provide a distribution of the crisis prevention and response plan,
transition plan, person-centered service plan, and other documents within the
first thirty (30) days of the service to the chosen ABI service provider and as
information is updated;
6. Shall
provide twenty-four (24) hour telephone access to a participant and chosen ABI
provider;
7. Shall work in
conjunction with an ABI provider selected by a participant to develop a crisis
prevention and response plan, which shall be:
a. Individual-specific; and
b. Updated as a change occurs and at each
recertification;
8.
Shall assist a participant in planning resource use and assuring protection of
resources;
9.
a. Shall conduct two (2) face-to-face
meetings with a participant within a calendar month occurring at a covered
service site with one (1) visit quarterly at the participant's residence;
and
b. For a participant receiving
supervised residential care, shall conduct at least one (1) of the two (2)
monthly visits at the participant's supervised residential care provider
site;
10. Shall ensure
twenty-four (24) hour availability of services; and
11. Shall ensure that the participant's
health, welfare, and safety needs are met; and
(h) Be documented in the MWMA by a detailed
staff note, which shall include:
1. The
participant's health, safety, and welfare;
2. Progress toward outcomes identified in the
approved person-centered service plan;
3. The date of the service;
4. The beginning and ending times;
5. The signature and title of the individual
providing the service; and
6. A
quarterly summary, which shall include:
a.
Documentation of monthly contact with each chosen ABI provider; and
b. Evidence of monitoring of the delivery of
services approved in the participant's person-centered service plan and of the
effectiveness of the person-centered service plan.
(6) Case management
shall involve:
(a) A constant recognition of
what is and is not working regarding a participant; and
(b) Changing what is not working.
Section 6. Covered
Services.
(1) An ABI waiver service shall:
(a) Not be covered unless it has been
prior-authorized by the department; and
(b) Be provided pursuant to the participant's
person-centered service plan.
(2) The following services shall be provided
to a participant by an ABI waiver provider:
(a) Case management services in accordance
with Section 4 of this administrative regulation;
(b) Behavior programming services, which
shall:
1. Be the systematic application of
techniques and methods to influence or change a behavior in a desired
way;
2. Include a functional
analysis of the participant's behavior which shall include:
a. An evaluation of the impact of an ABI on
cognition and behavior;
b. An
analysis of potential communicative intent of the behavior;
c. The history of reinforcement for the
behavior;
d. Critical variables
that precede the behavior;
e.
Effects of different situations on the behavior; and
f. A hypothesis regarding the motivation,
purpose and factors which maintain the behavior;
3. Include the development of a behavioral
support plan, which shall:
a. Be developed by
the behavioral specialist;
b. Not
be implemented by the behavior specialist who wrote the plan;
c. Be revised as necessary;
d. Define the techniques and procedures
used;
e. Include the hierarchy of
behavior interventions ranging from the least to the most
restrictive;
f. Reflect the use of
positive approaches; and
g.
Prohibit the use of prone or supine restraint, corporal punishment, seclusion,
verbal abuse, and any procedure which denies private communication, requisite
sleep, shelter, bedding, food, drink, or use of a bathroom facility;
4. Include the provision of
training to other ABI providers concerning implementation of the behavioral
intervention plan;
5. Include the
monitoring of a participant's progress, which shall be accomplished through:
a. The analysis of data concerning the
frequency, intensity, and duration of a behavior;
b. Reports involved in implementing the
behavioral service plan; and
c. A
monthly summary, which assesses the participant's status related to the plan of
care;
6. Be provided by
a behavior specialist who shall:
a.
(i) Be a psychologist;
(ii) Be a psychologist with autonomous
functioning;
(iii) Be a licensed
psychological associate;
(iv) Be a
psychiatrist;
(v) Be a licensed
clinical social worker;
(vi) Be a
clinical nurse specialist with a master's degree in psychiatric nursing or
rehabilitation nursing;
(vii) Be an
advanced practice registered nurse;
(viii) Be a board certified behavior analyst;
or
(ix) Be a licensed professional
clinical counselor; and
b. Have at least one (1) year of behavior
specialist experience or provide documentation of completed coursework
regarding learning and behavior principles and techniques; and
7. Be documented in the MWMA by a
detailed staff note which shall include:
a.
The date of the service;
b. The
beginning and ending time; and
c.
The signature and title of the behavioral specialist;
(c) Companion services, which
shall:
1. Include a nonmedical service,
supervision or socialization as indicated in the recipient's plan of
care;
2. Include assisting with but
not performing meal preparation, laundry and shopping;
3. Include light housekeeping tasks which are
incidental to the care and supervision of a participant;
4. Include services provided according to the
approved plan of care which are therapeutic and not diversional in
nature;
5. Include accompanying and
assisting a participant while utilizing transportation services;
6. Include documentation in the MWMA by a
detailed staff note which shall include:
a.
Progress toward goal and objectives identified in the approved plan of
care;
b. The date of the
service;
c. Beginning and ending
time; and
d. The signature and
title of the individual providing the service;
7. Not be provided to a participant who
receives supervised residential care; and
8. Be provided by:
a. A home health agency licensed and
operating in accordance with
902 KAR 20:081;
b. A community mental health center licensed
and operating in accordance with
902 KAR 20:091 and certified at
least annually by the department;
c. A community habilitation program certified
by the department; or
d. A
supervised residential care provider;
(d) Supervised residential care level I
services, which:
1. Shall be provided by:
a. A community mental health center licensed
and operating in accordance with
902 KAR 20:091 and certified at
least annually by the department; or
b. An ABI provider;
2. Shall not be provided to a participant
unless the participant has been authorized to receive residential care by the
department's residential review committee, which shall:
a. Consider applications for residential care
in the order in which the applications are received;
b. Base residential care decisions on the
following factors:
(i) Whether the applicant
resides with a caregiver or not;
(ii) Whether the applicant resides with a
caregiver but demonstrates maladaptive behavior which places the applicant at
significant risk of injury or jeopardy if the caregiver is unable to
effectively manage the applicant's behavior or the risk it poses, resulting in
the need for removal from the home to a more structured setting; or
(iii) Whether the applicant demonstrates
behavior which may result in potential legal problems if not
ameliorated;
c. Be
comprised of three (3) Cabinet for Health and Family Services employees:
(i) With professional or personal experience
with brain injury or other cognitive disabilities; and
(ii) None of whom shall be supervised by the
manager of the acquired brain injury branch; and
d. Only consider applications at a monthly
committee meeting if the applications were received at least three (3) business
days before the committee convenes;
3. Shall not have more than three (3)
participants simultaneously in a residence rented or owned by the ABI
provider;
4. Shall provide
twenty-four (24) hours of supervision daily unless the provider implements,
pursuant to subparagraph 5 of this paragraph, an individualized plan allowing
for up to five (5) unsupervised hours per day;
5. May include the provision of up to five
(5) unsupervised hours per day per participant if the provider develops an
individualized plan for the participant to promote increased independence. The
plan shall:
a. Contain provisions necessary to
ensure the participant's health, safety, and welfare;
b. Be approved by the participant's treatment
team, with the approval documented by the provider; and
c. Contain periodic reviews and updates based
on changes, if any, in the participant's status;
6. Shall include assistance and training with
daily living skills including:
a.
Ambulating;
b. Dressing;
c. Grooming;
d. Eating;
e. Toileting;
f. Bathing;
g. Meal planning;
h. Grocery shopping;
i. Meal preparation;
j. Laundry;
k. Budgeting and financial matters;
l. Home care and cleaning;
m. Leisure skill instruction; or
n. Self-medication instruction;
7. Shall include social skills
training including the reduction or elimination of maladaptive behaviors in
accordance with the participant's person-centered service plan;
8. Shall include provision or arrangement of
transportation to services, activities, or medical appointments as
needed;
9. Shall include
accompanying or assisting a participant while the participant utilizes
transportation services as specified in the participant's person-centered
service plan;
10. Shall include
participation in medical appointments or follow-up care as directed by the
medical staff;
11. Shall be
documented in the MWMA by a detailed staff note which shall document:
a. Progress toward goals and objectives
identified in the approved person-centered service plan;
b. The date of the service;
c. The beginning and ending time of the
service; and
d. The signature and
title of the individual providing the service;
12. Shall not include the cost of room and
board;
13. Shall be provided to a
participant who:
a. Does not reside with a
caregiver;
b. Is residing with a
caregiver but demonstrates maladaptive behavior that places him or her at
significant risk of injury or jeopardy if the caregiver is unable to
effectively manage the behavior or the risk it presents, resulting in the need
for removal from the home to a more structured setting; or
c. Demonstrates behavior that may result in
potential legal problems if not ameliorated;
14. May utilize a modular home only if the:
a. Wheels are removed;
b. Home is anchored to a permanent
foundation; and
c. Windows are of
adequate size for an adult to use as an exit in an emergency;
15. Shall not utilize a motor
home;
16. Shall provide a sleeping
room which ensures that a participant:
a. Does
not share a room with an individual of the opposite gender who is not the
participant's spouse;
b. Does not
share a room with an individual who presents a potential threat; and
c. Has a separate bed equipped with
substantial springs, a clean and comfortable mattress, and clean bed linens as
required for the participant's health and comfort; and
17. Shall provide service and training to
obtain the outcomes for the participant as identified in the approved
person-centered service plan;
(e) Supervised residential care level II
services, which shall:
1. Meet the
requirements established in paragraph (d) of this subsection, except for the
requirements established in paragraph (d)4 and 5;
2. Provide twelve (12) to eighteen (18) hours
of daily supervision, the amount of which shall:
a. Be based on the participant's
needs;
b. Be approved by the
participant's treatment team; and
c. Be documented in the participant's
person-centered service plan, which shall also contain periodic reviews and
updates based on changes, if any, in the participant's status; and
3. Include provision of
twenty-four (24) hour on-call support;
(f) Supervised residential care level III
services, which shall:
1. Meet the
requirements established in paragraph (d) of this subsection except for the
requirements established in paragraph (d)4 and 5;
2. Be provided in a single family home,
duplex, or apartment building to a participant who lives alone or with an
unrelated roommate;
3. Not be
provided to more than two (2) participants simultaneously in one (1) apartment
or home;
4. Not be provided in more
than two (2) apartments in one (1) building;
5. If provided in an apartment building, have
staff:
a. Available twenty-four (24) hours per
day and seven (7) days per week; and
b. Who do not reside in a dwelling occupied
by a participant; and
6.
Provide less than twelve (12) hours of supervision or support in the residence
based on an individualized plan developed by the provider to promote increased
independence which shall:
a. Contain
provisions necessary to ensure the recipient's health, safety, and
welfare;
b. Be approved by the
participant's treatment team, with the approval documented by the provider;
and
c. Contain periodic reviews and
updates based on changes, if any, in the participant's status;
(g) Counseling
services, which:
1. Shall be designed to help
a participant resolve personal issues or interpersonal problems resulting from
his or her ABI;
2. Shall assist a
family member in implementing an approved person-centered service
plan;
3. In a severe case, shall be
provided as an adjunct to behavioral programming;
4. Shall include substance abuse or chemical
dependency treatment, if needed;
5.
Shall include building and maintaining healthy relationships;
6. Shall develop social skills or the skills
to cope with and adjust to the brain injury;
7. Shall increase knowledge and awareness of
the effects of an ABI;
8. May
include a group therapy service if the service is:
a. Provided to a minimum of two (2) and a
maximum of eight (8) participants; and
b. Included in the participant's approved
person-centered service plan for:
(i)
Substance abuse or chemical dependency treatment, if needed;
(ii) Building and maintaining healthy
relationships;
(iii) Developing
social skills;
(iv) Developing
skills to cope with and adjust to a brain injury, including the use of
cognitive remediation strategies consisting of the development of compensatory
memory and problem solving strategies, and the management of impulsivity;
and
(v) Increasing knowledge and
awareness of the effects of the acquired brain injury upon the participant's
functioning and social interactions;
9. Shall be provided by:
a. A psychiatrist;
b. A psychologist;
c. A psychologist with autonomous
functioning;
d. A licensed
psychological associate;
e. A
licensed clinical social worker;
f.
A clinical nurse specialist with a master's degree in psychiatric
nursing;
g. An advanced practice
registered nurse; or
h. A certified
alcohol and drug counselor;
i. A
licensed marriage and family therapist;
j. A licensed professional clinical
counselor;
k. A licensed clinical
alcohol and drug counselor associate effective and contingent upon approval by
the Centers for Medicare and Medicaid Services; or
l. A licensed clinical alcohol and drug
counselor effective and contingent upon approval by the Centers for Medicare
and Medicaid Services; and
10. Shall be documented in the MWMA by a
detailed staff note, which shall include:
a.
Progress toward the goals and objectives established in the person-centered
service plan;
b. The date of the
service;
c. The beginning and
ending time; and
d. The signature
and title of the individual providing the service;
(h) Occupational therapy which
shall be:
1. A physician-ordered evaluation of
a participant's level of functioning by applying diagnostic and prognostic
tests;
2. Physician-ordered
services in a specified amount and duration to guide a participant in the use
of therapeutic, creative, and self-care activities to assist the participant in
obtaining the highest possible level of functioning;
3. Exclusive of maintenance or the prevention
of regression;
4. Provided by an
occupational therapist or an occupational therapy assistant if supervised by an
occupational therapist in accordance with
201 KAR 28:130; and
5. Documented in the MWMA by a detailed staff
note, which shall include:
a. Progress toward
goal and objectives identified in the approved person-centered service
plan;
b. The date of the
service;
c. The beginning and
ending times; and
d. The signature
and title of the individual providing the service;
(i) Personal care services, which
shall:
1. Include the retraining of a
participant in the performance of an activity of daily living by using
repetitive, consistent and ongoing instruction and guidance;
2. Be provided by:
a. An adult day health care center licensed
and operating in accordance with
902 KAR 20:066;
b. A home health agency licensed and
operating in accordance with
902 KAR 20:081;
c. A personal services agency; or
d. Another ABI provider;
3. Include the following activities of daily
living:
a. Eating, bathing, dressing or
personal hygiene;
b. Meal
preparation; and
c. Housekeeping
chores including bed-making, dusting and vacuuming;
4. Be documented in the MWMA by a detailed
staff note which shall include:
a. Progress
toward goal and objectives identified in the approved person-centered service
plan;
b. The date of the
service;
c. Beginning and ending
time; and
d. The signature and
title of the individual providing the service; and
5. Not be provided to a participant who
receives supervised residential care
(j) A respite service, which shall:
1. Be provided only to a participant unable
to administer self-care;
2. Be
provided by a:
a. Nursing facility;
b. Community mental health center;
c. Home health agency;
d. Supervised residential care provider;
or
e. Community habilitation
program;
3. Be provided
on a short-term basis due to absence or need for relief of a non-paid primary
caregiver;
4. Be limited to 336
hours per one (1) year authorized person-centered service plan period unless an
individual's non-paid caregiver is unable to provide care due to a:
a. Death in the family;
b. Serious illness; or
c. Hospitalization;
5. Not be provided to a participant who
receives supervised residential care;
6. Not include the cost of room and board if
provided in a nursing facility; and
7. Be documented in the MWMA by a detailed
staff note, which shall include:
a. Progress
toward goals and objectives identified in the approved person-centered service
plan;
b. The date of the
service;
c. The beginning and
ending time; and
d. The signature
and title of the individual providing the service;
(k) Speech- language pathology
services, which shall be:
1. A
physician-ordered evaluation of a participant with a speech, hearing, or
language disorder;
2. A
physician-ordered habilitative service in a specified amount and duration to
assist a participant with a speech and language disability in obtaining the
highest possible level of functioning;
3. Exclusive of maintenance or the prevention
of regression;
4. Provided by a
speech language pathologist; and
5.
Documented in the MWMA by a detailed staff note, which shall include:
a. Progress toward goals and objectives
identified in the approved person-centered service plan;
b. The date of the service;
c. The beginning and ending time;
and
d. The signature and title of
the individual providing the service;
(l) Adult day training services, which shall:
1. Be provided by:
a. An adult day health care center that is
certified by the department and licensed and operating in accordance with
902 KAR 20:066;
b. An outpatient rehabilitation facility that
is certified by the department and licensed and operating in accordance with
902 KAR 20:190;
c. A community mental health center licensed
and operating in accordance with
902 KAR 20:091;
d. A community habilitation
program;
e. A sheltered employment
program; or
f. A therapeutic
rehabilitation program;
2. Rehabilitate, retrain and reintegrate a
participant into the community;
3.
Not exceed a staffing ratio of five (5) participants per one (1) staff person,
unless a participant requires individualized special service;
4. Include the following services:
a. Social skills training related to
problematic behaviors identified in the participant's person-centered service
plan;
b. Sensory or motor
development;
c. Reduction or
elimination of a maladaptive behavior;
d. Prevocational; or
e. Teaching concepts and skills to promote
independence including:
(i) Following
instructions;
(ii) Attendance and
punctuality;
(iii) Task
completion;
(iv) Budgeting and
money management;
(v) Problem
solving; or
(vi) Safety;
5. Be provided in a
nonresidential setting;
6. Be
developed in accordance with a participant's overall approved person-centered
service plan;
7. Reflect the
recommendations of a participant's interdisciplinary team;
8. Be appropriate:
a. Given a participant's age, level of
cognitive and behavioral function and interest;
b. Given a participant's ability prior to and
since his or her injury; and
c.
According to the approved person-centered service plan and be therapeutic in
nature and not diversional;
9. Be coordinated with occupational, speech,
or other rehabilitation therapy included in a participant's person-centered
service plan;
10. Provide a
participant with an organized framework within which to function in his or her
daily activities;
11. Entail
frequent assessments of a participant's progress and be appropriately revised
as necessary; and
12. Be documented
in the MWMA by a detailed staff note, which shall include:
a. Progress toward goal and objectives
identified in the approved person-centered service plan;
b. The date of the service;
c. The beginning and ending time;
d. The signature and title of the individual
providing the service; and
e. A
monthly summary that assesses the participant's status related to the approved
person-centered service plan;
(m) Supported employment services, which
shall be:
1. Intensive, ongoing services for a
participant to maintain paid employment in an environment in which an
individual without a disability is employed;
2. Provided by a:
a. Supported employment provider;
b. Sheltered employment provider;
or
c. Structured day program
provider;
3. Provided
one-on-one;
4. Unavailable under a
program funded by either the Rehabilitation Act of 1973 (29 U.S.C. Chapter
16)
or
Pub.L.
99-457 (34 C.F.R. Parts
300 to
399), proof of which shall be
documented in the participant's file;
5. Limited to forty (40) hours per week alone
or in combination with structured day services;
6. An activity needed to sustain paid work by
a participant receiving waiver services including supervision and
training;
7. Exclusive of work
performed directly for the supported employment provider; and
8. Documented in the MWMA by a time and
attendance record, which shall include:
a.
Progress towards the goals and objectives identified in the person-centered
service plan;
b. The date of
service;
c. The beginning and
ending time; and
d. The signature
and title of the individual providing the service;
(n) Specialized medical equipment
and supplies, which shall:
1. Include durable
and nondurable medical equipment, devices, controls, appliances, or ancillary
supplies;
2. Enable a participant
to increase his or her ability to perform daily living activities or to
perceive, control, or communicate with the environment;
3. Be ordered by a physician, documented in a
participant's person-centered service plan, and entered into the MWMA by the
participant's case manager or support broker, and include three (3) estimates
if the equipment is needed for vision and hearing;
4. Include equipment necessary to the proper
functioning of specialized items;
5. Not be available through the department's
durable medical equipment, vision or hearing programs;
6. Not be necessary for life
support;
7. Meet applicable
standards of manufacture, design and installation; and
8. Exclude those items which are not of
direct medical or remedial benefit to a participant;
(o) Environmental modifications, which shall:
1. Be provided in accordance with applicable
state and local building codes;
2.
Be provided to a participant if:
a. Ordered by
a physician;
b. Prior-authorized by
the department;
c. Specified in the
participant's approved person-centered service plan and entered into the MWMA
by the participant's case manager or support broker;
d. Necessary to enable a participant to
function with greater independence within his or her home; and
e. Without the modification, the participant
would require institutionalization;
3. Not include a vehicle
modification;
4. Be limited to no
more than $2,000 for a participant in a twelve (12) month period; and
5. If entailing:
a. Electrical work, be provided by a licensed
electrician; or
b. Plumbing work,
be provided by a licensed plumber;
(p) An assessment, which shall:
1. Be a comprehensive assessment which shall
identify:
a. A participant's needs;
and
b. Services that a
participant's family cannot manage or arrange for the participant;
2. Evaluate a participant's
physical health, mental health, social supports, and environment;
3. Be requested by:
a. An individual requesting ABI waiver
services;
b. A family member of the
individual requesting ABI services; or
c. A legal representative of the individual
requesting ABI services;
4. Be conducted:
a. By an ABI case manager or support broker;
and
b. Within seven (7) calendar
days of receipt of the request for an assessment;
5. Include at least one (1) face-to-face
contact in the participant's home between the assessor, the participant, and,
if appropriate, the participant's family; and
6. Not be reimbursable if the individual no
longer meets ABI program eligibility requirements; or
(q) A reassessment, which shall:
1. Be performed at least once every twelve
(12) months;
2. Be conducted:
a. Using the same procedures as for an
assessment; and
b. By an ABI case
manager or support broker;
3. Be timely conducted to enable the results
to be submitted to the department within three (3) weeks prior to the
expiration of the current level of care certification to ensure that
certification is consecutive;
4.
Not be reimbursable if the individual no longer meets ABI program eligibility
requirements; and
5. Not be
retroactive.
Section 7. Exclusions of the Acquired Brain
Injury Waiver Program. A condition included in the following list shall not be
considered an acquired brain injury requiring specialized rehabilitation:
(1) A stroke treatable in a nursing facility
providing routine rehabilitation services;
(2) A spinal cord injury for which there is
no known or obvious injury to the intracranial central nervous
system;
(3) Progressive dementia or
another condition related to mental impairment that is of a chronic
degenerative nature, including senile dementia, organic brain disorder,
Alzheimer's Disease, alcoholism or another addiction;
(4) A depression or a psychiatric disorder in
which there is no known or obvious central nervous system damage;
(5) A birth defect;
(6) An intellectual disability without an
etiology to an acquired brain injury;
(7) A condition which causes an individual to
pose a level of danger or an aggression which is unable to be managed and
treated in a community; or
(8)
Determination that the participant has met his or her maximum rehabilitation
potential.
Section 8.
Incident Reporting Process.
(1)
(a) There shall be two (2) classes of
incidents.
(b) The following shall
be the two (2) classes of incidents:
1. An
incident; or
2. A critical
incident.
(2)
An incident shall be any occurrence that impacts the health, safety, welfare,
or lifestyle choice of a participant and includes:
(a) A minor injury;
(b) A medication error without a serious
outcome; or
(c) A behavior or
situation which is not a critical incident.
(3) A critical incident shall be an alleged,
suspected, or actual occurrence of an incident that:
(a) Can reasonably be expected to result in
harm to a participant; and
(b)
Shall include:
1. Abuse, neglect, or
exploitation;
2. A serious
medication error;
3.
Death;
4. A homicidal or suicidal
ideation;
5. A missing person;
or
6. Other action or event that
the provider determines may result in harm to the participant.
(4)
(a) If an incident occurs, the ABI provider
shall:
1. Report the incident by making an
entry into the MWMA that includes details regarding the incident; and
2. Be immediately assessed for potential
abuse, neglect, or exploitation.
(b) If an assessment of an incident indicates
that the potential for abuse, neglect, or exploitation exists:
1. The incident shall immediately be
considered a critical incident;
2.
The critical incident procedures established in subsection (5) of this section
shall be followed; and
3. The ABI
provider shall report the incident to the participant's case manager and
participant's guardian, if the participant has a guardian, within twenty-four
(24) hours of discovery of the incident.
(5)
(a) If a
critical incident occurs, the individual who witnessed the critical incident or
discovered the critical incident shall immediately act to ensure the health,
safety, and welfare of the at-risk participant.
(b) If the critical incident:
1. Requires reporting of abuse, neglect, or
exploitation, the critical incident shall be immediately reported via the MWMA
by the individual who witnessed or discovered the critical incident;
or
2. Does not require reporting of
abuse, neglect, or exploitation, the critical incident shall be reported via
the MWMA by the individual who witnessed or discovered the critical incident
within eight (8) hours of discovery.
(c) The ABI provider shall:
1. Conduct an immediate investigation and
involve the participant's case manager in the investigation; and
2. Prepare a report of the investigation,
which shall be recorded in the MWMA and shall include:
a. Identifying information of the participant
involved in the critical incident and the person reporting the critical
incident;
b. Details of the
critical incident; and
c. Relevant
participant information including:
(i) Axis I
diagnosis or diagnoses;
(ii) Axis
II diagnosis or diagnoses;
(iii)
Axis III diagnosis or diagnoses;
(iv) A listing of recent medical
concerns;
(v) An analysis of causal
factors; and
(vi) Recommendations
for preventing future occurrences.
(6)
(a) Following a death of a participant
receiving ABI services from an ABI provider, the ABI provider shall enter
mortality data documentation into the MWMA within fourteen (14) days of the
death.
(b) Mortality data
documentation shall include:
1. The
participant's person-centered service plan at the time of death;
2. Any current assessment forms regarding the
participant;
3. The participant's
medication administration records from all service sites for the past three (3)
months along with a copy of each prescription;
4. Progress notes regarding the participant
from all service elements for the past thirty (30) days;
5. The results of the participant's most
recent physical exam;
6. All
incident reports, if any exist, regarding the participant for the past six (6)
months;
7. Any medication error
report, if any exists, related to the participant for the past six (6)
months;
8. The most recent
psychological evaluation of the participant;
9. A full life history of the participant
including any update from the last version of the life history;
10. Names and contact information for all
staff members who provided direct care to the participant during the last
thirty (30) days of the participant's life;
11. Emergency medical services notes
regarding the participant if available;
12. The police report if available;
13. A copy of:
a. The participant's advance directive,
medical order for scope of treatment, living will, or health care directive if
applicable;
b. Any functional
assessment of behavior or positive behavior support plan regarding the
participant that has been in place over any part of the past twelve (12)
months; and
c. The cardiopulmonary
resuscitation and first aid card for any ABI provider's staff member who was
present at the time of the incident that resulted in the participant's
death;
14. A record of
all medical appointments or emergency room visits by the participant within the
past twelve (12) months; and
15. A
record of any crisis training for any staff member present at the time of the
incident that resulted in the participant's death.
(7)
(a) An ABI provider shall report a medication
error to the MWMA.
(b) An ABI
provider shall document all medication error details on a medication error log
retained on file at the ABI provider site.
Section 9. ABI Waiting List.
(1) An individual of age eighteen (18) years
or older applying for an ABI waiver service shall be placed on a statewide
waiting list which shall be maintained by the department.
(2) In order to be placed on the ABI waiting
list, an individual or individual's representative shall:
(a) Apply for 1915(c) home and community
based waiver services via the MWMA;
(b) Complete and upload into the MWMA a MAP -
115 Application Intake - Participant Authorization; and
(c) Upload to the MWMA a completed MAP-10,
Waiver Services - Physician's Recommendation that has been signed by a
physician.
(3) The order
of placement on the ABI waiting list shall be determined by the:
(a) Chronological date of complete
application information regarding the individual being entered into the MWMA;
and
(b) Category of need.
(4) The ABI waiting list
categories of need shall be emergency or nonemergency.
(5) To be placed in the emergency category of
need, an individual shall be determined by the emergency review committee to
meet the emergency category criteria established in subsection (8) of this
section.
(6) The emergency review
committee shall:
(a) Be comprised of three (3)
individuals from the department:
1. Who shall
each have professional or personal experience with brain injury or cognitive
disabilities; and
2. None of whom
shall be supervised by the branch manager of the department's acquired brain
injury branch; and
(b)
Meet during the fourth (4th) week of each month to review and consider
applications for the acquired brain injury waiver program to determine if
applicants meet the emergency category of need criteria established in
subsection (8) of this subsection.
(7) An individual's application via the MWMA
shall be completed no later than three (3) business days prior to the fourth
(4th) week of each month in order to be considered by the emergency review
committee during that month's emergency review committee meeting.
(8) An applicant shall meet the emergency
category of need criteria if the applicant is currently demonstrating behavior
related to his or her acquired brain injury:
(a) That places the individual, caregiver, or
others at risk of significant harm; or
(b) Which has resulted in the applicant being
arrested.
(9) An
applicant who does not meet the emergency category of need criteria established
in subsection (8) of this subsection shall be considered to be in the
nonemergency category of need.
(10)
In determining chronological status of an applicant, the original date of the
individual's complete application information being entered into the MWMA
shall:
(a) Be maintained; and
(b) Not change if the individual is moved
from one (1) category of need to another.
(11) A written statement by a physician or
other qualified mental health professional shall be required to support the
validation of risk of significant harm to a recipient or caregiver.
(12) Written documentation by law enforcement
or court personnel shall be required to support the validation of a history of
arrest.
(13) A written notification
of placement on the waiting list shall be mailed to the individual or his or
her legal representative and case management provider if identified.
(14) Maintenance of the ABI waiting list
shall occur as follows:
(a) The department
shall, at a minimum, annually update the waiting list during the birth month of
an individual;
(b) If an individual
is removed from the ABI waiting list, written notification shall be mailed by
the department to the individual and his or her legal representative and also
the ABI case manager; and
(c) The
requested data shall be received by the department within thirty (30) days from
the date on the written notice required by subsection (13) of this
section.
(15)
Reassignment of an applicant's category of need shall be completed based on the
updated information and validation process.
(16) An individual or legal representative
may submit a request for consideration of movement from one category of need to
another at any time that an individual's status changes.
(17) An individual shall be removed from the
ABI waiting list if:
(a) After a documented
attempt, the department is unable to locate the individual or his or her legal
representative;
(b) The individual
is deceased;
(c) The individual or
individual's legal representative refuses the offer of ABI placement for
services and does not request to be maintained on the waiting list;
(d) An ABI placement for services offer is
refused by the individual or legal representative; or
(e) The individual does not access services
without demonstration of good cause within sixty (60) days of the placement
allocation date.
1. The individual or
individual's legal representative shall have the burden of providing
documentation of good cause including:
a. A
signed statement by the individual or the legal representative;
b. Copies of letters to providers;
and
c. Copies of letters from
providers.
2. Upon
receipt of documentation of good cause, the department shall grant one (1)
sixty (60) day extension in writing.
(18) If an individual is removed from the ABI
waiting list, written notification shall be mailed by the department to the
individual or individual's legal representative and the ABI case
manager.
(19) The removal of an
individual from the ABI waiting list shall not prevent the submittal of a new
application at a later date.
(20)
Potential funding allocated for services for an individual shall be based upon:
(a) The individual's category of need;
and
(b) The individual's
chronological date of placement on the waiting list.
Section 10. Participant-Directed
Services.
(1) Covered services and supports
provided to a participant receiving PDS shall include:
(a) Home and community support
services;
(b) Community day support
services;
(c) Goods or services;
or
(d) Financial
management.
(2) A home
and community support service shall:
(a) Be
available only as a participant-directed service;
(b) Be provided in the participant's home or
in the community;
(c) Be based upon
therapeutic goals;
(d) Not be
diversional in nature;
(e) Not be
provided to an individual if the same or similar service is being provided to
the individual via non-PDS ABI services; and
(f)
1. Be
respite for the primary caregiver; or
2. Be supports and assistance related to
chosen outcomes to facilitate independence and promote integration into the
community for an individual residing in his or her own home or the home of a
family member and may include:
a. Routine
household tasks and maintenance;
b.
Activities of daily living;
c.
Personal hygiene;
d.
Shopping;
e. Money
management;
f. Medication
management;
g.
Socialization;
h. Relationship
building;
i. Meal
planning;
j. Meal
preparation;
k. Grocery shopping;
or
l. Participation in community
activities.
(3) A community day support service shall:
(a) Be available only as a
participant-directed service;
(b)
Be provided in a community setting;
(c) Be based upon therapeutic
goals;
(d) Not be diversional in
nature;
(e) Be tailored to the
participant's specific personal outcomes related to the acquisition,
improvement, and retention of skills and abilities to prepare and support the
participant for:
1. Work;
2. Community activities;
3. Socialization;
4. Leisure; or
5. Retirement activities; and
(f) Not be provided to an
individual if the same or similar service is being provided to the individual
via non-PDS ABI services.
(4) Goods or services shall:
(a) Be individualized;
(b) Be utilized to:
1. Reduce the need for personal care;
or
2. Enhance independence within
the participant's home or community;
(c) Not include experimental goods or
services; and
(d) Not include
chemical or physical restraints.
(5) To be covered, a PDS shall be specified
in a participant's person-centered service plan.
(6) Reimbursement for a PDS shall not exceed
the department's allowed reimbursement for the same or a similar service
provided in a non-PDS ABI setting.
(7) A participant, including a married
participant, shall choose providers and the choice of PDS provider shall be
documented in his or her person-centered service plan.
(8)
(a) A
participant may designate a representative to act on the participant's
behalf.
(b) The PDS representative
shall:
1. Be twenty-one (21) years of age or
older;
2. Not be monetarily
compensated for acting as the PDS representative or providing a PDS;
and
3. Be appointed by the
participant on a MAP-2000 form.
(9) A participant may voluntarily terminate
PD services by completing a MAP-2000 and submitting it to the support
broker.
(10) The department shall
immediately terminate a participant from CDO services if:
(a) Imminent danger to the participant's
health, safety, or welfare exists;
(b) The recipient's person-centered service
plan indicates he or she requires more hours of service than the program can
provide, thus jeopardizing the recipient's safety or welfare due to being left
alone without a caregiver present; or
(c) The recipient, caregiver, family member,
or guardian threatens or intimidates a support broker or other PDS
staff.
(11) The
department may terminate a participant from PDS if it determines that the
participant's PDS provider has not adhered to the person-centered service
plan.
(12) Prior to a participant's
termination from PDS, the support broker shall:
(a) Notify the assessment or reassessment
service provider of potential termination;
(b) Assist the participant in developing a
resolution and prevention plan;
(c)
Allow at least thirty (30), but no more than ninety (90), days for the
participant to resolve the issue, develop and implement a prevention plan, or
designate a PDS representative;
(d)
Complete and submit to the department a MAP-2000 form terminating the
participant from PDS if the participant fails to meet the requirements in
paragraph (c) of this subsection; and
(e) Assist the participant in transitioning
back to traditional ABI services.
(13) Upon an involuntary termination of PDS,
the department shall:
(a) Notify a participant
in writing of its decision to terminate the participant's PDS participation;
and
(b) Inform the participant of
the right to appeal the department's decision in accordance with Section 10 of
this administrative regulation.
(14) A PDS provider:
(a) Shall be selected by the
participant;
(b) Shall submit a
completed Kentucky Participant-Directed Services Employee Provider Contract to
the support broker;
(c) Shall be
eighteen (18) years of age or older;
(d) Shall be a citizen of the United States
with a valid Social Security number or possess a valid work permit if not a
U.S. citizen;
(e) Shall be able to
communicate effectively with the participant, participant's representative, or
family;
(f) Shall be able to
understand and carry out instructions;
(g) Shall be able to keep records as required
by the participant;
(h) Shall
submit to a criminal background check conducted by the Administrative Office of
the Courts if the individual is a Kentucky resident or equivalent out-of-state
agency if the individual resided or worked outside Kentucky during the year
prior to selection as a provider of PDS;
(i) Shall submit to a check of the Central
Registry maintained in accordance with
922 KAR 1:470 and not be found on
the registry:
1. A participant may employ a
provider prior to a Central Registry check result being obtained for up to
thirty (30) days; and
2. If a
participant does not obtain a Central Registry check result within thirty (30)
days of employing a provider, the participant shall cease employment of the
provider until a favorable result is obtained;
(j) Shall submit to a check of the:
1. Nurse Aide Abuse Registry maintained in
accordance with
906 KAR 1:100 and not be found on
the registry; and
2. Caregiver
Misconduct Registry maintained in accordance with
922 KAR 5:120 and not be found on
the registry;
(k) Shall
not have pled guilty or been convicted of committing a sex crime or violent
crime as defined in KRS 17.165(1) through
(3);
(l) Shall complete training on the reporting
of abuse, neglect or exploitation in accordance with
KRS
209.030 or
620.030 and on the needs of the
participant;
(m) Shall be approved
by the department;
(n) Shall
maintain and submit timesheets documenting hours worked; and
(o) Shall be a friend, spouse, parent, family
member, other relative, employee of a provider agency, or other person hired by
the participant.
(15) A
PDS provider may use Kentucky's national background check program established
by
906 KAR 1:190 to satisfy the
background check requirements of subsection (14)(h), (i), and (j) of this
section.
(16) A parent, parents
combined, or a spouse shall not provide more than forty (40) hours of services
in a calendar week (Sunday through Saturday) regardless of the number of family
members who receive waiver services.
(17)
(a)
1. The department shall establish a budget
for a participant based on the individual's historical costs minus five (5)
percent to cover costs associated with administering the participant-directed
services.
2. If no historical cost
exists for the participant, the participant's budget shall equal the average
per capita historical costs of ABI recipients minus five (5) percent.
(b) Cost of services authorized by
the department for the individual's prior year person-centered service plan but
not utilized may be added to the budget if necessary to meet the individual's
needs.
(c) The department may
adjust a participant's budget based on the participant's needs and in
accordance with paragraphs (d) and (e) of this subsection.
(d) A participant's budget shall not be
adjusted to a level higher than established in paragraph (a) of this subsection
unless:
1. The participant's support broker
requests an adjustment to a level higher than established in paragraph (a) of
this subsection; and
2. The
department approves the adjustment.
(e) The department shall consider the
following factors in determining whether to allow for a budget adjustment:
1. If the proposed services are necessary to
prevent imminent institutionalization;
2. The cost effectiveness of the proposed
services;
3. Protection of the
participant's health, safety, and welfare; and
4. If a significant change has occurred in
the recipient's:
a. Physical condition
resulting in additional loss of function or limitations to activities of daily
living and instrumental activities of daily living;
b. Natural support system; or
c. Environmental living arrangement resulting
in the recipient's relocation.
(f) A participant's budget shall not exceed
the average per capita cost of services provided to individuals with a brain
injury in a nursing facility.
(18) Unless approved by the department
pursuant to subsection (16)(b) through (e) of this section, if a PDS is
expanded to a point in which expansion necessitates a budget allowance
increase, the entire service shall only be covered via a traditional (non-PDS)
waiver service provider.
(19)
(a) A support broker shall:
1. Provide needed assistance to a participant
with any aspect of PDS or blended services;
2. Be available to a participant by phone or
in person:
a. Twenty-four (24) hours per day,
seven (7) days per week; and
b. To
assist the participant in obtaining community resources as needed;
3. Comply with applicable federal
and state laws and requirements;
4.
Continually monitor a participant's health, safety, and welfare; and
5. Complete or revise a person-centered
service plan in accordance with Section 4 of this administrative
regulation.
(b) For a
PDS participant, a support broker may conduct an assessment or
reassessment.
(c) Services provided
by a supporter broker shall meet the conflict free requirements established for
case management in Section 5(4) of this administrative regulation.
(20) Financial management shall:
(a) Include managing, directing, or
dispersing a participant's funds identified in the participant's approved PDS
budget;
(b) Include payroll
processing associated with the individual hired by a participant or the
participant's representative;
(c)
Include:
1. Withholding local, state, and
federal taxes; and
2. Making
payments to appropriate tax authorities on behalf of a participant;
(d) Be performed by an entity
that:
1. Is enrolled as a Medicaid provider in
accordance with
907 KAR 1:672;
3. Has at least two (2) years of experience
working with individuals with an acquired brain injury; and
(e) Include preparation of fiscal
accounting and expenditure reports for:
1. A
participant or participant's representative; and
2. The department.
Section 11. Electronic
Signature Usage. The creation, transmission, storage, or other use of
electronic signatures and documents shall comply with the requirements
established in KRS
369.101 to
369.120.
Section 12. Appeal Rights.
(1) An appeal of a department decision
regarding a participant or applicant based upon an application of this
administrative regulation shall be in accordance with
907 KAR 1:563.
(2) An appeal of a department decision
regarding Medicaid eligibility of an individual based upon an application of
this administrative regulation shall be in accordance with
907 KAR 1:560.
(3) An appeal of a department decision
regarding a provider based upon an application of this administrative
regulation shall be in accordance with
907 KAR 1:671.
Section 13. Incorporation by
Reference.
(1) The following material is
incorporated by reference:
(a) "MAP-10, Waiver
Services - Physician's Recommendation", June 2015;
(b) "MAP - 115 Application Intake -
Participant Authorization", May 2015;
(c) "MAP - 116 Service Plan - Participant
Authorization", May 2015;
(d) "MAP
- 531 Conflict-Free Case Management Exemption", October 2015;
(e) "MAP-2000, Initiation/Termination of
Participant-Directed Services (CDO)", June 2015;
(f) "MAP-350, Long Term Care Facilities and
Home and Community Based Program Certification Form", June 2015;
(g) "Family Guide to the Rancho Levels of
Cognitive Functioning", August 2006;
(h) "MAP-351, Medicaid Waiver Assessment",
July 2015;
(i) "Mayo-Portland
Adaptability Inventory-4", March 2003;
(j) "MAP-4100a", September 2010;
and
(k) "Kentucky
Participant-Directed Services Employee Provider Contract", June 2015.
(2) This material may be
inspected, copied, or obtained, subject to applicable copyright law:
(a) At the Department for Medicaid Services,
275 East Main Street, Frankfort, Kentucky 40621, Monday through Friday, 8 a.m.
to 4:30 p.m.; or