Appendix

Appendix A

REGIONAL OFFICE OF DBHDD CONTACT LIST
DBHDD Region 1
DBHDD Region 2
DBHDD Region 3
Charles Fetner
Audrey Sumner
Lynn Copeland
Regional Coordinator
Regional Coordinator
Regional Coordinator
cafetner@dbhdd.ga.gov
acsumner@dbhdd.ga.gov
lcopelan@dbhdd.ga.gov
Ronald Wakefield
Karla Brown
Carole Crowley
Regional Services Administrator – DD
Regional Services Administrator – DD
Regional Services Administrator – DD
rfwakefield@dbhdd.ga.gov
KBBrown8@dbhdd.ga.gov
cacrowley@dbhdd.ga.gov
705 North Division Street
3405 Mike Padgett Highway
100 Crescent Centre Parkway
Building 104
Building 3
Suite 900
Rome, Georgia 30165
Augusta, Georgia 30906
Tucker, Georgia 30084-7055
Phone 706-802-5272
Phone 706-792-7733
Phone 770-414-3052
Fax 706-802-5280
FAX 706-792-7740
FAX 770-414-3048
Toll Free 1-800-646-7721
Toll free 1-866-380-4835
DBHDD Region 4
DBHDD Region 5
DBHDD Region 6
Michael Link
Leland Johnson
Michael Link
Acting Regional Coordinator
Regional Coordinator
Acting Regional Coordinator
Michael.Link@dbhdd.ga.gov
lhjohnson1@dbhdd.ga.gov
Michael.Link@dbhdd.ga.gov
Michael Bee
Vacant
Valona Baldwin
Regional Services Administrator – DD
Regional Services Administrator – DD
Regional Services Administrator –DD
MBee@dbhdd.ga.gov
vjbaldwin@dbhdd.ga.gov
P.O. Box 1378
1915 Eisenhower Dr., Building 2
3000 Shatulga Rd., Bldg. 4
Thomasville, Georgia 31799-1378
Savannah, GA 31406
P.O. Box 12435
Phone 229-225-5099
Phone: 912-303-1670
Columbus, Georgia 31907-2435
FAX 229-227-2918
FAX: 912 303-1681
Phone (706)565-7835
Toll Free 1-877-683-8557
Toll Free 1-800-348-3503
FAX (706)565-3565
January 1, 2015 Comprehensive Supports Waiver Program B-1

APPENDIX B

January 1, 2015 Comprehensive Supports Waiver Program B-2
January 1, 2015 Comprehensive Supports Waiver Program B-3
January 1, 2015 Comprehensive Supports Waiver Program C-1

APPENDIX C

Section A – Identifying Information
1. Applicant’s Name/Address:
County
2. Medicaid Number:
3. Social Security Number
————
4. Sex
Age
4A. Birthdate
7. Patient’s Name (Last, First, Middle Initial)
5. Type of Facility (Check One)
1.  Nursing Facility
2.  ICF/MR
6. Type of Recommendation
1.  Nursing Facility
2.  ICF/MR
3.  Continued Placement
8. Date of Nursing Facility Admission
/ /
9. Patient Transferring From (Check One):
 Hospital  Home  Another Nursing home
 Private Pay  Medicare
Recipient’s Home Address:
Recipient’s Telephone Number:
Date of Medicaid Application
9A. State Authority (MH & MR Screening)
/ /
Level I/II
This is to certify that the facility of attending physician is hereby authorized to provider the Department of Community Health, Division of Medical Assistance and the Division of Family and Children Services, Department of Human Resources with necessary information including Medical Data.
10. Signature _______________________ 11. Date
(Patient, Spouse, Parent or other Relative or Legal Representative)
Restricted Auth Code Date
9B. This is not a re-admission for OBRA purposes
Restricted Auth Code Date
Section B – Physician’s Report and Recommendation
1. ICD-9
2. ICD-9
3. ICD-9
12. Diagnosis on admission to the facility (hospital transfer report may be attached)
1. Primary 2. Secondary 3. Other
12A. Diagnosis on admission to the facility (hospital transfer report may be attached)
1. Primary 2. Secondary 3. Other
1. ICD-10
2. ICD-10
3. ICD-10
13. Treatment Plan (Attach copy of order sheet if more convenient) Hospital Dates: to
Hospital Diagnosis 1. Primary 2. Secondary 3. Other
Medications
16. Diagnostic and Treatment Procedures
Name
Dosage
Route
Frequency
Type Frequency
14. Recommendation Regarding Level of Care Considered Necessary
1.  Skilled 2.  Intermediate 3.  Intermediate Care for
the Mentally Retarded
15. Length of Time Care Needed Months
1.  Permanent 2.  Temporary ___________ estimated
16. Is Patient free of communicable diseases?
1.  Yes 2.  No
17. This patient’s condition  could  could not be managed by provisions
of  community care or  home health services.
18. I certify that the patient requires the level of care provide by a nursing facility or an Intermediate care facility for the mentally retarded.
_______________________________________________________________
Physician’s Signature
19. Physician’s Name (Print)
Physician’s Address (Print)
20. Date Signed by Physician
/ /
21. Physician’s License Number
Physician’s Phone Number
( )
Section C– Evaluation of Nursing Care Needed (check appropriate box only)
22. Diet
23. Bowel
24. Overall Condition
25. Restorative Potential
26. Mental & Behavioral Status
 Regular
 Diabetic
 Formula
 Low Sodium
 Tube feeding
 Other
 Continent
 Occas. Incontinent
 Incontinent
 Colostomy
 Improving
 Stable
 Fluctuating
 Deteriorating
 Critical
 Terminal
 Good
 Fair
 Poor
 Questionable
 None
 Agitated  Noisy  Dependent
 Confused  Nonresponsive  Independent
 Cooperative  Vacillating  Anxious
 Depressed  Violent  Well Adjusted
 Forgetful  Wanders  Disoriented
 Alert  Withdrawn  Inappropriate Reaction
27. Decubitus
28. Bladder
30. Indicate Frequency Per Week
 Yes  Surgery
 No Date:
 Infected
 On Admission
 Continent
 Occas. Incontinent
 Incontinent
 Catheter
Physical Therapy
Occupational Therapy
Remotive Therapy
Reality Orientation
Speech Therapy
Bowel and Bladder Retrain
Activities Program
Received
29. Hours Out of Bed  Catheter Care
Per Day ________  Colostomy Care
 Intake  IV  Sterile Dressing
 Output  Bedrest  Suctioning
Needed
31. Record Appropriate Legend
IMPAIRMENTS
ACTIVITIES OF DAILY LIVING
1. Severe
2. Moderate
3. Mild
4. None
Sight Hear Speech Ltd. Motion Paralysis
    
1. Dependent
2. Needs Asst.
3. Independent
4. Not App
Eats Wheelchair Transfer Bath Ambulation Dressing
     
32. Remarks
33. Pre-Admission Certification Number
34. Signed
35. Date Signed
/ /
DO NOT WRITE BELOW THIS LINE
Continued Stay Review Date: Payment Date Approved for _Days
36. Level of Care Recommended by GMCF
LOS
37. Signature (GMCF)
Date:
/ /
38. Attachments (GMCF)
1.  Yes 2.  No
January 1, 2015 Comprehensive Supports Waiver Program C-2
PHYSICIAN’S RECOMMENDATION CONCERNING NURSING FACILITY CARE OR
INTERMEDIATE CARE FOR THE MENTALLY RETARDED
Form DMA-6 Instructions
This section provides detailed instructions for completion of the Form DMA-6. Before payment can be made, a Form DMA-6 must be completed and signed by the admitting physician.
Section A – Identifying Information
Item 1: Applicant’s Name and Address
Enter the complete name and address of the applicant including the city and zip code.
Item 2: Medicaid Number
Enter the Medicaid number exactly as it appears on the Medical Assistance Eligibility Certification (this number may change so it is imperative that you review the Certification during each month of service.). A valid Medicaid number will be formatted in one of three ways:
a. If the member or applicant is in the Medicaid System, the ID number will be the 12-digit number, e.g., 111222333444;
b. If the member or applicant was previously determined eligible by DFCS staff or making application for services, the number will be the 9-digit SUCCESS number plus a “P”, e.g., 123456789P; or
c. If the individual is eligible for Medicaid due to the receipt of Supplemental Security Income (SSI), the number will be the 9-digit Social Security number plus an “S”, e.g., 123456789S.
The entire number must be placed on the form correctly. In exceptional instances, it may be necessary to contact the caseworker in the DFCS office for the Medicaid number.
Item 3: Social Security Number
Enter the applicant’s nine-digit Social Security number.
Item 4: Sex &Age
Enter the applicant’s sex, whether male or female and age.
Item 4A: Date of birth
Enter applicant date of birth.
Item 5: Type of Facility
Enter a check in the box corresponding to the type of facility.
Item 6: Type of Recommendation
Enter a check in the box corresponding to the type of recommendation being made. If the recommendation is for a recipient’s initial admission or readmission to the facility, the box corresponding to initial should be checked. If the recommendation is for continued placement, the box corresponding to continued placement should be checked on the subsequent recommendation form.
Item 7: Patient’s Name (Last, First, Middle Initial)
Enter the patient’s full name, first name, and middle initial in that order.
January 1, 2015 Comprehensive Supports Waiver Program C-3
Item 8: Date of Nursing Facility Admission
Enter the date of the recipient’s admission to the nursing facility.
Item 9: Patient Transferred From:
Enter a check in the box corresponding to either hospital, private pay, home, another nursing facility, or Medicare, according to the recipient’s status immediately preceding admission to the facility.
Enter the recipient’s home address, mother’s maiden name, and the date of Medicaid application.
Item 9A: State Authority (MH & MR Screening)
Please enter the restricted authorization code and date assigned by the Contractor. This field is for new admissions only.
Item 9B: State Authority (MH & MR Screening)
Please enter the restricted authorization code and date assigned by the Contractor originally (new admission PA). This field should be used for a readmission or transfer to another nursing facility.
Item 10 & 11: Signature
Authorization for Facility or Attending Physician to provide the Department of Community Health, Division of Medical Assistance and the Division of Family and chi1dren Services, Department of Human Resources with necessary information including Medical Data.
Have the patient, his/her spouse, parents or other relative or legal representative sign and date (Item 11) the authorization.
Section B – Physician’s Examination Report and Recommendation
Item 12: ICD-9 Diagnosis (Add attachment(s) for additional diagnoses)
Describe the primary, secondary, and any third ICD-9 diagnoses relevant to the
applicant’s condition on the appropriate lines. Leave the blocks labeled ICD blank. The
Contractor’s staff will complete these boxes.
Item 12A: ICD-10 Diagnosis Code (Add attachment(s) for additional diagnoses)
Describe the primary, secondary, and any third ICD-10 diagnoses relevant to the
applicant’s condition on the appropriate lines. Leave the blocks labeled ICD blank. The
Contractor’s staff will complete these boxes.
Item 13: Treatment Plan (Attach a Copy of the Order Sheet if More Convenient), Hospital Dates, Hospital Diagnosis
The admitting diagnoses (primary, secondary and other) and dates of admission and discharge must be recorded. The treatment plan also should include all medications the recipient is to receive. Names of drugs with dosages, routes, and frequencies of administration are to be included. Any diagnostic or treatment procedures and frequencies should be indicated.
Item 14: Recommendation Regarding Level of Care Considered Necessary
Enter a check in the correct box for Skilled or Intermediate Care for Mentally Retarded. The Skilled box is appropriated as the nursing facility level of care.
Item 15: Length of time is Needed
Enter the length of time as permanent
Item 16: Is Patient free of communicable disease?
Enter a check in the appropriate box (Yes or No)
January 1, 2015 Comprehensive Supports Waiver Program C-4
Item 17: Alternatives to Nursing Home Placement
The admitting or attending physician must indicate whether the patient’s condition could be managed by provision of Community Care or Home Health Services. Enter a check in the box corresponding to “could” and either/both the box(es) corresponding to Community Care and/or Home Health Services if either/or both is appropriate. Enter a check in the box corresponding to “could not “ if neither is appropriate.
Item 18: Certification Statement of the Physician and Signature
The admitting or attending physician must certify that the applicant requires the level of care provided by a nursing facility, hospital, or an intermediate care facility for the mentally retarded. Signature stamps are not acceptable. If the physician does not agree that institutional care is appropriate, enter N/A and sign.
Item 19: Physician’s Name and Address (Print)
Print the admitting or attending physician’s name and address in the spaces provided.
Item 20: Date signed by the physician
Enter the date the physician signs the form.
Item 21: Physician’s Licensure Number and Physician’s Telephone Number
Enter the Georgia license number for the attending or admitting physician.
Enter the attending or admitting physician’s telephone number including area code.
Section C – Evaluation of Nursing Care Needed (Check Appropriate box only)
All items in Section C of this form must be completed by Licensed personnel involved in the care of the applicant.
Item 22: Diet
Enter the appropriate diet for the recipient. If “other” is checked, please specify type of diet.
Item 23: Bowel
Check the appropriate box to indicate the bowel and bladder habits of the recipient.
Item 24: Overall Condition
Check the appropriate box to indicate the recipient’s overall condition.
Item 25: Restorative
Check the appropriate box to indicate the recipient’s restorative potential.
Item 26: Mental & Behavioral Status
Check all appropriate boxes to indicate the recipient’s mental and behavioral status.
Item 27: Decubiti
Check the appropriate box to indicate if the recipient has decubiti. If “yes” is checked and “surgery” is also checked, the date of surgery should be included in the space provided.
Item 28: Bladder
Check the appropriate box to indicate bladder habits of the recipient.
January 1, 2015 Comprehensive Supports Waiver Program C-5
Item 29: Hours Out of Bed Per Day
Indicate the number of hours the recipient is to be out of bed per day in the space provided. Check other treatment procedures the recipient requires.
Item 30: Indicate Frequency Per Week
If applicable, indicate the number of treatment or therapy sessions per week the recipient receives or needs.
Item 31: Record Appropriate Legend
Enter appropriate number indicating the level of impairment or level of assistance needed in the boxes provided.
Item 32: Remarks
Indicate the patient’s vital signs, height, weight, and other pertinent information not otherwise indicated on this form.
Item 33: Pre-admission Certification Number
Indicate the pre-admission certification number (if applicable).
Item 34: Signed
The person completing Section C should sign in this space.
Item 35: Date Signed
Enter the date this section of the form is completed.
Item 43: Print Name of MD or RN
The individual completing Section C should print their name and sign the DMA-6.
Do Not Write Below This Line
Items 44 through 52
January 1, 2015 Comprehensive Supports Waiver Program C-6
January 1, 2015 Comprehensive Supports Waiver Program C-7
January 1, 2015 Comprehensive Supports Waiver Program C-8
January 1, 2015 Comprehensive Supports Waiver Program C-9
.
January 1, 2015 Comprehensive Supports Waiver Program C-10
Protocol for Physicians Signature
A physician’s signature is required on the ISP if-
 When the completed HRST indicates
a level 3 or above, a physician
review is required. When the CMC
screening tool indicates a level 3 or
above, a physician review is
required. If the CMC screening tool
indicates a level 2, then the nurse
will use their judgment to determine
the need for physician review of the
ISP.
The nurse will-
 The comprehensive assessment will
be uploaded into Miscellaneous
Docs section. * Note- if a
comprehensive assessment is
uploaded, a note will be placed in
the blank built-in nursing
assessment to see
comprehensive assessment in
misc. docs and the nurse will
electronically sign the built in
assessment.
 The nurse will then check the
physician review box in Section 1 of
the ISP.
Personal Information
Consumer Name:
First Name: MI: Last Name:
Preferred Name:
Allergies:
NKA
Physician’s
Review
Required
Physician will –
 Complete and sign the Physician Review form in the electronic ISP and check
the physician’s review button.
 If the I&E physician identifies any issues that need any special prompt attention
the RN will be contacted by phone/email in addition to the physician writing the
recommendations in the physician’s review section
 The R.N will be responsible for contacting the Support Coordinator and provider
to ensure follow up.
January 1, 2015 Comprehensive Supports Waiver Program C-11
 A revision or addendum to the goals/ action plan and or risk protection page will be recommended accordingly
 OA’s will approve the ISP
January 1, 2015 Comprehensive Supports Waiver Program C-12
Type of Program: Nursing Facility GAPP
TEFRA/Katie Beckett MR/DD
PEDIATRIC DMA 6(A)
PHYSICIAN’S RECOMMENDATION FOR PEDIATRIC CARE
Section A – Identifying Information
1. Applicant’s Name/Address:
DFCS County_ Mailing Address
2. Medicaid Number:
3. Social Security Number
—————————————-
4. Sex
Age
4A. Birthdate
5. Primary Care Physician
6. Applicant’s Telephone #
7. In the caretaker’s opinion, would the child require institutionalization if
the child did not receive community services? Yes No
8. Does child attend school? Yes
9. Date of Medicaid Application
//
Name of Caregiver #1: Name of Caregiver #2:
I hereby authorize the physician, facility or other health care provider named herein to disclose protected health information and release the medical records of the applicant/beneficiary to
the Department of Community Health and the Department of Human Resources, as may be requested by those agencies, for the purpose of Medicaid eligibility determination. This authorization expires twelve (12) months from the date signed or when revoked by me, whichever comes first.
10. Signature: 11. Date: (Parent or other Legal Representative)
Section B – Physician’s Report and Recommendation
12. History: (attach additional sheet if needed)
1. ICD-9
2. ICD-9
3. ICD-9
13. ICD-9Diagnosis
1) 2) 3)
(Add attachment for additional diagnoses)
13A. ICD-10Diagnosis
1) 2) 3)
(Add attachment for additional diagnoses)
1. ICD-10
2. ICD-10
3. ICD-10
15. Medications
16. Diagnostic and Treatment Procedures
Name
Dosage
Route
Frequency
Type Frequency
17. Treatment Plan (Attach copy of order sheet if more convenient or other pertinent documents)
Previous Hospitalizations:_ Rehabilitative/Habilitative Services:_ Other Health Services: Hospital Diagnosis: 1)_ 2) Secondary 3) Other
18. Anticipated Dates of Hospitalization: _/
/
19. Level of Care Recommended Hospital sing FacIC/MR Facility
20. Type of Recommendation: Initial Change Level of Care Continued Placement
21. Patient Transferred from (check one): Hospital nother NF Private Pay ves at home
22. Length of Time Care Needed Months
1) Permanent
2) Temporary estimated
23. Is patient free of
communicable diseases?
24. This patient’s condition could could not be managed by
provision o Community Care o Home Health Services
25. Physician’s Name (Print):
Physician’s Address (Print):
26. I certify that this patient requires the level of care provided
by a nursing facility, IC/MR facility, or hospital
Physician’s Signature
27. Date signed by Physician
28. Physician’s Licensure No.
28. Physician’s Telephone #:
( )
Section C– Evaluation of Nursing Care Needed (check appropriate box only)
29. Nutrition
30. Bowel
31. Cardiopulmonary Status
32. Mobility
33. Behavioral S tatus Regular Diabetic Shots Formula-Special Tube feeding N/G-tube/G-tube Slow Feeder FTT or Premature Hyperal IV Use Medications/GT Meds Age Dependent
Incontinence Incontinent – Age > 3 Colostomy Continent Other Monitoring CPAP/Bi-PAP) CP Monitor Pulse Ox Vital signs > 2/day Therapy Oxygen Home Vent Trach Nebulizer Tx Suctioning Chest – Physical Tx oom Air Prosthesis Splints Unable to ambulate >
18 months old wheel chair Normal Agitated Cooperative Alert Developmental Delay Mental Retardation Behavioral Problems
(please describe, if checked) Suicidal Hostile
34. Integument System
35. Urogenital
36. Surgery
37. Therapy/Visits
38. Neurological Status Burn Care Sterile Dressings Decubiti Bedridden Eczema-severe Normal Dialysis in home Ostomy Incontinent – Age > 3 Catheterization ontinent Level 1 (5 or > surgeries) Level II (< 5 surgeries) None
Day care Services High Tech – 4 or more times per week Low Tech – 3 or less times per week or MD visits > 4
per month None Deaf Blind Seizures Neurological Deficits Paralysis Normal
39. Other Therapy Visits Five days per week Less than 5 days per week
40. Remarks
41. Pre-Admission Certification Number
42. Date Signed
43. Print Name of MD or RN:
Signature of MD or RN:
DO NOT WRITE BELOW
44. Continued Stay Review Date: Admission Date Approved for _Days or Months
45. Are nursing services, rehabilitative/habilitative services or other health related services requested ordinarily provided in an institution? Yes
46A. State Authority MH & MR Screening)
Level I/II
Restricted Auth. Code Date
46B. This is not a re-admission for OBRA purposes
47. Hospitalization Precertification Meet
Restricted Auth. Code Date
48. Level of Care Recommended by Contractor ang Facility Facility
49. Approval Period
50. Signature (Contractor)
51. Date
/ /
52. Attachments (Contractor) Yes No
DMA-6A (12/2013)
January 1, 2015 Comprehensive Supports Waiver Program C-13
PHYSICIAN’S RECOMMENDATION FOR PEDIATRIC CARE
INSTRUCTIONS FOR COMPLETING THE PEDIATRIC CARE FORM DMA-6(A)
This section provides detailed instructions for completion of the Form DMA-6 (A).
Before payment can be made, a Form DMA-6 (A) must be completed by the Primary
Care Physician (PCP) and the parent or legal representative and signed by the PCP.
The Form DMA-6 (A) is considered valid only if it is signed by the Primary Care
Physician and dated.
Section A – Identifying Information
It is the responsibility of the responsible party to see that Section A of the form is
completed with the applicant’s name and address.
Item 1: Applicant’s Name and Address
Enter the complete name and address of the applicant including the city and zip code.
The caseworker in the Department of Family and Children Services (DFCS) will
complete the mailing address and county of the originating application.
Item 2: Medicaid Number
Enter the Medicaid number exactly as it appears on the Medicaid card or Form 962. A
valid Medicaid number will be formatted in one of three ways:
a. If the member or applicant is in the Medicaid System, the ID number will be the 12-
digit number, e.g., 111222333444;
b. If the member or applicant was previously determined eligible by DFCS staff or
making application for services, the number will be the 9-digit SUCCESS number plus a
“P”, e.g., 123456789P; or
c. If the individual is eligible for Medicaid due to the receipt of Supplemental Security
Income (SSI), the number will be the 9-digit Social Security number plus an “S”, e.g.,
123456789S.
The entire number must be placed on the form correctly. In exceptional instances, it
may be necessary to contact the caseworker in the DFCS office for the Medicaid number.
Item 3: Social Security Number
Enter the applicant’s nine-digit Social Security number.
Item 4 & 4A: Sex, Age and Date of birth
Enter the applicant’s sex, age, and date of birth.
Item 5: Primary Care Physician
Enter the entire name of the Primary Care Physician (PCP).
Item 6: Telephone Number
Enter the telephone number including area code of the applicant’s parent or the legal
representative.
Item 7: Does the child meet the Level of Care (LOC) criteria? (Refer to the DCH’s
January 1, 2015 Comprehensive Supports Waiver Program C-14
website for the LOC definitions.) Statement being asked to caregiver to support
LOC. Please check the appropriate box.
Item 8: Does the child attend school?
Please check the appropriate box if the member attends school.
Item 9: Date of Medicaid Application
Enter the date the family made application for Medicaid services.
Fields below Item 9:
Please enter the name of the primary caregiver for the applicant. If a secondary caregiver
is available to care for the applicant, please indicate the name of the caregiver.
Read the statement below the name(s) of the caregiver(s) and then;
Item 10: Signature
The parent or legal representative for the applicant should sign the DMA-6 (A).
Item 11: Date
Please include the date the DMA-6 (A) was signed by the parent or the legal
representative.
Section B – Physician’s Examination Report and Recommendation
Item 12: History (attach additional sheet(s) if needed)
Describe the applicant’s medical history (Hospital records may be
attached).
Item 13: Diagnosis (Add attachment(s) for additional diagnoses)
Describe the primary, secondary, and any third ICD-9 diagnoses relevant to the
applicant’s condition on the appropriate lines. Leave the blocks labeled ICD blank. The
Contractor’s staff will complete these boxes.
Item 13A: Diagnosis (Add attachment(s) for additional diagnoses)
Describe the primary, secondary, and any third ICD-10 diagnoses relevant to the
applicant’s condition on the appropriate lines. Leave the blocks labeled ICD blank. The
Contractor’s staff will complete these boxes.
Item 14: Medications (Add attachment(s) for additional medication(s)
The name of all medications the applicant is to receive should be listed. Name of drugs
with dosages, routes, and frequencies of administration are to be included.
Item 15: Diagnostic and Treatment Procedures
Any diagnostic or treatment procedures and frequencies should be indicated.
Item 16: Treatment Plan (Attach copy of order sheet if more convenient or other
pertinent documentation)
List previous hospitalization dates, as well as rehabilitative/habilitative, and other health
care services the applicant has received or currently receiving. The hospital admitting
diagnoses (primary, secondary, and other diagnoses) and dates of admission and
discharge must be recorded. The treatment plan may also include other pertinent
documents to assist with the evaluation of the applicant.
January 1, 2015 Comprehensive Supports Waiver Program C-15
Item 17: Anticipated Dates of Hospitalization
List any dates the applicant may be hospitalized in the near future for services. Enter
N/A if not applicable.
Item 18: Level of Care Recommended
Recommendation regarding the level of care considered necessary. Enter a check in the
correct box for hospital, nursing facility, or an intermediate care facility for the mentally
retarded. Enter N/A if institutional care is not applicable.
Item 19: Type of Recommendation
Indicate if this is an initial recommendation for services, a change in the member’s level
of care, or a continued placement review for the member.
Item: 20: Patient Transferred from (Check one)
Indicate if the applicant was transferred from a hospital, private pay, another nursing
facility or lives at home.
Item 21: Length of Time Care Needed
Enter the length of time the applicant will require care and services from the Medicaid
program. Check the appropriate box on the length of time care is needed either permanent
or temporary. If temporary, please provide an estimate of the length of time care will be
needed.
Item 22: Is Patient Free of Communicable Diseases?
Enter a check in the appropriate box.
Item 23: Alternatives to Nursing Facility Placement
The admitting or attending physician must indicate whether the applicant’s
condition could or could not be managed by provision of the Community Care or Home
Health Care Services Programs. Enter a check in the box corresponding to “could” and
either/both the box(es) corresponding to Community Care and/or Home
Health Services if either/or both is appropriate. Enter a check in the box corresponding to
“could not” if neither is appropriate.
Item 24: Physician’s Name and Address
Print the admitting or attending physician’s name and address in the spaces provided.
Item 25: Certification Statement of the Physician and Signature
The admitting or attending physician must certify that the applicant requires
the level of care provided by a nursing facility, hospital, or an intermediate care facility
for the mentally retarded. Signature stamps are not acceptable. If the physician does not
agree that institutional care is appropriate, enter N/A and sign.
Item 26: Date signed by the physician
Enter the date the physician signs the form.
Item 27: Physician’s Licensure Number
Enter the Georgia license number for the attending or admitting physician.
Item 28: Physician’s Telephone Number
Enter the attending or admitting physician’s telephone number including area code.
January 1, 2015 Comprehensive Supports Waiver Program C-16
——————————————————————————————————
Section C – Evaluation of Nursing Care Needed (Check Appropriate box only)
Licensed personnel involved in the care of the applicant should complete Section C of
this form.
Item 29: Nutrition
Check the appropriate box(es) regarding the nutritional needs of the applicant.
Item 30: Bowel
Check the appropriate box(es) to indicate the bowel and bladder habits of the applicant.
Item 31: Cardiopulmonary Status
Check the appropriate box(es) to indicate the cardiopulmonary status of the applicant.
Enter N/A, if not applicable.
Item 32: Mobility
Check the appropriate box(es) to indicate the mobility of the applicant.
Item 33: Behavioral Status
Check all appropriate box(es) to indicate the applicant’s mental and behavioral status.
Item 34: Integument System
Check the appropriate box(es) to indicate the integument system of the applicant.
Item 35: Urogenital
Check the appropriate box(es) for the urogenital functioning of the applicant.
Item 36: Surgery
Check the appropriate box regarding the number of surgeries the applicant has had to
your knowledge or obtain this information from the parent or other legal representative.
Item 37: Therapy/Visits
Check the appropriate box to indicate the amount of therapy visits the applicant receives.
Item 38: Neurological Status
Check the appropriate box (es) regarding the neurological status of the applicant.
Item 39: Other Therapy Visits
If applicable, indicate the number of treatment or therapy sessions per week the applicant
receives or needs. Enter N/A, if not applicable.
Item 40: Remarks
Indicate the patient’s vital signs, height, weight, and other pertinent information not
otherwise indicated on this form or any additional comments.
Item 41: Pre-admission Certification Number
Indicate the pre-admission certification number (if applicable).
Item 42: Date Signed
Enter the date this section of the form is completed.
January 1, 2015 Comprehensive Supports Waiver Program C-17
Item 43: Print Name of MD or RN
The individual completing Section C should print their name and sign the DMA-6 (A).
Do Not Write Below This Line
Items 44 through 52
January 1, 2015 Comprehensive Supports Waiver Program C-19
Protocol for Physicians Signature
A physician’s signature is required on the ISP if-
 When the completed HRST indicates
a level 3 and/or the CMC screening
tool indicates a level 2 than the
nurse will use their judgment to
determine the need for physician
review of the ISP.
The nurse will-
 Bold the need for physician’s review
as the first recommendation in the
nursing assessment (annual or
comprehensive).
 The comprehensive assessment will
be uploaded into Miscellaneous
Docs section. * Note- if a
comprehensive assessment is
uploaded, a note will be placed in
the blank built-in nursing
assessment to see
comprehensive assessment in
misc. docs and the nurse will
electronically sign the built in
assessment.
 The nurse will then check the
physician review box in Section 1 of
the ISP.
Personal Information
Consumer Name:
First Name: MI: Last Name:
Preferred Name:
Allergies:
NKA
Physician’s
Review
Required
Physician will
January 1, 2015 Comprehensive Supports Waiver Program C-20
 Complete and sign the Physician Review form, uploaded the form into the Misc. Docs section and uncheck the physician’s review button.
 If the I&E physician identifies any issues that need any special prompt attention the RN will be contacted by phone/email in addition to the physician writing the recommendations in the physician’s review section
 The R.N will be responsible for contacting the Support Coordinator and provider to ensure follow up.
 A revision or addendum to the goals/ action plan and or risk protection page will be recommended accordingly
 OA’s will approve the ISP
January 1, 2015 Comprehensive Supports Waiver Program C-22
Level of Care Re-Evaluation Form for ICF/ID
NAME:
SS#
Region
Support Plan Effective Date:
Level of Care Eligibility: The individual meets one of the following criteria and is eligible to receive the services provided in an ICF/ID. Check the criteria that are met.
The individual’s disability is intellectual disability.
The individual is eligible under the category of Other Closely Related Condition.
Please check all that Apply:

Disability Conditions

Major Life Activities
Ambulation Deficits
Self Care
Sensory Deficits
Understanding and Use of Language
Chronic Health Problems
Learning
Behavior Problems
Mobility
Autism
Self Direction
Cerebral Palsy
Capacity for Independent Living
Epilepsy
Spina Bifida
Prader-Willi Syndrome
Other__________________________
Medicaid Eligibility:
Individual has a current Medicaid Number. Medicaid # is ____________________
Eligibility Determination: Check the correct statement:
Individual has met Level of Care Eligibility (1) has a Medicaid number (2) and is eligible for Waiver Services.
Individual has not met the Level of Care Eligibility and is not eligible for Waiver Services.
Individual is in an ICF-ID and was referred for Medicaid eligibility on ________________
Date
The result was: Eligible ____ Ineligible ____ Date of Determination_____________________
Home and Community Based Waiver Level of Care Re-Evaluation (if applicable)
 Support Coordinator signs the Level of Care Re-Evaluation
 LOC Nurse with the Regional Intake and Evaluation Team signs the Level of Care Re-Evaluation
Support Coordinator: Date:
Regional Level of Care RN Signature: Date:
Approval Period:
ICF-ID Facility Level of Care Re-Evaluation (if applicable)
 Facility RN and Regional LOC RN sign the Level of Care Re-Evaluation
Facility RN Signature: Date:
Regional Level of Care RN Signature: Date:
Approval Period:
Individual/Representative Signatures:
 This section is only completed for individuals residing in the community
It is the policy of the State of Georgia that services are delivered in the least restrictive manner that addresses the service needs of the individual while enhancing the promotion of social integration. Further, it is the policy of the State to recognize the recipient’s full citizenship and individual dignity; providing safeguards to protect rights, health and the welfare of recipients. I have been offered waiver services and choose to receive community based supports and services. I understand that I have a choice of enrolled providers.
Individual Signature:
Date:
Representative (if applicable):
Date:
DMA-7 (Rev 4/13)
January 1, 2015 Comprehensive Supports Waiver Program C-22
INSTRUCTIONS FOR COMPLETING THE LEVEL OF CARE
RE-EVALUATION FOR ICF-ID (DMA-7)
This document provides detailed instructions for completion of the Level of Care (LOC) Re-Evaluation Form. Before payment can be made, the LOC Re-Evaluation form must be completed by the individual’s Support Coordinator and approved by the DBHDD Regional Office.
Item 1: Participant’s Name
Enter the complete name beginning with the Last Name then the First Name of the participant
Item 2: Social Security Number
Enter the participant’s nine-digit Social Security number.
Item 3: Region
Enter the participant’s DBHDD Region
Item 4: Support Plan Effective Date
Enter the start date of the most current ISP
Item 5: Level of Care Eligibility: The individual meets one of the following criteria and is eligible to receive the services provided in an ICF/ID. Check the criteria that are met.
1. Check that the individual’s disability is an intellectual disability if the individual’s waiver eligibility determination indicated eligibility by diagnosis of an intellectual disability.
2. Check that the individual is eligible under the category of “Other Related Condition” if the individual’s waiver eligibility determination indicated eligibility by diagnosis of a condition found to be closely related to an intellectual disability and attributable to: (a) cerebral palsy or epilepsy; or (b) any other condition, other than mental illness, which results in impairment of general intellectual functioning or adaptive behavior similar to that of persons with an intellectual disability.
Item 6a: Please check all Disability Conditions that apply to the individual: Disability Conditions
Ambulation Deficits
Sensory Deficits
Chronic Health Problems
Behavior Problems
Autism
Cerebral Palsy
Epilepsy
Spina Bifida
Prader-Willi Syndrome
Other: ______________________ (Specify any other disability conditions)
Item 6b: Please check all Major Life Activities that apply to the LOC Re-Evaluation: Major Life Activities: Check all areas in which the individual has substantial deficits.
January 1, 2015 Comprehensive Supports Waiver Program C-23
Note: To meet ICF/ID Level of Care the individual must have substantial deficits in at least two areas if the individual’s disability is intellectual disability and in at least three areas if the individual is eligible under the category of Other Closely Related Condition.
Self Care – Basic Activities of Daily Living include:
 Bathing and showering (washing the body)
 Bowel and bladder management (recognizing the need to relieve oneself)
 Dressing
 Personal hygiene and grooming (including washing hair)
 Eating (including chewing and swallowing)
 Feeding (setting up food and bringing it to the mouth)
 Toilet hygiene (completing the act of relieving oneself)
Understanding and Use of Language – Impairments in receptive and/or expressive language. This major life activity includes ability to understand others and to fully express oneself in own language (including sign language) with adaptive communication devices if used by individual.
Learning – Limitations in practical and functional academics, such as reading, computation, and telling time. This major life activity includes the ability to apply reasoning and problem solving, learn new tasks, apply to new situations, or adapt to change
Mobility – limitation in one’s ability to move the body or one or more extremities independently. This major life activity includes physical movement of one’s body from place to place, with adaptive aids if used by individual, and consists of the ability to transfer, to walk, or to be reliant on a wheelchair or scooter for mobility. It does not include vehicle transportation.
Self Direction – limitation in making decisions and setting and carrying out goals independently. This major life activity includes the ability to make decisions that match one’s own values and desires.
Capacity for Independent Living – limitation in age appropriate behaviors for the individual to live independently. This major life activity includes ability to prepare food, manage money, clean house, do laundry, work independently or use the telephone with assistive devices if uses them.
Item 7: Medicaid Eligibility
Enter the Medicaid number exactly as it appears on the Medicaid card or Form 962. A valid Medicaid number will be formatted in one of three ways:
a. If the member or applicant is in the Medicaid System, the ID number will be the 12-digit number, e.g., 111222333444;
b. If the member or applicant was previously determined eligible by DFCS staff or making application for services, the number will be the 9-digit SUCCESS number plus a “P”, e.g., 123456789P; or
c. If the individual is eligible for Medicaid due to the receipt of Supplemental Security Income (SSI), the number will be the 9-digit Social Security number plus an “S”, e.g., 123456789S.
Item 8: Eligibility Determination: Check the correct statement:
Individual has met Level of Care Eligibility (1) has a Medicaid number and is (2) eligible for waiver services.
Individual has not met the Level of Care Eligibility and is not eligible for Waiver Services
Individual is in an ICF-ID and was referred for Medicaid Eligibility on (enter the date).
January 1, 2015 Comprehensive Supports Waiver Program C-23
The result was ___Eligible ____Ineligible Date of Determination: ______
Item 8: Home and Community Based Waiver LOC Re-Evaluation (if applicable)
The individual’s Support Coordinator and the Regional Level of Care RN must sign and date this section. The Regional RN reviews the LOC Re-Evaluation form, the ISP, and any accompanying assessment updates to determine whether the person continues to meet the level of care requirement. The Regional RN will sign and date this document after that review. The signature of the Regional LOC RN must be within 30 days of the date the Support Coordinator signed this document
Item 9: Approval Period
This section is completed by the LOC RN and is the time period for which the LOC has been re-certified for Home and Community Based Waiver services. The initial date the completed LOC Re-evaluation form is received by the DBHDD Regional Office with all additional required documentation for recertification will constitute the earliest re-certification date once approved.
Item 10: ICF-ID Facility Level of Care Re-Evaluation (if applicable)
The facility RN completes the Level of Care Re-Evaluation Form, signs and forwards the completed form, the current individualized program plan, and any accompanying assessment updates to the Regional Level of Care RN for review. The Regional Level of Care RN signs and dates this section.
Approval Period: This section is completed by the LOC RN and is the time period for which the LOC has been re-certified for ICF-ID Facility based services. The initial date the completed LOC Re-evaluation form is received by the DBHDD Regional Office with all additional required documentation for recertification will constitute the earliest re-certification date once approved.
Item 11: Individual/Representative Signature
This section is only completed for individuals residing in the community. The participant should sign or make their mark in this section. The participant’s signature should be dated.
If the participant is a minor or has been adjudicated legally incompetent, this block should contain the signature of the legal guardian. That signature should be dated.
January 1, 2015 Comprehensive Supports Waiver Program D-2
Appendix D
I&E Screening Tool for Chronic Medical Conditions
*NOTE: All conditions Level 3 and above require forwarding ISP to I&E Physician for Review; Conditions at Level 2 require nurse judgment for forwarding for I & E Physician Review
Individual: Birthdate: Completed by: Date Completed:
CMC L-1 L-2 * L-3 * L-4 *
Diabetes
If end stage organ damage present increase to next level (Ex: Kidney Disease, Heart Disease, Eye Involvement)
Diagnosis; no medications
Fasting Blood sugar 100-120
A1C (If available) –Under 6%
1-2 oral meds
Fasting Blood sugar 120-140
A1C Over 6%
2 or more oral meds
Fasting Blood Sugar 140-180
A1C Over 7%
To L 4 if end organ damage
Insulin Dependent
and /or
Fasting Blood sugar level over 180
A1C Over 7%
Hypertension
If end stage organ damage present increase to next level (Ex: Kidney Disease, Heart Disease, Eye Involvement)
BP 120/80 – 139/89
No prescribed medications
BP 140/90-159/99
Less than 2 meds
BP 160/100 or higher
2 or more meds and/or
Organ damage
Hyperlipidemia
Total Cholesterol – over 200
Triglycerides – over 200
HDL under 50 LDL over 130
Diet only – No prescribed medications and history of Coronary Artery Disease
Cholesterol Triglycerides, HDL, LDL, same as Level 1 Plus
Takes prescribed medications
No history of CAD
Level 2 with a history of CAD,CVD, or PAD
Respiratory Conditions Symptoms may include wheeze, chest tightness, shortness of breath, and/or cough
Symptoms less than 2 x month
Symptoms more than 2 x week ;
Night-time-symptoms more than 2 x month
Daily use of albuterol or other bronchodilator (rescue inhaler)
Continuous symptoms with severe exacerbations
Frequent night time symptoms
History or current (inhaled or oral) corticosteroids
January 1, 2015 Comprehensive Supports Waiver Program D-2
COPD
Diagnosis of COPD (Emphysema, Chronic Bronchitis)
Chronic cough with presence of sputum
Same as level 1
Plus
Dyspnea on exertion
Mild-Moderate airflow obstruction per spirometry
May use PRN Oxygen Therapy
Continuous Oxygen Therapy
Dyspnea with little exertion
Severe airflow obstruction per Spirometry With or without history of Respiratory Failure/Right Heart Failure
Cardiac Conditions
Asymptomatic, but has a history of MI, Angina, Valvular Heart Disease, Heart Failure
No activity limitations
Symptomatic (Ex: Angina, Dyspnea, Edema, etc)
Heart Failure
Limited functional status
ESRD
End Stage Renal Disease
or Chronic Kidney Disease
Stable with prescribed medications
Undergoing Dialysis on routine basis and/or awaiting kidney transplant
Obesity
If unable to obtain weight, note reason. Mention any reported weight changes
BMI 25-30lbs (Overweight)
BMI over 30 (Obese)
BMI Over 40
(Morbid or Severe Obesity)
Cancer
History of cancer in remission and no treatment
Current diagnosis malignancy.
Current or recent history of Immune-Suppressive therapy.
Osteoporosis
Risk Factors:
Non-ambulatory, Anticonvulsant,, Small frame, Caucasian, Natural or artificial menopause, Smoking, Family History
Under 65years of age with
no history of fractures.
And
Any known risk factors:
Any age with a history of fracture and/or the following:
Any known risk factors:
May or may not have proven Osteopenia or Osteoporosis
January 1, 2015 Comprehensive Supports Waiver Program D-2
Substance Abuse
History of alcohol, drugs, or nicotine abuse.
Current abuse of alcohol, drugs or nicotine.
Chronic Pain
As determined by levels L2 on the “smiley face” scoring sheet
Dementia
Dementia of any etiology and a Developmental Disability
Electrolyte Imbalance
Risk Factors:
Medication, Kidney disease, History Diabetes Insipidus, Pychogenicpolydypsia
Any risk factor that could cause an imbalance
Treatment requiring interventions in the past or current treatment.
Mental Health
No medication
History of mental illness
Current Diagnosis with medications
January 1, 2015 Comprehensive Supports Waiver Program D-2
Medical Condition
Description
Detailed on “Risks” sheet? yes/no
Diabetes, Type 2
aka adult-onset diabetes
( Takes two oral meds )
Carbohydrate metabolism d/o that results in inadequate secretion or utilization of the hormone insulin; symptoms include polyuria (excessive urination), polydipsia (excessive thirst), polyphagia (excessive hunger), weight loss and high sugar levels in the blood and urine
Type 2: develops most often in adults and persons who are overweight; characterized by high blood sugar that results from the body’s impaired ability to use and secrete insulin
Hyperlipidemia
(takes no prescribed meds)
Increased triglycerides/cholesterol (excess fat or lipids) in blood stream: Triglycerides > 200 HDL < 50 ;
LDL > 130; Total Cholesterol > 200
January 1, 2015 Comprehensive Supports Waiver Program D-2
I&E Screening Tool for Chronic Medical Conditions
*NOTE: All conditions Level 3 and above require ISP signature by I&E Physician Review; Conditions at Level 2 require nurse judgment for forwarding for I & E Physician Review
Individual: Birthdate: Completed by: Date Completed:
Chronic Medical Condition L-1 L-2 L-3 L-4 Comments
Diabetes
Hypertension
Hyperlipidemia
↑ expands ↓
Respiratory Conditions
COPD
Cardiac Conditions
ESRD
Obesity
Cancer
Osteoporosis
Substance Abuse
Chronic Pain
Dementia
Electrolyte Imbalance
Mental Health
RN Signature: __________________________Date: ________________________
January 1, 2015 Comprehensive Supports Waiver Program E- 1
APPENDIX E
Comprehensive Supports Waiver Program
FREEDOM OF CHOICE
(Statement of Informed Consent)
It is the policy of the State of Georgia that services are delivered in the least restrictive manner that addresses the service needs of the individual while enhancing the promotion of social integration. Further, it is the policy of the State to recognize the recipient’s full citizenship and individual dignity; providing safeguards to protect rights, health and the welfare of recipients.
Based on these beliefs the State of Georgia assures that potential recipients and their authorized representative(s) will be afforded an opportunity to make an informed choice concerning services and providers.
Once a recipient is determined to be likely to require the level of care provided in an SNF, ICF or ICF/ID the recipient and his/her authorized representative will be informed of any feasible alternative available under the waiver and given the choice of either institutional or home and community-based services. This choice of care is documented.
Recipients may request through the regional office that a different support coordinator be assigned. Recipients have the choice of qualified providers in all areas of care and may request a change in providers through the region.
The substance of the information provided will make one reasonably familiar with service options, provider options, their alternatives, and possible benefits and hazards, and the disclosure of said information is designed to be fully understood and appears to be fully understood.
Verification
I have verified that the recipient and his/her authorized representative have been informed about their choices in the manner outlined above. The recipient has received a copy of this signed form.
________________________________________ ___________________
Planning List Administrator/Support Coordinator Date
or Authorized Designee
Acceptance
I and/or my authorized representative have been informed of my choices and have chosen to accept the program and providers described in the attached Individualized Service Plan.
________________________________ _____________________
Recipient Date
________________________________ _____________________
Authorized Representative Date
________________________________ _____________________
Witness Date
Refusal
I and/or my authorized representative have been informed of my choices and have chosen to refuse waiver services.
________________________________ _____________________
Recipient Date
________________________________ _____________________
Authorized Representative Date
________________________________ _____________________
Witness Date
Rev. 07 2011
January 1, 2015 Comprehensive Supports Waiver Program E- 2
Comprehensive Supports Waiver Program
FREEDOM OF CHOICE FORM INSTRUCTIONS
Purpose
The intent of this form is to assure that the participants and their representatives will be:
(1) Informed of any alternatives available under the waiver and
(2) Given the choice of either institutional or home and community-based services.
This process assures that recipients and their representatives can make an informed choice concerning service options(s). The presumption of the law is that a person may consent for him/herself. This presumption should be abandoned only when it is evident that the individual is not capable of doing so. The very nature of a diagnosed condition of an intellectual/developmental disability confirms that the individual who is diagnosed with an intellectual/developmental disability lacks capacity. The recognized reality and trend in the law is that individuals with intellectual/developmental disabilities are often neither wholly competent nor wholly incompetent. The New Options Waiver Program has chosen to involve and recognize the rights of all recipients while at the same time protecting the rights of recipients through the request of concurrent consent by recipients’ authorized representatives.
Whoever is selected as authorized representative must meet the three tests for effect consent: that is, he/she must be competent, adequately informed about the factors involved in the decision and be knowledgeable about the person for whom consent is sought, and voluntary (free from coercion or conflict of interest). The authorized representative must act on the basis of the best interest of the person for whom his or her consent is sought. A suggested list of potential candidates for authorized representatives includes, but is not limited to the following: guardian or conservator, parent, participant’s spouse, adult child, adult next-of-kin, any responsible relative, and attorney(s). In the absence of an available, suitable candidate an advocate appointed by the Georgia Advocacy Office may serve as the designated representative.
Process
Step (1) Provide an overview of service options, noting pro’s and con’s related to
each option; this includes inherent and potential risks, benefits, and stigmas.
A) The content of the overview should make one reasonably familiar with service options.
B) The presentation of information should be designed to match the recipient’s and/or his/her representative’s level of comprehension.
C) Evidence of participant/representative’s understanding of information should be evidenced in the discussion of the same.
Step (2) Once information has been provided and appears to be understood, the
Planning List Administrator/Support Coordinator (or designee) should verify that this information has been provided appropriately and is understood. Once verified, the form should be signed at the designated sign-off under verification statement.
Step (3) Informed participant/representative chooses a service option. The
Informed participant/representative should sign under the appropriate statement that reflects their choice. In cases where the individual participant is a minor, and/or unable due to physical and/or mental causes to sign his/her name, and/or unable to legibly write his/her name, the participant’s name should be printed, above his/her signature or mark, if any, and be initialed by the participant’s authorized representative.
January 1, 2015 Comprehensive Supports Waiver Program E- 3
A witness should sign verifying both the participant’s and authorized representative’s signature. The witness may be the Planning List Administrator/Support Coordinator or his/her authorized designee.
Step (4) Once the form is completed (with signatures under appropriate statements), it should be placed in the participant’s record.
January 1, 2015 Comprehensive Supports Waiver Program F- 1
APPENDIX F
MR/DD WAIVER PROGRAM COMMUNICATOR
MAO DETERMINATION
Participant Name
Address
City State Zip Code
County
Soc. Sec. #
Date of Birth
MHID #
Medicaid #
(Area Code) Phone #
Provider Phone #
SECTION I COMPLETED BY PLANNING LIST ADMIN/SUPPORT COORDINATOR
_________ Date participant was determined eligible for New Options Waiver (NOW)/Comprehensive Supports Waiver (COMP)
Signature: Date
SECTION II COMPLETED BY PLANNING LIST ADMIN/SUPPORT COORDINATOR (check those which apply)
Participant currently resides in an ICF-MR which receives Medicaid reimbursement for his/her services. Please compute cost share. Discharge Date: ________________
NOW/COMP Enrollment Date: _________________
Participant currently resides in the community and does not receive Medicaid. Please determine eligibility and cost share. Date services begin:
Participant is currently receiving MAO. Please compute cost share.
Participant needs annual re-determination of MAO status and cost share.
Participant requires a home visit for application. (Reason in Remarks)
Signature: Phone No. Date
SECTION III COMPLETED BY DFACS CASEWORKER
Date participant applied for MAO ELIGIBILITY DATE:
$ Participant’s cost share Effective Date:
$ Participant’s cost share due to liability change Effective Date:
Date participant was determined INELIGIBLE. (Reason in Remarks)
Signature: Phone No. Date
SECTION IV COMPLETED BY NOW/COMP PLANNING LIST ADMIN/SUPPORT COORDINATOR
This member has been released from the NOW/COMP effective , for the following reason.
Signature: Phone No. Date
SECTION V COMPLETED BY NOW/COMP SUPPORT COORDINATOR OR DFACS CASEWORKER
REMARKS:
Rev. 01 2009
January 1, 2015 Comprehensive Supports Waiver Program G-1
APPENDIX G Prior Authorization Form
January 1, 2015 Comprehensive Supports Waiver Program H-1
APPENDIX H
Exceptional Rate Request or
Request to Exceed Maximum Allowable Units for Traditional Provider Agency
NOTE: Appendix H Revision effective January 1, 2014 will be implemented according to the annual renewal process.
In extraordinary circumstances related to transition of an individual from an institution or imminent risk of institutionalization of an individual, providers may request the payment of a rate that exceeds the established maximum rate for a Comprehensive Supports Waiver (COMP)service. Exceptional rate requests are subject to the Department of Behavioral Health and Developmental Disabilities approval with notification of approval to the Department of Community Health. Providers must be authorized by the DBHDD Regional Office and the Division of Developmental Disabilities to receive exceptional rates beyond the Medicaid maximum rates for waiver services. Any approval of an exceptional rate is time limited up to a maximum of one year.
Services Eligible for Exceptional Rates:
Exceptional rate requests may be submitted for the following COMP waiver services:
a. Community Residential Alternative Services
b. Community Living Support Services
c. Community Access Group Services
d. Respite Overnight Services
e. Specialized Medical Supplies to exceed allowable units
f. Specialized Medical Equipment to exceed allowable units
Eligibility Criteria for Exceptional Rates:
To be considered for an exceptional rate or to exceed maximum allowable units, extraordinary circumstances must be demonstrated by the following:
1. Extraordinary Placement Circumstances: Extraordinary circumstances related to the placement or continued stay of the participant in the community must be documented by:
The individual is currently in an institution and unable to move to the least restrictive alternative in the community due to needed services requiring rate(s) above the established maximum rate(s), OR
The extent of an individual participant’s needs presents imminent risk of institutionalization (i.e., the only options are institutionalization or enhanced waiver service delivery beyond that provided by the established Medicaid maximum rate);
Rev. 04 2014
January 1, 2015 Comprehensive Supports Waiver Program H-2
AND
2. Assessed Exceptional Needs of the Participant: Exceptional needs of the participant must be documented by at least one of the following assessment findings from the Health Risk Screening Tool or the Supports Intensity Scale.
a. Health Risk Screening Tool (HRST)
a. A rating of 4 on Eating or Toileting in the HRST Category I – Functional Status, with Georgia licensed Registered Nurse review and signature, OR
b. A rating of 4 on Self Abuse or Aggression Toward Others and Property in the HRST Category II – Behaviors, with Georgia licensed Registered Nurse review, signature, and documented consultation of RN with Qualified Mental Retardation Professional (QMRP) level psychology professional, OR
c. Any rating of 4 on Treatments in the HRST Category III – Physiological, with Georgia licensed Registered Nurse review and signature, OR
d. Four or more ratings of 4 overall on the HSRT, with Georgia licensed Registered Nurse review and signature,
OR
b. Supports Intensity Scale (SIS)
a. A rating of 2 (Extensive Support Needed) on Lifting and/or Transferring, Turning or Positioning, or Seizure Management in the Supports Intensity Scale (SIS) Section 3A: Exceptional Medical Supports Needed, with Georgia licensed Registered Nurse review and signature, OR
b. A rating of 2 (Extensive Support Needed) on Prevention of Assaults/Injuries to Others, Prevention of Property Destruction, or Prevention of Tantrums/Outbursts in the SIS Section 3B: Exceptional Behavioral Supports Needed with Georgia licensed Registered Nurse review, signature, and documented consultation of RN with Qualified Intellectual Disability Professional (QIDP) level psychology professional, OR
c. A Total Rating of at least 6 that includes a minimum of one rating of 2 in the SIS Section 3A: Exceptional Medical Supports Needed or the SIS Section 3B: Exceptional Behavioral Supports Needed, with Georgia licensed Registered Nurse review and signature, and documented consultation of RN with Qualified Intellectual Disability Professional (QIDP) level psychology professional if exceptional rate request relates to exceptional behavior support needs;
January 1, 2015 Comprehensive Supports Waiver Program H-3
AND
3. Enhanced Service Delivery Requirements: Service delivery requirements for the participant must be demonstrated to:
Exceed that provided by the established Medicaid maximum rate for the service for which the exceptional rate is being requested; AND
Link to the assessed exceptional needs of the participant;
AND
4. Individual Service Plan: The assessed exceptional needs of the participant that support the exceptional rate request;
AND
5. Interdisciplinary Team Approval: The Interdisciplinary Team must approve the need for an exceptional rate, as documented in the ISP for hospital transitions, the Clinical Triage Team serves as the Interdisciplinary Team and identifies the exceptional medical and/or behavioral supports needed by the individual.
Enhanced Medical and Behavior Support
A clinical based review and specification of the enhanced medical and/or behavior supports required by an individual will be conducted by the Intake & Evaluation Team for individuals currently on the waivers or entering the waivers from the community. A Transition Triage Team will conduct the clinically based review and specification of the enhanced medical and/or behavioral supports required by individuals transitioning to the community.
For individuals entering the waivers with approved exceptional rates, a clinical review of the initial, enhanced medical and/or behavioral supports will occur for the first birthday renewal. If the clinical review supports that there are no changes in the enhanced medical and/or behavioral supports needed by the individual, then the exceptional rate as initially approved will be maintained until the following annual birthday renewal.
Individual Support Plan
Enhanced Service Delivery Requirements must be written in the Individual Support Plan that describes the direct service delivery related to the care of the participant. The exceptional rate must derive from the enhanced service delivery specific to the exceptional needs of the participant, which include one or more of the following:
 Extraordinary Staffing Requirements: Additional paraprofessional, direct care staffing requirements and duties for support, which include enhanced paraprofessional, direct care staffing ratios, and/or additional hours of direct
Rev 10 2014
January 1, 2015 Comprehensive Supports Waiver Program H-4
Medical or Behavioral service provision. DDP staffing for exceptional rates are DDPs in the nursing and behavioral categories only.
Developmental Disability Professional: DDP service provision for medical must be provided by an individual who meets DDP requirements such as Registered Nurse (Associate Degree or Diploma) or Registered Nurse (Bachelor Degree) and exceptional behavioral support needs must be provided by an individual who meets the DDP requirements for a Behavior Specialist or Board Certified Behavior Analyst. DDP staffing for exceptional rates are DDPs in the nursing and behavioral categories only. See NOW/COMP policies Appendix I for additional information on DDP.
 Specialized Medical Supplies Requirements: Additional frequency of use of medical supplies, which results in an exceptional quantity of medical supplies, or requirements for multiple types of medical supplies on a frequent basis.
 Specialized Medical Equipment Requirements: Extraordinary medical equipment requirements, which result in need for a one-time purchase at the lifetime maximum.
Documentation for Exceptional Rate Request or Request to Exceed Maximum Allowable Units
 Provider completes Exceptional Rate Request template and Exceptional Rate Budget template for exceptional rate which includes the reimbursement amounts for all participants served in any congregated residential site and forwards to DBHDD Regional Office (templates available in the Providers Toolkit at www.dbhdd.georgia.gov). Hourly wage for direct care and DDP staff included in the Exceptional Rate Budget template are as indicated in DBHDD policy on the Exceptional Rate Submission and Review Procedures (available at https://gadbhdd.policystat.com).
 The most recent annual Health Risk Screening Tool (HRST) and Supports Intensity Scale (SIS) full assessment findings; either of these assessments supporting the renewal of an exceptional rate must be updated within 120 days to 90 days prior to the expiration of an existing exceptional rate.
 Individual Service Plan (ISP) documentation of the enhanced supports due to the exceptional medical and/or behavioral supports needs of the individual recommended by the Regional Intake & Evaluation & Transition Triage Team.
 Crisis Plan submission is required for all Exceptional Rate Requests. Crisis Plan for any crisis is defined as an occurrence that poses a health and safety risk to the participant and/or others as a result of the exceptional behavioral or medical support needs of the participant; the Crisis Plan, as applicable to the exceptional rate request, includes, but is not limited to, the following:
 Back up plans when critical staff are absent for all exceptional rate requests;
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January 1, 2015 Comprehensive Supports Waiver Program H-5
 Crisis interventions when behaviors occur that pose health and safety risks to the participant and/or others both in the home, the community, or in transit for Behavioral Support Exceptional Rate Requests; and/or
 Support protocol for any participant at risk of elopement in the event of an elopement for Behavioral Support Exceptional Rate Requests.
Requests for Exceptional Rates based on the Exceptional Behavioral Support needs of the Participant must include the following:
 An agency developed and approved behavior support plan applicable to service provision by the provider agency requesting the exceptional rate for all renewals and within 90 days for initials.
 Documentation that provider agency employees, or individuals under contract, supporting the participant with exceptional behavioral support needs are trained in the use of emergency safety interventions. These employees or individuals must maintain certification in a DBHDD approved emergency safety intervention curriculum. The circumstances under which the emergency intervention shall be implemented should be detailed in the participant’s behavior support plan and crisis plan.
 If available, a graph, or graphs, of behavioral data are preferred submissions. Quantitative data in the form of frequency, rate, or duration should be provided for each target behavior identified in the behavior support plan. This data must include the most recent three (3) month period of continuous data collection for each behavior targeted by the behavior support plan. Data should be in an objective, numerical, and graphical form.
Exceptional Rate or Exceeding Maximum Allowable Units Request Review:
DBHDD, Division of Developmental Disabilities conducts a clinical/programmatic review of the basis for the exceptional rate or exceeding maximum allowable units request and a review of the enhanced service delivery requirements associated with the requested exceptional rate as follows:
 Clinical/Programmatic Review: The Division of DD will deny any exceptional rate or exceeding maximum allowable units request that:
a. Does not meet or adequately document the meeting of Extraordinary Circumstances Requirements for an Exceptional Rate; OR
b. Does not adequately link the Enhanced Service Delivery Requirements to the exceptional needs of the individual participant.
 Enhanced Service Delivery Requirements Review: The Division of DD does not approve any exceptional rate request that has inadequate documentation of the Enhanced Service Delivery Requirements for the participant.
Administrative Cost for Exceptional Rates
Administrative costs are based on 15 percent of the standard maximum rate for the service:
January 1, 2015 Comprehensive Supports Waiver Program H-6
however, the administrative cost determination will differ for Specialized Medical Supplies (SMS). The administrative costs for SMS Exceptional Rates include ordering, billing, handling, delivery, processing, and documenting. The administrative costs are based on the unique items ordered. For example, formula is one unique item, and 12 cases of formula are regarded as one unique item.
NOTE: Any supplies in the category of over-the-counter medications are counted as one unique item for all supplies in this category. Also, any supplies in the category of herbal supplements, nutritional oils, other non-nutritional supplements, and vitamins are counted as one unique item for all supplies in this category.
Administrative costs for SMS Exceptional Rates are based on unique items as defined above. The administrative costs are as follows:
Number of Unique Items
Annual Administrative Costs
1 to 4
$250
5 to 8
$335
9 to 12
$449
13 to 16
$602
Above 16
$807
For additional information on the processing of exceptional rates, please review the link for DBHDD home page: http://gadbhdd.policystat.com
Accountability and Program Integrity
Delivery of services must be documented based upon the enhanced service delivery requirements for the participant due to his or her exceptional needs and in accordance with Medicaid guidelines. Failure by the provider to deliver services as approved will result in recoupment. All exceptional rates are subject to DCH Program Integrity audits and quality and compliance reviews by DBHDD State and Regional Offices. DBHDD State and Regional Offices make referrals to DCH Program Integrity if reviews indicate failure of the provider to deliver services as approved.
ANY EXCEPTIONAL RATE OR ADDITIONAL UNITS ABOVE THE ANNUAL MAXIMUM THAT EXPIRES WITHOUT A REQUEST FOR CONTINUATION AND APPROVAL FOR CONTINUATION BY THE DIVISION OF DD WILL BE TERMINATED ON THE DATE OF THE EXPIRATION.
January 1, 2015 Comprehensive Supports Waiver Program I-1
APPENDIX I
Glossary of Terms
Approved Accrediting Bodies
National accrediting organizations approved and recognized by the Georgia Department of Behavioral Health and Developmental Disabilities are the following:
1. CARF – the Rehabilitation Accreditation Commission
2. JCAHO – The Joint Commission on Accreditation of Healthcare Organizations
3. The Council – The Council on Quality and Leadership
4. COA – Council on Accreditation of Services for Families and Children
5. ACHC – The Accreditation Council for Health Care for Community Residential
Alternative (CRA) and Community Living Support (CLS) Nursing
Services only.
Accreditation
A review process conducted by a nationally recognized and approved accrediting body of a person or agency that is a direct service provider for people with mental illness, developmental disabilities or addictive diseases, focusing on prescribed standards as they relate to services and supports for those individuals.
Certification
A review process conducted by the Certification Unit of the Georgia Department of Behavioral Health and Developmental Disabilities of a person or agency that is a direct service provider for people with mental illness, developmental disabilities or addictive diseases, focusing on standards found in the “Core Requirements for All Providers.”
COMP – Comprehensive Supports Waiver Program
A home and community based services waiver developed to serve individuals with mental retardation/developmental disabilities that have been transferred to the community from an institution or are living in the community and require comprehensive and intensive services.
Core Requirements for All Providers
Core standards or requirements of the Georgia Department of Behavioral Health and Developmental Disabilities that are applicable to all individual and organizational providers who receive funds authorized by the division through contract, sub-contract or letter of agreement, regardless of the accreditation or certification status of the provider.
Developmental Disability Professional (DDP)
All intellectual/developmental disabilities services are provided by or under the direct supervision of a Developmental Disability Professional. The following are considered to be Developmental Disability Professionals:
a. Advanced Practice Nurse – A registered professional nurse who meets those educational, practice, certification requirements, OR any combination of such requirements, as specified by the Georgia Board of Nursing AND includes certified nurse midwives, nurse practitioners, certified registered nurse anesthetists, clinical nurse specialists in psychiatric/mental health, AND others recognized by the board AND who have one year experience in treating
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January 1, 2015 Comprehensive Supports Waiver Program I-2
individuals with intellectual/developmental disabilities in a medical setting or a community-based setting for delivery of nursing services.
b. Behavior Specialist – A behavior specialist who has completed of a Master’s degree in psychology, school psychology, counseling, vocational rehabilitation or a related field which included one course in psychometric testing and two courses in any combination of the following: behavior analysis or modification, therapeutic intervention, counseling, or psychosocial assessment, AND one year of individualized treatment programming, monitoring and observing behavior; collecting and recording behavioral observations in a treatment setting and developing and implementing behavior management plans for individuals with intellectual disabilities OR developmental disabilities OR completion of a Bachelor’s degree in psychology, counseling, OR a related field which included one course in psychometric testing and two courses in any combination of the following: behavior analysis or modification, counseling, learning theory or psychology of adjustment AND two years of individualized treatment programming, monitoring and observing behavior; collecting and recording behavioral observations in a treatment setting and developing and implementing behavior management plans for individuals with intellectual/developmental disabilities.
c. Board Certified Behavior Analyst (BCBA) – A BCBA who has completed a Master’s degree, with 225 hours of approved graduate coursework, AND 1500 hours of experience in the field with 5% of those hours being supervised by a BCBA, AND has received a passing score on the Behavior Analyst Certification Board Exam, AND maintains a prescribed number of continuing educations units annually, AND has specialized training in developmental disabilities as evidenced by college coursework or practicum/internship experience OR one year of experience in providing services to individuals with intellectual/developmental disabilities.
d. Educator – An educator with a degree in education from an accredited program that includes a concentration in Special Education in college coursework OR teaching certificate in Special Education, AND one year of classroom experience in teaching individuals with intellectual/developmental disabilities.
e. Human Service Professional – A human services professional with a bachelor’s degree in social work OR a bachelor’s degree in human services field other than social work (including the study of human behavior, human development or basic human care needs) AND with specialized training OR one year of experience in providing human services to individuals with intellectual/developmental disabilities.
f. Master’s or Doctoral Degree Holders – A person with a Masters or Doctoral degree in one of the behavioral OR social sciences AND with specialized training in developmental disabilities as evidenced by college coursework OR practicum/internship experience OR one year of experience in providing services to individuals with intellectual/developmental disabilities.
January 1, 2015 Comprehensive Supports Waiver Program I-3
g. Physical or Occupational Therapist – A licensed physical or occupational therapist who has specialized training in developmental disabilities as evidenced by college coursework OR practicum/internship experience OR one year of experience in treating individuals with intellectual/developmental disabilities.
h. Physician – A physician licensed under State law to practice medicine or osteopathy AND with specialized training in developmental disabilities OR one year of experience in treating individuals with intellectual/developmental disabilities in a medical setting.
i. Physician’s Assistant – A skilled person qualified by academic and practical training to provide patients´ services not necessarily within the physical presence but under the personal direction or supervision of a physician, AND who has one year experience in treating individuals with intellectual/developmental disabilities in a medical setting.
j. Psychologist – A holder of a doctoral degree from an accredited university or college, AND who is licensed in the State of Georgia AND who has specialized training in developmental disabilities OR one year of experience in evaluating or providing psychological services to individuals with intellectual/developmental disabilities.
k. Registered Nurse (Associate Degree or Diploma) – A registered nurse who is authorized by a license to practice nursing as a registered professional nurse, who holds an associate or diploma degree in nursing AND who has three years of experience, two of which are in treating individuals with intellectual/developmental disabilities in a medical setting or a community-based setting for delivery of nursing services.
l. Registered Nurse (Bachelor Degree) – A registered nurse who is authorized by a license to practice nursing as a registered professional nurse AND who holds a bachelor’s degree in nursing with one year experience in treating individuals with intellectual/developmental disabilities in a medical setting or a community-based setting for delivery of nursing services.
m. Speech Pathologist or Audiologist – A licensed speech pathologist or audiologist who has specialized training in developmental disabilities as evidenced by college coursework or practicum/internship experience OR one year of experience in treating individuals with intellectual/developmental disabilities.
n. Therapeutic Recreation Specialist – A therapeutic recreation specialist who graduated from an accredited program AND who had specialized training in developmental disabilities as evidenced by college coursework OR practicum/internship experience OR one year experience in providing therapeutic recreational services to individuals with intellectual/developmental disabilities.
DBHDD – Department of Behavioral Health and Developmental Disabilities
The Department of Behavioral Health and Developmental Disabilities is responsible for the administration of the DD waiver programs. This is done through DBHDD’s Division of Developmental Disabilities.
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January 1, 2015 Comprehensive Supports Waiver Program I-4
DMA – Division of Medicaid
The Division of Medicaid is responsible for the final approval of all services and claims reimbursed to providers. DMA contracts with the Department of Behavioral Health and Developmental Disabilities for the overall coordination and daily administration of the waiver programs.
Family
Family is defined as a person who is related by blood within the third degree of consanguinity or by marriage. Third degree of consanguinity means mother, father, grandmother, grandfather, sister, brother, daughter, son, granddaughter, grandson, aunt, uncle, great aunt, great uncle, niece, nephew, grand niece, grand nephew, 1st cousins, 1st cousins once removed and 2nd cousins.
Funding through Authorization
Cumulative monies received by providers including any combination of funds through
contract(s) or letter(s) of agreement with the department through the division:
1. State Dollars
2. Medicaid Waiver Funds
Facility
A provider owned or operated building or place.
GHP – Georgia Health Partnership
DMA contracts with GHP to process all Provider Enrollment Applications, assign provider enrollment numbers, and process provider claims.
Individual Service Plan – ISP
An ISP is a written comprehensive plan that identifies in measurable terms the expected outcomes of all services to be provided to the participant. The ISP is directed toward achieving self-sufficiency and community integration.
Intake and Evaluation
The Intake and Evaluation Regional Office staff who evaluate applicant’s eligibility for waiver-funded services. The team includes a physician, nurse, social worker, and a psychologist or behavioral specialist. Other disciplines that provide services to the applicant must also be a part of the team (Occupational Therapist, Speech Therapist, Physical Therapist and others which may provide services).
Interdisciplinary Team
The interdisciplinary team is a group of individuals representing various disciplines that work together to develop the Individual Service Plan for a participant. The interdisciplinary team must include a social worker, nurse, and behavior specialist or psychologist. Additionally, if a participant receives services from an occupational therapist, physical therapist, and/or speech therapist, that professional(s) also must be part of the interdisciplinary team. Similarly, the
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January 1, 2015 Comprehensive Supports Waiver Program I-5
physician also must be part of the interdisciplinary team if a participant receives services from a physician (beyond the annual physical and acute care).
License or Certificate
Proof of legal authority to operate. Examples of agencies that are required to be licensed or certified to provide direct care to consumers are (but are not limited to) the following:
1. Personal Care Homes
2. Private Home Care Providers
3. Freestanding Residential Detoxification Services
4. Nursing Homes
2. Crisis Stabilization Programs
3. Community Living Arrangements
NOW – New Options Waiver Program
A home and community based services waiver developed to serve individuals with mental retardation/developmental disabilities who live in their own or family home.
Regional DBHDD Offices
The Regional DBHDD Office coordinates and monitors the waiver as well as funding for other services and resources for Georgia’s MR/DD population. The state is currently divided into 5 regions. Individuals seeking MR/DD services should apply through the Regional Office that serves their county.
Waiver of Accreditation
A letter stating that a person or agency may have an extension of a period of time during which to complete their accreditation process.
Waiver of Certification
A letter stating that a person or agency may have an extension of a period of time during which to complete their certification process.
January 1, 2015 Comprehensive Supports Waiver Program I-6
APPENDIX J
Georgia Health Partnership (GHP)
Provider Correspondence Provider Enrollment
(Including claims submission) HPES
HPES P.O. Box 105201
P.O. Box 105200 Tucker, GA 30085-5201
Tucker, GA 30085-5200
Prior Authorization & Electronic Data Interchange (EDI)
Pre-Certification
GMCF 1-877-261-8785
P.O. Box 105329
Atlanta, GA 30348
5. Asynchronous
6. Web portal
7. Physical media
8. Network Data Mover (NDM)
9. Systems Network Architecture (SNA)
10. Transmission Control Protocol/
Internet Protocol (TCP/IP)
Provider Inquiry Numbers:
~ 800-766-4456 (Toll free)
The web contact address is www.mmis.georgia.gov
January 1, 2015 Comprehensive Supports Waiver Program K-1
APPENDIX K
January 1, 2015 Comprehensive Supports Waiver Program L-1
APPENDIX L
Medicaid Provider Application Process for DBHDD Services
January 1, 2015 Comprehensive Supports Waiver Program M-1
April, 2014 Georgia Families
Georgia Families (GF) is a statewide program designed to deliver health care services to members of Medicaid and PeachCare for Kids®. The program is a partnership between the Department of Community Health (DCH) and private Care Management Organizations (CMOs). By providing a choice of health plans, Georgia Families allows members to select a health care plan that fits their needs.
It is important to note that GF is a full-risk program; this means that the three CMOs licensed in Georgia to participate in GF are responsible and accept full financial risk for providing and authorizing covered services. This also means a greater focus on case and disease management with an emphasis on preventative care to improve individual health outcomes. In addition, each CMO may contract with a behavioral health or therapy service organization in order to coordinate physical and mental health services to improve member care, coordination, and efficiency.
Medicaid and PeachCare for Kids® members will continue to be eligible for the same services they receive through traditional Medicaid as well as new services. Members will not have to pay more than they paid for Medicaid co-payments or PeachCare for Kids® premiums. With a focus on health and wellness, the CMOs will provide members with health education and prevention programs as well as expanded access to plans and providers, giving them the tools needed to live healthier lives. Providers participating in Georgia Families will have the added assistance of the CMOs to educate members about accessing care, referrals to specialists, member benefits, and health and wellness education.
The Department of Community Health has contracted with three CMOs to provide these services: Amerigroup Community Care, Peach State Health Plan and WellCare of Georgia.
Members can contact Georgia Families at www.georgia-families.com or call 1-888-GA-ENROLL (1-888-423-6765) for assistance to determine which program best fits their family’s needs. If members do not select a plan, Georgia Families will select a health plan for them.
CMOs
Amerigroup Community Care
800-600-4441
www.myamerigroup.com
Peach State Health Plan
800-704-1484 www.pshpgeorgia.com
WellCare of Georgia
866-231-1821
www.wellcare.com
Children, pregnant women and women with breast or cervical cancer on Medicaid, as well as children enrolled in PeachCare for Kids® are eligible to participate in Georgia Families.
January 1, 2015 Comprehensive Supports Waiver Program M-2
Georgia Families Regions
Region
Counties
Health Plans
Atlanta
Barrow, Bartow, Butts, Carroll, Cherokee, Clayton, Cobb, Coweta, DeKalb, Douglas, Fayette, Forsyth, Fulton, Gwinnett, Haralson, Henry, Jasper, Newton, Paulding, Pickens, Rockdale, Spalding, Walton
Amerigroup Community Care
Peach State Health Plan
WellCare of Georgia
Central
Baldwin, Bibb, Bleckley, Chattahoochee, Crawford, Crisp, Dodge, Dooly, Harris, Heard, Houston, Johnson, Jones, Lamar, Laurens, Macon, Marion, Meriwether, Monroe, Muscogee, Peach, Pike, Pulaski, Talbot, Taylor, Telfair, Treutlen, Troup, Twiggs, Upson, Wheeler, Wilcox, Wilkinson
Amerigroup Community Care
Peach State Health Plan
WellCare of Georgia
East
Burke, Columbia, Emanuel, Glascock, Greene, Hancock, Jefferson, Jenkins, Lincoln, McDuffie, Putnam, Richmond, Taliaferro, Warren, Washington, Wilkes
Amerigroup Community Care
Peach State Health Plan
WellCare of Georgia
North
Banks, Catoosa, Chattooga, Clarke, Dade, Dawson, Elbert, Fannin, Floyd, Franklin, Gilmer, Gordon, Habersham, Hall, Hart, Jackson, Lumpkin, Madison, Morgan, Murray, Oconee, Oglethorpe, Polk, Rabun, Stephens, Towns, Union, Walker, White, Whitfield
Amerigroup Community Care
Peach State Health Plan
WellCare of Georgia
Southeast
Appling, Bacon, Brantley, Bryan, Bulloch, Camden, Candler, Charlton, Chatham, Effingham, Evans, Glynn, Jeff Davis, Liberty, Long, McIntosh, Montgomery, Pierce, Screven, Tattnall, Toombs, Ware, Wayne
Amerigroup Community Care
Peach State Health Plan
WellCare of Georgia
Southwest
Atkinson, Baker, Ben Hill, Berrien, Brooks, Calhoun, Clay, Clinch, Coffee, Colquitt, Cook, Decatur, Dougherty, Early, Echols, Grady, Irwin, Lanier, Lee, Lowndes, Miller, Mitchell, Quitman, Randolph, Schley, Seminole, Stewart, Sumter, Terrell, Thomas, Tift, Turner, Webster, Worth
Amerigroup Community Care
Peach State Health Plan
WellCare of Georgia
January 1, 2015 Comprehensive Supports Waiver Program M-3
Georgia Families Eligibility Categories
Included Populations
Excluded Populations
PeachCare for Kids®
Nursing home
Low-Income Medicaid (LIM)
Federally Recognized Indian Tribe
Right from the Start Medicaid (RSM)
Georgia Pediatric Program (GAPP)
Women’s Health Medicaid (WHM)
Community Based Alternative for Youths (CBAY)
Transitional Medicaid
Children’s Medical Services program
Refugees
Medicare Eligible
Planning for Healthy Babies
Supplemental Security Income (SSI) Medicaid
Medically Needy
Resource Mother’s Outreach
Long-term care
Children (Newborn)
Breast and Cervical Cancer
Included Categories of Eligibility:
COE DESCRIPTION
104
LIM – Adult
105
LIM – Child
118
LIM – 1st Yr Trans Med Ast Adult
119
LIM – 1st Yr Trans Med Ast Child
120
LIM – 2nd Yr Trans Med Ast Adult
121
LIM – 2nd Yr Trans Med Ast Child
122
CS Adult 4 Month Extended
123
CS Child 4 Month Extended
126
Stepchild
135
Newborn Child
170
RSM Pregnant Women
171
RSM Child
194
RSM Expansion Pregnant Women
195
RSM Expansion Child < 1 Yr
196
RSM Expn Child w/DOB < = 10/1/83
197
RSM Preg Women Income < 185 FPL
245
BCC Waiver
471
RSM Child
506
Refugee (DMP) – Adult
507
Refugee (DMP) – Child
508
Post Ref Extended Med – Adult
509
Post Ref Extended Med – Child
510
Refugee MAO – Adult
511
Refugee MAO – Child
571
Refugee RSM – Child
595
Refugee RSM Exp. Child < 1
January 1, 2015 Comprehensive Supports Waiver Program M-4
596
Refugee RSM Exp Child DOB </= 10/01/83
790
Peachcare < 150% FPL
791
Peachcare 150 – 200% FPL
792
Peachcare 201 – 235% FPL
793
Peachcare > 235% FPL
800
Presumptive BCC
804
Lim REI Adult
805
Lim REI Child
818
TMA REI Adult
819
TMA REI Child
835
Newborn
836
Newborn (DFACS)
871
RSM (DHACS)
872
RSM 150% Expansion (DHACS)
876
RSM Pregnant Women (DHACS)
894
RSM Exp Pregnant Women (DHACS)
895
RSM Exp Child < 1 (DHACS)
896
RSM Exp Child </= 10/01/83 (DHACS)
897
RSM Pregnant Women Income > 185% FPL (DHACS)
898
RSM Child < 1 Moth Aid = 897 (DHACS)
918
LIM Adult
919
LIM Child
920
Refugee Adult
921
Refugee Child
Excluded Categories of Eligibility:
COE DESCRIPTION
124
Standard Filing Unit – Adult
125
Standard Filing Unit – Child
131
Child Welfare Foster Care
132
State Funded Adoption Assistance
147
Family Medically Needy Spend down
148
Pregnant Women Medical Needy Spend down
172
RSM 150% Expansion
177
Family Planning Waiver
180
Interconceptional Waiver
210
Nursing Home – Aged
211
Nursing Home – Blind
212
Nursing Home – Disabled
215
30 Day Hospital – Aged
216
30 Day Hospital – Blind
217
30 Day Hospital – Disabled
218
Protected Med/1972 Cola – Aged
January 1, 2015 Comprehensive Supports Waiver Program M-5
219
Protected Med/1972 Cola – Blind
220
Protected Med/1972 Cola – Disabled
221
Disabled Widower 1984 Cola – Aged
222
Disabled Widower 1984 Cola – Blind
223
Disabled Widower 1984 Cola – Disabled
224
Pickle – Aged
225
Pickle – Blind
226
Pickle – Disabled
227
Disabled Adult Child – Aged
228
Disabled Adult Child – Blind
229
Disabled Adult Child – Disabled
230
Disabled Widower Age 50-59 – Aged
231
Disabled Widower Age 50-59 – Blind
232
Disabled Widower Age 50-59 – Disabled
233
Widower Age 60-64 – Aged
234
Widower Age 60-64 – Blind
235
Widower Age 60-64 – Disabled
236
3 Mo. Prior Medicaid – Aged
237
3 Mo. Prior Medicaid – Blind
238
3 Mo. Prior Medicaid – Disabled
239
Abd Med. Needy Defacto – Aged
240
Abd Med. Needy Defacto – Blind
241
Abd Med. Needy Defacto – Disabled
242
Abd Med Spend down – Aged
243
Abd Med Spend down – Blind
244
Abd Med Spend down – Disabled
246
Ticket to Work
247
Disabled Child – 1996
250
Deeming Waiver
251
Independent Waiver
252
Mental Retardation Waiver
253
Laurens Co. Waiver
254
HIV Waiver
255
Cystic Fibrosis Waiver
259
Community Care Waiver
280
Hospice – Aged
281
Hospice – Blind
282
Hospice – Disabled
283
LTC Med. Needy Defacto – Aged
284
LTC Med. Needy Defacto –Blind
285
LTC Med. Needy Defacto – Disabled
286
LTC Med. Needy Spend down – Aged
January 1, 2015 Comprehensive Supports Waiver Program M-6
287
LTC Med. Needy Spend down – Blind
288
LTC Med. Needy Spend down – Disabled
289
Institutional Hospice – Aged
290
Institutional Hospice – Blind
291
Institutional Hospice – Disabled
301
SSI – Aged
302
SSI – Blind
303
SSI – Disabled
304
SSI Appeal – Aged
305
SSI Appeal – Blind
306
SSI Appeal – Disabled
307
SSI Work Continuance – Aged
308
SSI Work Continuance – Blind
309
SSI Work Continuance – Disabled
315
SSI Zebley Child
321
SSI E02 Month – Aged
322
SSI E02 Month – Blind
323
SSI E02 Month – Disabled
387
SSI Trans. Medicaid – Aged
388
SSI Trans. Medicaid – Blind
389
SSI Trans. Medicaid – Disabled
410
Nursing Home – Aged
411
Nursing Home – Blind
412
Nursing Home – Disabled
424
Pickle – Aged
425
Pickle – Blind
426
Pickle – Disabled
427
Disabled Adult Child – Aged
428
Disabled Adult Child – Blind
429
Disabled Adult Child – Disabled
445
N07 Child
446
Widower – Aged
447
Widower – Blind
448
Widower – Disabled
460
Qualified Medicare Beneficiary
466
Spec. Low Inc. Medicare Beneficiary
575
Refugee Med. Needy Spend down
660
Qualified Medicare Beneficiary
661
Spec. Low Income Medicare Beneficiary
662
Q11 Beneficiary
663
Q12 Beneficiary
664
Qua. Working Disabled Individual
815
Aged Inmate
817
Disabled Inmate
870
Emergency Alien – Adult
873
Emergency Alien – Child
874
Pregnant Adult Inmate
January 1, 2015 Comprehensive Supports Waiver Program M-7
915
Aged MAO
916
Blind MAO
917
Disabled MAO
983
Aged Medically Needy
984
Blind Medically Needy
985
Disabled Medically Needy
January 1, 2015 Comprehensive Supports Waiver Program M-8
HEALTH CARE PROVIDERS
For information regarding the participating health plans (enrollment, rates, and procedures), please call the numbers listed below.
Prior to providing services, you should contact the member’s health plan to verify eligibility, PCP assignment and covered benefits. You should also contact the health plan to check prior authorizations and submit claims.
Amerigroup Community Care
800-454-3730 (general information)
888-821-1108 (provider recruitment)
www.amerigroupcorp.com
Peach State Health Plan
866-874-0633 (general information)
866-874-0633 (claims)
800-704-1483 (medical management)
www.pshpgeorgia.com
WellCare of Georgia
866-231-1821
www.wellcare.com
Registering immunizations with GRITS:
If you are a Vaccine for Children (VFC) provider, please continue to use the GRITS (Georgia Immunization Registry) system for all children, including those in Medicaid and PeachCare for Kids®, fee-for-service, and managed care.
Important tips for the provider to know/do when a member comes in:
Understanding the process for verifying eligibility is now more important than ever. You will need to determine if the patient is eligible for Medicaid/PeachCare for Kids® benefits and if they are enrolled in a Georgia Families health plan. Each plan sets its own medical management and referral processes. Members will have a new identification card and primary care provider assignment.
You may also contact Hewlett Packard (HP) at 1-800-766-4456 (statewide) or www.mmis.georgia.gov for information on a member’s health plan.
Use of the Medicaid Management Information System (MMIS) web portal:
The call center and web portal will be able to provide you information about a member’s Medicaid eligibility and health plan enrollment. HP will not be able to assist you with benefits, claims processing or prior approvals for members assigned to a Georgia Families health plan. You will need to contact the member’s plan directly for this information.
Participating in a Georgia Families’ health plan:
A Medicaid provider makes a business decision whether to participate in one, two or all three health plans. To participate in a health plan, the provider must be enrolled in Medicaid and sign a contract and be credentialed by the health plan. Each health plan has its own contracting procedures and credentialing requirements. If a provider is interested in participating with a health plan, he/she should contact the plan’s provider enrollment department.
Assignment of separate provider numbers by all of the health plans:
January 1, 2015 Comprehensive Supports Waiver Program M-9
Each health plan will assign provider numbers, which will be different from the provider’s Medicaid provider number and the numbers assigned by other health plans.
Billing the health plans for services provided:
For members who are in Georgia Families, you should file claims with the member’s health plan.
If a claim is submitted to HP in error:
HP will deny the claim with a specific denial code. Prior to receiving this denial, you may go ahead and submit the claim to the member’s health plan.
Receiving payment:
Claims should be submitted to the member’s health plan. Each health plan has its own claims processing and you should consult the health plan about their payment procedures.
Health plans payment of clean claims:
Each health plan (and subcontractors) has its own claims processing and payment cycles. The claims processing and payment timeframes are as follows:
Amerigroup Community Care
Amerigroup runs claims cycles twice each week (on Monday and Thursday) for clean claims that have been adjudicated.
Monday Claims run: Checks mailed on Tuesday. Providers enrolled in ERA/EFT receive the ACH on Thursday.
Thursday Claims run: Checks mailed on Wednesday. Providers enrolled in ERA/EFT receive the ACH on Tuesday.
Dental: Checks are mailed weekly on Thursday for clean claims.
Vision: Checks are mailed weekly on Wednesday for clean claims (beginning June 7th)
Pharmacy: Checks are mailed to pharmacies weekly on Friday (except when a holiday falls on Friday, then mailed the next business day).
Peach State Health Plan
Peach State has two weekly claims payment cycles per week that produces payments for clean claims to providers on Tuesday and Friday.
For further information, please refer to the Peach State website, or the Peach State provider manual.
WellCare of Georgia
WellCare runs claims payment cycles up to six (6) times each week for clean claims.
For further information, please refer to the WellCare website, the WellCare provider manual, or contact Customer Service at 866-231-1821.
How often can a patient change his/her PCP?
Amerigroup Community Care
Peach State Health Plan
WellCare of Georgia
January 1, 2015 Comprehensive Supports Waiver Program M-10
Anytime
Within the first 90 days of a member’s enrollment, he/she can change PCP monthly. If the member has been with the plan for 90 days or longer, the member can change PCPs once every six months. There are a few exclusions that apply and would warrant an immediate PCP change.
Anytime
Once the patient requests a PCP change, how long it takes for the new PCP to be assigned:
Amerigroup Community Care
Next business day
Peach State Health Plan
PCP changes are updated in Peach State’s systems daily.
WellCare of Georgia
PCP changes made between the 1st and 10th of the month will go into effect right away. Changes made after the 10th of the month will take effect at the beginning of the next month.
PHARMACY
Georgia Families does provide pharmacy benefits to members. Check with the member’s health plan about the who to call to find out more about enrolling to provide pharmacy benefits, including information about their plans reimbursement rates, specific benefits that are available, including prior approval requirements.
To request information about contracting with the health plans, you can call the CMOs provider enrollment services.
Amerigroup Community Care
888-821-1108
www.amerigroupcorp.com
Peach State Health Plan
866-874-0633
www.pshpgeorgia.com
WellCare of Georgia
866-231-1821
https://georgia.wellcare.com/
All providers must be enrolled as a Medicaid provider to be eligible to contract with a health plan to provide services to Georgia Families members.
The CMO Pharmacy Benefit Managers (PBM) and the Bin Numbers, Processor Control Numbers and Group Numbers are:
Health Plan
PBM
BIN #
PCN
Amerigroup
Caremark
610415
PCS
Peach State Health Plan
US Script
008019
Not Required
January 1, 2015 Comprehensive Supports Waiver Program M-11
WellCare
CatamaranRx
603286
01410000
If a patient does not have an identification card:
Providers can check the enrollment status of Medicaid and PeachCare for Kids® members through HP by calling 1-800-766-4456 or going to the web portal at www.mmis.georgia.gov. HP will let you know if the member is eligible for services and the health plan they are enrolled in. You can contact the member’s health plan to get the member’s identification number.
Use of the member’s Medicaid or PeachCare for Kids® identification number to file a pharmacy claim:
Amerigroup Community Care
No, you will need the member’s health plan ID number
Peach State Health Plan
Yes
WellCare of Georgia
Yes
Health plans preferred drug list, prior authorization criteria, benefit design, and reimbursement rates:
Each health plan sets their own procedures, including preferred drug list, prior authorization criteria, benefit design, and reimbursement rates.
Will Medicaid cover prescriptions for members that the health plans do not?
No, Medicaid will not provide a “wrap-around” benefit for medications not covered or approved by the health plan. Each health plan will set its own processes for determining medical necessity and appeals.
Who to call to request a PA:
Amerigroup Community Care
1 (800) 454-3730, option 3, option 3
Peach State Health Plan
1 (866) 874-0633
WellCare of Georgia
1 (866) 269-5251 (phone)
1 (866) 455-6558 (fax)
January 1, 2015 Comprehensive Supports Waiver Program N-1
APPENDIX N
Non-Emergency Transportation Broker System
People enrolled in the Medicaid program need to get to and from health care services, but many do not have any means of transportation. The Non-Emergency Transportation Program (NET) provides a way for Medicaid recipients to get that transportation so they can receive necessary medical services covered by Medicaid.
How do I get non-emergency transportation services?
If you are a Medicaid recipient and have no other way to get to medical care or services covered by Medicaid, you can contact a transportation broker to take you. In most cases, you must call three days in advance to schedule transportation. Urgent care situations and a few other exceptions can be arranged more quickly. Each broker has a toll-free telephone number to schedule transportation services, and is available weekdays (Monday-Friday) from 7 a.m. to 6 p.m. All counties in Georgia are grouped into five regions for NET services. A NET Broker covers each region. If you need NET services, you must contact the NET Broker serving the county you live in to ask for non-emergency transportation. See the chart below to determine which broker serves your county, and call the broker’s telephone number for that region.
What if I have problems with a NET broker?
The Division of Medical Assistance (DMA) monitors the quality of the services brokers provide, handling consumer complaints and requiring periodic reports from the brokers. The state Department of Audits also performs on-site evaluations of the services provided by each broker. If you have a question, comment or complaint about a broker, call the Member CIC at 866-211-0950.
Region
Broker / Phone number
Counties served
North
Southeastrans
Toll free
1-866-388-9844
Local
678-510-4555
Banks, Barrow, Bartow, Catoosa, Chattooga, Cherokee, Cobb, Dade, Dawson, Douglas, Fannin, Floyd, Forsyth, Franklin, Gilmer, Gordon, Habersham, Hall, Haralson, Jackson, Lumpkin, Morgan, Murray, Paulding, Pickens, Polk, Rabun, Stephens, Towns, Union, Walker, Walton, White and Whitfield
Atlanta
Southeastrans 404-209-4000
Fulton, DeKalb and Gwinnett
Central
LogistiCare
Toll free
1-888-224-7981
Baldwin, Bibb, Bleckley, Butts, Carroll, Clayton, Coweta, Dodge, Fayette, Heard, Henry, Jasper, Jones, Lamar, Laurens, Meriwether, Monroe, Newton, Pike, Putnam, Rockdale, Spalding, Telfair, Troup, Twiggs and Wilkinson
East
LogistiCare
Toll free
Appling, Bacon, Brantley, Bryan, Bulloch, Burke, Camden, Candler, Charlton, Chatham, Clarke, Columbia, Effingham, Elbert, Emanuel, Evans,
Rev 07 2012 2010
January 1, 2015 Comprehensive Supports Waiver Program N-2
1-888-224-7988
Glascock, Glynn, Greene, Hancock, Hart, Jeff Davis, Jefferson, Jenkins, Johnson, Liberty, Lincoln, Long, Madison, McDuffie, McIntosh, Montgomery, Oconee, Oglethorpe, Pierce, Richmond, Screven, Taliaferro, Tattnall, Toombs, Treutlen, Ware, Warren, Washington, Wayne, Wheeler and Wilkes
Southwest
LogistiCare
Toll free 1-888-224-7985
Atkinson, Baker, Ben Hill, Berrien, Brooks, Calhoun, Chattahoochee, Clay, Clinch, Coffee, Colquitt, Cook, Crawford, Crisp, Decatur, Dooly, Dougherty, Early, Echols, Grady, Harris, Houston, Irwin, Lanier, Lee, Lowndes, Macon, Marion, Miller, Mitchell, Muscogee, Peach, Pulaski, Quitman, Randolph, Schley, Seminole, Stewart, Sumter, Talbot, Taylor, Terrell, Thomas, Tift, Turner, Upson, Webster, Wilcox and Worth
January 1, 2015 Comprehensive Supports Waiver Program O-1
APPENDIX O
Person Centered Planning
Person Centered Organizations: Creating Transformational Change
Basics of Person Centered Thinking (PCT):
(1) What is it?
 Set of tools that convey the core belief that all people are valued
 A common language, easily communicated, that activate the agency’s values
 A set of skills that result in teams keeping the focus on the person who needs support –not agency or turf issues
 A way to describe the desired lifestyle of the person who is supported, not the lifestyle desired by the agency
 Creates a blueprint for critical thinking skills for frontline staff, supervisors and managers that is consistent
(2) How does it benefit an Organization?
 Aligns the agency’s approach towards its employees with its approach towards people supported
 Creates a focus on the preferences of the customer, resulting in context necessary to address issues of health, safety and valued social roles.
 Replaces jargon with a common language
 Uses a set of tools, easily taught, that build critical thinking skills for employees
 Tools are interrelated –one supports the next
 Initial Two-Day Training builds knowledge, followed by structured practice to develop skill
 Same tools used to develop and support the people served are used to develop and support the abilities of all employees throughout the agency.
January 1, 2015 Comprehensive Supports Waiver Program O-2
How does PCT do this?
 Person Centered Planning-> PC Plan (many people involved, one person’s plan)
 Person Centered Thinking(changes in our language)
 Person Centered Practices–(changes in our Tools and documents)
 Person Centered Organizations–(changes in our Processes-business and program)
 Person Centered Systems–(changes in our Relationships with external agencies)
The Evolution of the Efforts
Training in Person Centered Planning 1990
Training in Person Centered Thinking 2001
Training + the Development and Support of Coaches 2002
Training and Coaches + the Sustained Engagement of Organizational Leadership – 2005
Training, Coaches, Organizational Leadership + Sustained Engagement of System Leadership – 2006
 Teaching person centered thinking skills
 Developing and supporting coaches to spread the skills
 Creating structured ways for leadership to listen to coaches
 Building local capacity/creating sustainability
o
o Person centered thinking trainers
o Teaching leadership/quality management skills

1. Intentionally building better partnerships between all of the key stakeholders
The structure of the effort –
2. Transactional Dynamics –the everyday interactions and exchanges that create the working climate; changes in these interactions can change the climate of the workplace; structure, roles, reporting, tasks, management practice, supervisory activities etc.
3. Transformative Change –change within an organization that creates a shift in values or culture; generally requires “entirely new behavior sets on the part of organization members”
January 1, 2015 Comprehensive Supports Waiver Program O-3
Transactional vs. Transformative*
*From W. Warner Burke, Diagnosis for Organizational Change

Culture Change permeates the full organization:
a. Leadership
b. Employees
c. Service Delivery/Programs
d. Business Departments –Finance, Information Technology, HR
e. Mission/Vision/Values and Strategy
f. Relationships with external organizations and partners
Transformative Change
 Customer Focus clearly defines expectations, and ties to the M/V/V and strategy of the organization
 Leaders demonstrate through their own language, and clear messages that labels are not acceptable

a. People are referred to respectfully throughout the organization
b. Really effective leaders realize that their job is not to have all the answers, but rather to understand what questions they should ask to help their employees discover the answers
i. Customer desired outcomes drive service delivery approach

a. I am listened to
b. What is important to me is recognized and present every day

ii. Focus on becoming a learning organization –continuous quality improvement
 Dedicated to learning from all engagements, alleviating blame culture, and building strong partnerships internally and externally
iii. Full organization is focused on how to move beyond simply meeting standards –
 Recognizing compliance as the floor, not the ceiling, of high quality
January 1, 2015 Comprehensive Supports Waiver Program O-4
service/performance.

iv. What should be shared?
a. With others in the organization
b. With others outside of the organization
ii. What should be celebrated?
iii. What should be changed?
a. Is this story typical practice or is it exceptional practice?
b. What organizational issues of structure, practice, rules or communication are getting in the way of implementing person centered practice? (Level 2)
c. What system-wide issues (as above) exist? (Level 3)
d. What did you hear in the story?
5. What methods/strategies will you use? Is it repeatable?
a. What is the sequence of activity?
b. Which departments will be included? Which areas, offices or locations? Which service sector?
c. Who will need to know, and how will they be informed?
d. How will you make sure it is uniform?
e. How will you determine that your approach is effective?
f. How will you know it is working? What is your strategy for learning from your approach?
g. What measures will you use?
6. Where does the change need to occur?
Answers to the QUESTION: What do you think you are doing differently because of your efforts at creating Person Centered Organizations?
From long term services organizations–July 2009
1. “This project made me look at people in a different way”
2. “I have gained the ability to listen to people better and more carefully and ask better questions as I try to get to know them” (regulator)
January 1, 2015 Comprehensive Supports Waiver Program O-5
3. “This program has (helped) us to become team players.”
4. “Whenever situations arise, we come together as a team.”
Answers to the QUESTION: What do you think you are doing differently because of your work?
From Developmental Disability Services:
i. “Opens up communication”
j. “The tools are versatile; you can use them with everyone”
k. “This effort has brought common sense into supporting people”
l. “Results in better lives and a better workplace”
m. “Keeps our organization focused” (from CEO)
n. “Makes our job easier”
o. “Helps us focus on the people and not just the regulations”
p. “I have been in the field for 19 years and this is so much better, not just collecting data, but learning about a better life”
q. “It brings people together and unifies them for the right purpose”
January 1, 2015 Comprehensive Supports Waiver Program ` P-1
APPENDIX P
LETTER OF INTENT TO PROVIDE SERVICES FORM
GEORGIA DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL DISABILITIES
Division of Developmental Disabilities
SERVICE SITE
(Legal name and address must be registered with the Georgia Secretary of State’s office)
Legal Name:
Tax ID #:
Corporate Street Address:
City: County: State: Zip Code:
Service Site Name:
Service Site Address:
City: County: State: Zip Code:
Mailing Address (if different):
City: County: State: Zip Code:
Owner:
Telephone: Fax:
Email Address: Website:
Director:
Telephone: Fax:
Email Address: Website:
Nurse:
Telephone: Fax:
Email Address: Website:
Developmental Disabilities Professional:
Telephone: Fax:
Email Address: Website:
EMAIL ADDRESSES MUST BE CURRENT AND CORRECT AS ALL FUTURE CORRESPONDENCE FROM DBHDD WILL BE CONDUCTED VIA EMAIL. IT IS THE RESPONSIBILITY OF THE POTENTIAL PROVIDER TO ENSURE THAT EMAILS FROM DBHDD ARE ACCEPTED BY YOUR EMAIL SYSTEM AND DO NOT GO TO THE “SPAM” MAILBOX.
January 1, 2015 Comprehensive Supports Waiver Program ` P-2
List below the Waiver Services that you are applying to provide and the number of individuals to be served in each Service.
Waiver Service
Such as CRA, CLS, SE etc.
Number of Individuals to be Served In Each Service
County of Service
Provision
Region of Service Provision
Licensed
Service
Y/N?
In accordance with Department of Community Health (DCH) Healthcare Facility Regulation Division (HFR) [which was formerly known as Office of Regulatory Services or ORS], please indicate all applicable license(s) that you possess:
 Child Placing Agency (CPA) license  Community Living Arrangement (CLA) license
 Home Health Agency (HHA) license  Personal Care Home (PCH) license
 Private Home Care (PHC) license
Please list any services that the organization has delivered to citizens with developmental disabilities within the past five years.
Name of Service Location of Service Length Of Service
January 1, 2015 Comprehensive Supports Waiver Program ` P-3
Please list any previous Contracts, Letters of Agreement (LOA) or Provider Agreements (PA) issued to the organization within the last five years by any of the following: Division of Mental Health, Developmental Disabilities & Addictive Diseases (DMHDDAD) – currently known as the Department of Behavioral Health and Developmental Disabilities (DBHDD)
Division of Aging – currently known as the Department of Human Services (DHS), Division of Aging Department of Community Health (DCH) List Agency Name Used On Contract or LOA List all Key Personnel Names Such as CEO/President Key Management Staff, Relative or Board of Directors Contact Phone Number And E-Mail Address of each Key Personnel Name Listed Department Issuing Contract Service Provided Such as Aging, ICWP, Source etc.
With this Letter of Intent to Provide Services Form, your organization must also submit all pre-qualifiers listed within the Recruitment and Application to Become a Provider of Developmental Disabilities Services Policy. Any incomplete Letter of Intent to Provide Services Form, and/or incomplete or deficient pre-qualifier will result in no invitation to move forward to the application process.
Under applicable state and federal laws, I do hereby affirm that I am the authorized agent to complete this document and that the information contained herein this document is complete, true, and correct.
Name of Organization (please print) Owner / Title (please print)
Signature of Owner/ Title Date
January 1, 2015 Comprehensive Supports Waiver Program Q-1
APPENDIX Q
MR/DD NEW SITE INSPECTION CHECKLIST
Sub Contractor Name:
Sub Contractor Phone:
Site Name (if applicable):
Alternate Phone:
Street:
Additional Sub Contractor Info / Extenuating Circumstances (if any):
City:
Zip:
County:
Licensed PCH: ___YES ___NO
Licensed CLA: ___YES ___NO
Host Home: ___YES ___NO
If YES, License #: Host Home Family Name:
License Date (From): (To):
Capacity:
Met
Criteria
OVERALL CONDITION OF THE HOME
Home is clean, no odors Heating and air conditioning systems operational and provides adequate heat and air
No needed repair work around the home, yard, deck
All areas are lighted sufficiently
Provides an area for use by residents and visitors that affords privacy
Furnishings and housekeeping present a clean and orderly appearance
No visible evidence of infestation
KITCHEN/LAUNDRY
Provides laundering facilities, at minimum 1 washer and 1 dryer
Provides common space, such as living room, and kitchen, for use by the residents without restriction
Food is stored properly
Maintains a 3-day supply of non-perishable foods for emergency needs. Check expiration dates on food
RESIDENT BEDROOMS
All bedrooms provide at a minimum 80 square feet for each resident
Bedrooms have at least one window
All bedrooms have standard non portable bed with springs and clean mattress
No Bedroom is a pass-through to reach another room or bathroom
All bedrooms have an adequate closet or wardrobe for each resident
All Bedrooms have lighting fixtures sufficient for reading and other activities
January 1, 2015 Comprehensive Supports Waiver Program Q-2
Sufficient bedding for all residents: Two sheets/pillow/pillowcase/blanket/bedspread for each bed
All bedrooms have doors that can be closed; occupant & staff have keys; no double-cylinder locks
Met
Criteria
BATHROOMS
Provides at least one functional toilet, lavatory, and bath/shower per 4 residents
One fully handicap accessible bathroom if any resident requires handicap access
Grab bars and non-skid surfacing in all showers/bath areas
Bath linens are present and sufficient
Bathrooms and toilet facilities have a window that can be opened or forced ventilation
Tub/ shower has a shower curtain or door
Plumbing/bathroom fixtures are in good working order & are clean & sanitary
Toilet tissue is available for use at each commode
Hand-washing facilities have hot and cold running water, liquid soap, and paper towels
EXTERIOR/ YARD
The yard area is free from hazards, nuisances, refuse, and litter
Residents dependent upon a wheelchair have at least 2 accessible exits
Proper storage/disposal of garbage
SAFETY
Space heaters are not present
Stairways/ramps have handrails; exterior stairways/decks/porches w/handrails on open sides unless low to ground Sufficient AC powered smoke detectors, with battery back up (Should keep record of when changed)* or Sufficient and operable smoke and carbon monoxide detectors in Host/Life Sharing Homes. Charged, 5 lb multipurpose ABC fire extinguisher on each floor & basement and checked w/in the last 12 months
Exterior doors are equipped with locks that do not require keys to open the door from the inside
The storage/disposal of biomedical wastes/hazardous wastes comply with applicable rules and standards
Wall-mounted electric outlets and lamps or light fixtures are safe and operational
Poisons, caustics, dangerous materials are to be stored in labeled, appropriate containers away from medication & food
Provides sufficient hot water not exceeding 120 degrees Fahrenheit
An evacuation plan w/ clear instructions is provided and a diagram posted (Posted diagram not required for Host Home)
Supply of first-aid materials available w/ band aids, antiseptic, gauze, tape, and a appropriate thermometer in home Sufficient safety precautions taken to prevent unauthorized access to in-ground or
January 1, 2015 Comprehensive Supports Waiver Program Q-3
above ground swimming pool (Host Homes) Fire arms stored in locked cabinet and ammunition store separately Fireplace securely screened and/or equipped with protective guards while in use. Stairways, halls, doorways and exits from the rooms and from the house are unobstructed. Flammable and combustible supplies/equipment stored away from the heat sources.
First Aid Kit in vehicle and Fire extinguisher in vehicle
Notes and Information:
SITE MEETS ALL CRITERIA: YES________ NO_________
LICENSE ATTACHED:
YES_______ NO________
Inspector Signature:
Date:
Printed Name:
Title
RC or Support Coord. Signature:
Date Reviewed:
Printed Name:
Title
Regional Coordinator or Designee Signature:
Date Approved:
January 1, 2015 Comprehensive Supports Waiver Program R-1
Appendix R
Antipsychotic Medications
Generic Trade
Aripiprazole Abilify
Chlorpromazine Thorazine
Chlorprothixene Taractan
Clozapine Clozaril
Fluphenazine Permitil, Prolixin*
Haloperidol Haldol*
Loxapine Loxitane
Mesoridazine Serentil
Molindone Lidone, Moban
Olanzapine Zyprexa
Palinperidone Invega*
Perphenazine Trilafon
Pimozide (for Tourette’s) Orap
Quetiapine Seroquel
Risperidone Risperdal*
Thioridazine Mellaril
Thiothixene Navane
Trifluoperazine Stelazine
Trifluopromazine Vesprin
Ziprasidone Geodon
*Also has a sustained release injectable form
Rev. 01 2011
January 1, 2015 Comprehensive Supports Waiver Program R-2
Mood Stabilizer Medications
Generic Trade
Lithium Carbonate Eskalith
Lithium Carbonate Lithonate
Divalproex Sodium Depakote
Tiagabine Gabatril
Levetiracetam Keppra
Lamotrigine Lamitcal
Gabapentin Neurontin
Carbamazepine Tegretol
Oxcarbazepine Trileptal
Topiramate Topamax
Zonisamide Zonegran
Verapamil Calan
Clonidine Catapres
Propranolol Inderal
Mexiletine Mexitil
Guanfacine Tenex
January 1, 2015 Comprehensive Supports Waiver Program S-1
Appendix S
Documentation Progress Note and Summary Examples
(For all services except CRA, CLS and Respite)
Individual Progress Note Log
Person’s Name:
Provider Name:
MHN ID Number:
Service:
Support Plan Date: Addendum date: Procedure Code:
Month/Year:
Peer Quality Assurance Review: Date:
Codes:
Disclaimer: The use of this form does not guarantee compliance with all policies/standards for documentation.
ISP Goal A:
Service:
Date:
Time: In
Total hours/Units:
Time: Out
Objectives listed on ISP Action Plan
Frequency/completion date
Code
1.
2
3.
4.
Progress Note (Optional – Documentation can be written here if the person is not working on a specific goal for the day):
Direct Support Staff printed name/title:
Signature of Direct Support Staff: Date:
Weekly Additional Person Centered Progress Achievements Identified Barriers
What did he/she enjoy?
What did he/she not enjoy?
What worked and needs to be continued?
What did not work and needs to be changed?
You can place any other information about the goal into this section. OPTIONAL
Direct Support Staff printed name/title:
Signature of Direct Support Staff:
Date:
Weekly Additional Routine Person Centered Supports (Supports are pre-filled by the provider agency and additional supports can be added if necessary):
Additional Comments/Significant Events(s)(If no comments/significant events, indicate N/A):
Direct Support Staff printed name/title:
Signature of Direct Support Staff:
Date:
Rev. 04 2013
January 1, 2015 Comprehensive Supports Waiver Program S-2
Legend Individual Progress Note Log
Section I Individual Identifiable Information (This section is pre-filled by the provider agency)
a. Person’s Name:
g. Provider Name:
b. MHN ID Number:
h. Service:
c. Support Plan Date: f. Addendum date: i. Procedure Code:
d. Month/Year:
e. Peer Quality Assurance Review: j. Date:
a. Person’s Name: Name of the individual served
b. MHN ID Number: Individual’s MHN ID number
c. Support Plan Date: Identify the ISP timeframe
d. Month/Year: Identify month and year of when services are being documented
e. Peer Quality Assurance Review: Professional reviewer’s name and signature
f. Addendum date: Identify any addendum date if applicable
g. Provider Name: This is where you place your provider name
h. Service: Specific service documenting
i. Procedure Code: Code for the service providing.
j. Date: Date reviewed by the Peer Quality Assurance reviewer (not pre-filled by the provider agency)
Section II Codes
Codes:
Codes: In this section you identify the codes used to identify the level of intervention/support the person required at the time of the training. For example: I=Independent, GP=Gestural prompt, VP=Verbal prompt, H-H=Hand-over-Hand assistance, M=Modeling, PPA=Partial physical assistance, FPA=Full physical assistance, N/A=Not applicable at this stage of progress, R= Refused (The cues should be individualized and may depend on the objective. Codes can be added in this section)
Section III ISP Goal A:
a. Service:
b. Date:
c. Time: IN
e. Total hours/Units:
d. Time: Out
f. Objectives listed on ISP Action Plan
g. Frequency/completion date
h. Codes
1.
2
3.
4.
i. Progress Note (Optional – Documentation can be written here if the person is not working on a specific goal for the day):
J. Direct Support Staff printed name/title:
j. K. Signature of Direct Support Staff: l. Date:
January 1, 2015 Comprehensive Supports Waiver Program S-3
Section III
ISP Goal A: This is the Goal for the service listed in the individual’s ISP.
a. Service: Service rendered
b. Date: Date service provided
c. Time In: Start time
d. Time Out: End Time
e. Total hours/Units: Identify the total number of hours and units to be billed for the day
f. Objectives: List objectives identified on the person’s ISP
g. Frequency/completion date: For the objective (1) include the frequency on the ISP or if the objective was met, identify the completion date
h. Code: In this section you identify the codes used to identify the level of intervention or supports the person required at the time of the training.
i. Progress Notes: Optional – Documentation can be written here if the person is not working on a specific goal for the day): Staff can document on what the person did related to the services provided outside the scope of the goal/objectives. Include how the person responded, any significant event, new experiences, and/or what is next. Any requests the person makes for the service/supports provided. Elaborating on any progress needing to be documented or completion of objective/goal.
j. Direct Support Staff printed name/title: Name of direct support professional working with the individual on the goal
k. Signature of Direct Support Staff: Can be hand written or a secure electronic signature
l. Date: Date note written and service rendered
Section IV Weekly Additional Person Centered Progress Achievements Identified Barriers
a. What did he/she enjoy?
b. What did he/she not enjoy?
c. What worked and needs to be continued?
d. What did not work and needs to be changed?
e. You can place any other information about the goal into this section. OPTIONAL
f. Direct Support Staff printed name/title:
g. Signature of Direct Support Staff:
h. Date:
a. What did he/she enjoy? For the week services were rendered identify what the person enjoyed doing, working on and/or experiencing.
b. What did he/she not enjoy? For the week services were rendered identify what the person did not enjoy doing, working on and/or experiencing.
c. What worked and needs to be continued? For the week services were rendered identify what strategies, methods, techniques and supports worked for the person and needs to become a regular part of how supports and services are provided.
January 1, 2015 Comprehensive Supports Waiver Program S-4
d. What did not work and needs to be changed? For the week services were rendered identify what strategies, methods, techniques and supports did not work for the person and needs to change.
e. You can place any other information about the goal into this section. (Example: who, what, where, why, when and what’s next to progress) Can be a weekly summary of the person’s progress on goals/objectives and/or the supports and services provided and how the person responded.
f. Direct Support Staff printed name/title: Name of direct support professional working with the individual
g. Signature of Direct Support Staff: Can be hand written or a secure electronic signature
h. Date: Date note written and service rendered
Section V
a. Weekly Additional Routine Person Centered Supports (Supports are pre-filled by the provider agency and additional supports can be added if necessary):
b.
c. Additional Comments/Significant Events(s) (If no comments/significant events, indicate N/A):
d. Direct Support Staff printed name/title:
e. Signature of Direct Support Staff:
f. Date:
a. Weekly Additional Routine Person Centered Supports: This section is designed for routine supports/needs that the person may require on an on-going basis. This section should be individualized based upon the identified needs in the ISP.
b. Identified additional support: Identify any additional ongoing support/needs by each box. This section can be prefilled with the regular supports provided to the person and the staff will check off which specific supports occurred during the reporting period.
c. Additional Comments/Significant Events: The box below can be utilized to capture any significant events from the day or week that is in direct relationship to the person. The box below will expand when you write! (Examples: how the person reacted to a new experience, new faces-new places, significant event changes in the person life, choices made, and any information about rights, health, safety, community connections, etc.).
d. Direct Support Staff printed name/title: Name of direct support professional working with the individual.
e. Signature of Direct Support Staff: Can be hand written or a secure electronic signature.
f. Date: Date note written and service rendered.
Disclaimer: The use of this form does not guarantee compliance with all policies/standards for documentation.
January 1, 2015 Comprehensive Supports Waiver Program S-5
Monthly Quality Assurance Summary of Services
(This summary will be done by case manager or whoever is designated by the provider to have professional clinical oversight of individual’s services. When the clinical oversight staff provide direct supports and complete progress notes, the provider must assure oversight of this direct service provision.)
Person’s Name: Provider Name:
Support Plan/ Addendum Date: Procedure Code:
MHN ID Number: Month/ Year:
Disclaimer: The use of this form does not guarantee compliance with all policies/standards for documentation.
Support Plan Goals and Objectives by Service
Contact with Direct Support Professional
Name of Direct Support Staff: Date of Contact:
Monthly Summary by Service:
Follow-up from previous month:
Expectations: (Of these expectations, this summary must address B, H, I and J. Others are optional.)
A. Health/Medical/ Behavioral:
B. Person’s Perspective/Person Directed Planning:
C. Choice:
D. Rights:
E. Community Life:
F. Safety:
G. Collaboration:
H. Progress (what’s working/not working):
I. Significant Changes and Events:
J. Follow Up/Next Steps for future progression:
Printed Name of Clinical Oversight Staff: Credentials:
Signature of Clinical Oversight Staff: Date: Goal from ISP: Objectives:
January 1, 2015 Comprehensive Supports Waiver Program S-6
Legend Monthly Quality Assurance Summary of Services
(This summary will be done by case manager or whoever is designated by the provider to have professional clinical oversight of individual’s services. When the clinical oversight staff provide direct supports and complete progress notes, the provider must assure oversight of this direct service provision.)
Section I Individual Identifiable Information (Prefilled by the provider agency)
a. Person’s Name:
b. Provider Name:
c. Support Plan/Addendum Date:
d. Procedure Code:
e. MHN ID Number:
f. Month/Year
a. Person’s Name: Name of the individual served
b. Provider Name: This is where you place your provider name
c. Support Plan/Addendum Date: Identify the ISP timeframe or addendum date
d. Procedure Code: Code for the service providing
e. MHN ID Number: Individual’s MHN ID number
f. Month/Year: Identify month and year of when services are being documented
Section II Support Plan Goals and Objectives by Service
a. Goal from ISP: List the goals directly from the ISP
b. Objectives: List objectives identified on the person’s ISP
Section III Contact with Direct Support Professional
a. Name of Direct Support Staff: Name of DSP contacted for this report
b. Date of Contact: Day met with DSP
c. Monthly Summary by Service: Identify the service the monthly summary reflects
d. Follow-up from previous month: Identify what activities or actions completed to
follow-up from the previous month’s summary
Section IV Expectations (Of these expectations, this summary must address B, H, I and J. Others are optional)
A. Health/Medical/ Behavioral:
What education/ training took place on health related topics to support the individual to manage their own healthcare? Identify any health/medical/behavioral issues (picture a holistic approach) addressed or identified? Identify changes in health, medical and behavioral matters such as: doctor appointments, medications, critical incidents, behavioral incidents and tracking. Identify any follow-up done or needed, including but a. Goal from ISP: b. Objectives:
January 1, 2015 Comprehensive Supports Waiver Program S-7
not limited to referrals for treatment (Physical Therapy, Occupational Therapy, Speech & Language Pathologist, Registered Nurse, Physician, Registered Dietitian, and Mental Health Practitioner). Identify any adaptive equipment needs/repairs/modifications.
B. Person’s Perspective/Person Directed Planning:
How does the person feel he/she has progressed on his/her goals? What changes has the person requested to make to their supports, services and goals? Have they used their circle of supports to assist them in directing their goal this month? Reflect here what matters most to the person and any new preferences.
C. Choice:
What choice/ options have been explored by the person? What Education, Exposure and Experiences have been presented to the person in all areas of life? Identify any informed choices the person has made. Identify all options presented and/or rejected by the person.
D. Rights:
What training based upon the person’s learning style has the person received and/or learned concerning rights? Have they expresses what right matters most to them? Have they self-advocated for one of their rights to be upheld? Has any unresolved issue concerning rights been resolved this month? Has training taken place for the person’s legal representative concerning rights restrictions this month? Identify any complaints or grievances the person has expressed and the results/resolution. Identify any preferences related to exercising rights expressed by the person. What education, exposure and experiences were provided to the person to expand their knowledge of rights?
E. Community Life:
Has the person made any new acquaintances (other than paid staff/teachers/providers) or developed a social role within his/her community? What social and community inclusion (new places) have been explored to promote community integration this month based on the person’s preferences? How have already established social roles been supported?
F. Safety:
Identify any critical incidents filed on behalf of the individual and if necessary any interventions put into place to prevent further incidents. What education has taken place concerning abuse, neglect and exploitation? How has the person responded to training concerning prevention of abuse, neglect and exploitation and/or understanding for each of these? If the person has had a previous event from their past that needs to be addressed, what was done? Describe safety training in all areas of the person’s life, i.e. mobility, travel, community, home and personal safety. Document any skills the person has gained in self preservation. List any referrals for environmental safety modifications and results.
G. Collaboration:
Has any communication taken place with the person’s circle of support/team? What were the results of any brainstorming on behalf of the person? What self-advocacy has taken place by the person concerning his/her referrals or follow-ups? Has the process worked to the satisfaction of the person? Does further action need to be taken and who will take the lead?
H. Progress (what’s working/not working):
What has the person achieved on their Support plan/targeted goals/objectives? What are the results of the monthly tracking? What are the necessary steps left to take to assist the person to accomplish his/her targeted goal (s)? If the targeted goal is accomplished how did the person choose to celebrate? What mattered most to the person concerning his/her
January 1, 2015 Comprehensive Supports Waiver Program S-8
goal progress, and what would the person change or need to change to accomplish his/her goal? Have there been any changes developed based upon the lack of progress made to the person’s action plan? Has the supports and services been altered based upon the person’s learning style, communication style or other impact?
I. Significant Changes and Events:
Describe any additional changes or events not captured above and the person’s response.
J. Follow Up/Next Steps for future progression:
List the next steps and follow up needed based upon the summaries above and which will be worked on for the following month.
Section IV Printed Name of Person who has Clinical oversight and credentials
a. Printed Name of Clinical Oversight Staff: Name of the clinical oversight staff
b. Credentials: Credentials or job title
c. Signature of Clinical Oversight Staff: Can be hand written or a secure electronic signature
d. Date: Date report written
Disclaimer: The use of this form does not guarantee compliance with all policies/standards for documentation.
January 1, 2015 Comprehensive Supports Waiver Program S-9
Home Services Individual Training Log
(CRA, CLS & Respite services Only)
a. Person’s Name:
g. Provider Name:
b. MHN ID Number:
h. Service:
c. Support Plan Date: f. Addendum date: i. Procedure Code:
d. Month/Year:
e. Peer Quality Assurance Review: j. Date:
Disclaimer: The use of this form does not guarantee compliance with all policies/standards for documentation.
Code:
HOME SERVICES TRAINING LOG
Goal:
Objective
Frequency/Completion Date
1.
2.
3.
4.
Staff Instructions
Date:
1
2
3
4
5
6
7
8
9
10
11
12

25
26
27
28
29
30
31
Objective number (1-4) – which objective worked on
Objective met (+) or
(-) not met
Prompt Code Required – from list above
# of prompts
or cues
Staff Initials
Direct Support Staff printed name/title:
Signature of Direct Support Staff: (can be hand written or a secure electronic signature)
Weekly Additional Person Centered Progress Achievements Identified Barriers
What he/she enjoyed?
What he/she did not enjoy?
What worked and/or needs to continue?
What didn’t work and/or needs to change?
You can place any other information about the goal into this section. OPTIONAL
Direct Support Staff printed name/title:
Signature of Direct Support Staff:
Date:
Weekly Additional Routine Person Centered Supports:
Additional Comments/Significant Event(s) (If no comments/significant events, indicate N/A):
January 1, 2015 Comprehensive Supports Waiver Program S-10
Direct Support Staff printed name/title:
Signature of Direct Support Staff:
Date:
Legend for Home Services Training Log
Section I Individual Identifiable Information (This section is pre-filled by the provider agency)
a. Person’s Name:
g. Provider Name:
b. MHN ID Number:
h. Service:
c. Support Plan Date: f. Addendum date: i. Procedure Code:
d. Month/Year:
e. Peer Quality Assurance Review: j. Date:
a. Person’s Name: Name of the individual served
b. MHN ID Number: Individual’s MHN ID number
c. Support Plan Date: Identify the ISP timeframe
d. Month/Year: Identify month and year of when services are being documented
e. Peer Quality Assurance Review: Professional reviewer’s name and signature
f. Addendum date: Identify any addendum date if applicable
g. Provider Name: This is where you place your provider name
h. Service: Specific service documenting
i. Procedure Code: Code for the service providing.
j. Date: Date reviewed by the Peer Quality Assurance reviewer (not pre-filled by the provider agency)
Section II Codes
Codes:
Codes: In this section you identify the codes used to identify the level of intervention/support the person required at the time of the training. For example: I=Independent, GP=Gestural prompt, VP=Verbal prompt, H-H=Hand-over-Hand assistance, M=Modeling, PPA=Partial physical assistance, FPA=Full physical assistance, N/A=Not applicable at this stage of progress, R= Refused (The cues should be individualized and may depend on the objective. Codes can be added in this section)
Section III Home Services Residential Training Log
a. Goal
b. Objectives:
c. Frequency/completion date
1.
2.
3.
4.
d. Staff Instructions:
a. Goal This is the Goal for the service listed in the individual’s
ISP
b. Objectives: List objectives identified on the person’s ISP , list each
January 1, 2015 Comprehensive Supports Waiver Program S-11
objective by number
c. Frequency/completion date For the objective (1) include the frequency on the ISP or
if the objective was met, identify the completion date
d. Staff Instructions: Identify what strategies, methods, techniques and
supports needed for the person to meet their goal/objectives
Date:
1
2
3
4
5
6
7
8
9
10
11
12

25
26
27
28
29
30
31
e. Objective number (1-4) – which objective worked on
f.Objective met (+) or
(-) not met
g.Prompt Code Required – from list above
h.# of prompts
or cues
i. Staff Initials
Direct Support Staff printed name/title:
Signature of Direct Support Staff: (can be hand written or a secure electronic signature)
e. Objective Number List each objective by number that was worked on
f. Objective status List if the object was met or not met by using a plus or
negative symbol (+ / -)
g. Prompt code The codes used to implement the objective
h. Number of Prompts List how many times prompts or codes were used
i. Staff Initials Initials of staff training
Section IV Weekly Additional Person Centered Progress
Achievements Identified Barriers
i. What did he/she enjoy?
j. What did he/she not enjoy?
k. What worked and needs to be continued?
l. What did not work and needs to be changed?
m. You can place any other information about the goal into this section. OPTIONAL
n. Direct Support Staff printed name/title:
o. Signature of Direct Support Staff:
p. Date:
i. What did he/she enjoy? For the week services were rendered identify what the person enjoyed doing, working on and/or experiencing.
j. What did he/she not enjoy? For the week services were rendered identify what the person did not enjoy doing, working on and/or experiencing
January 1, 2015 Comprehensive Supports Waiver Program S-12
k. What worked and needs to be continued? For the week services were rendered identify what strategies, methods, techniques and supports worked for the person and needs to become a regular part of how supports and services are provided.
l. What did not work and needs to be changed? For the week services were rendered identify what strategies, methods, techniques and supports did not work for the person and needs to change. (Example: who, what, where, why, when and what’s next to progress) A weekly summary of the person’s progress on goals/objectives and/or the supports and services provided and how the person responded.
m. Direct Support Staff printed name/title: Name of direct support professional working with the individual
n. Signature of Direct Support Staff: Can be hand written or a secure electronic signature
o. Date: Date note written and service rendered
Section V a. Weekly Additional Routine Person Centered Support s (Supports are pre-filled by the provider agency and additional supports can be added if necessary):
b.
c. Additional Comments/Significant Event(s) (If no comments/significant events, indicate N/A):
d. Direct Support Staff printed name/title:
e. Signature of Direct Support Staff:
f. Date:
a. Weekly Additional Routine Person Centered Intervention: This section is designed for routine supports/needs that the person may require on an on-going basis. This section should be individualized based upon the identified needs in the ISP.
b. Identified additional support: Identify any additional ongoing support/needs by each box. This section can be prefilled with the regular supports provided to the person and the staff will check off which specific supports occurred during the reporting period.
c. Additional Comments/Significant Events: The box below can be utilized to capture any significant events from the day or week that is in direct relationship to the person. The box below will expand when you write! (Examples: how the person reacted to a new experience, new faces-new places, significant event changes in the person life, choices made, and any information about rights, health, safety, community connections, etc.).
d. Direct Support Staff printed name/title: Name of direct support professional working with the individual.
e. Signature of Direct Support Staff: Can be hand written or a secure electronic signature.
f. Date: Date note written and service rendered.
Disclaimer: The use of this form does not guarantee compliance with all policies/standards for documentation.
January 1, 2015 Comprehensive Supports Waiver Program T-1
APPENDIX T
ICD-10 Overview
On October 1, 2015, the United States’ health care system will undergo a major transformation from the use of Ninth Edition of the International Classification of Diseases (ICD-9) set of diagnosis and inpatient procedure codes to the Tenth Edition (ICD-10). ICD-10-CM replaces the ICD-9-CM diagnosis codes (volumes 1-2) and ICD-10-PCS replaces the ICD-9-CM procedure codes (Volume 3). The current system of ICD-9 has several limitations that prevent complete and precise coding and billing of health conditions and treatments. ICD-9 codes are a 35-year-old code set that contains outdated terminology and is inconsistent with current medical practice. The code length and alphanumeric structure limit the number of new codes that can be created, and many ICD-9 categories are already full.
ICD-10 allows for greater specificity and detail in describing a patient’s diagnosis, condition, diagnostic needs, and in classifying inpatient procedures. ICD-10 provides more specific data than ICD-9 and better reflects current medical practice. The added detail embedded within ICD-10 codes informs health care providers and health plans of patient incidence and history, which allows for more effective case management and better coordination of care.
This ICD-10 transition (which is mandatory) will have a major impact on every HIPAA compliant entity that uses health care information containing a diagnosis and/or inpatient procedure code. All covered entities as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) are required to adopt ICD-10 codes for services provided on or after October 1, 2015, the mandated compliance date.
GA Medicaid like other payers must institute new policies as a result of the transformation to the new ICD-10 code sets. The following policies are areas in GA Medicaid that are impacted with implementation of ICD-10 on or after October 1, 2015:
1. The Tenth Edition of the International Classification of Diseases (ICD-10) set of diagnosis (CM) and inpatient procedure (PCS) codes must be used on or after October 1, 2015. The Ninth Edition of the International Classification of Diseases (ICD-9) set of diagnosis and inpatient procedure codes will only be allowed on claims or any adjustments for dates of services/treatments rendered prior to October 1, 2015.
2. ICD-10 diagnosis (CM) and procedure (PCS) codes are required on all inpatient stays (admission) with discharge dates on or after October 1, 2015. With the ICD-10 transition on or after October 1, 2015, inpatient (admission) claims will be adjudicated based on the patient’s discharge date using ICD-10 CM and PCS codes.
3. The Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes are not impacted by ICD-10 and are not changing.
January 1, 2015 Comprehensive Supports Waiver Program T-2
4. To process ICD-10 claims or other transactions electronically, providers, payers, and vendors must first implement the “Version 5010” health care transaction standards mandated by HIPAA. The previous HIPAA “Version 4010/4010A1” transaction standards do not support the ICD-10 codes. This implementation was effective January 1, 2012.
5. Span dates on claims: GA Medicaid will not adjudicate claims submitted with dates that span the October 1, 2015 date except for inpatient stays or PRTF (psych residential) UB claims.
6. During the ICD-10 transition on and after October 1, 2015, both code sets (ICD-9 and ICD-10) will be supported in the GA Medicaid Management Information System (GAMMIS) for claim processing and adjustments. Any software vendors that provide business intelligence solutions should support both code sets, ICD-9 and ICD-10 codes, simultaneously during the transition.
7. An ICD-9 code submitted for a service on or after October 1, 2015 cannot be processed or paid under federal law.
8. Claims submitted for payment with both ICD-9 and ICD-10 (CM or PCS) codes will not be adjudicated in GAMMIS on or after October 1, 2015 and will be denied. Claims with span dates of services rendered prior to September 30, 2015 and on or after October 1, 2015, must be submitted on separate claims. The split (separate) claims must be billed with the appropriate ICD-9 or ICD-10 codes.
9. GA Medicaid has conducted mapping of thousands of ICD-9 diagnosis (CM) and procedure (PCS) codes to ICD-10 codes and the reverse. ICD-9 codes were mapped forward and backwards using General Equivalence Mappings (GEMs) to maximize all ICD-9 to ICD-10 code possibilities.
10. Unspecified or unlisted or non-specific diagnosis (CM) codes should be avoided on claims using ICD-10 codes. Unspecified codes may be acceptable on UB-04 (hospital) claims under ICD-10 but any other provider specialty types and/or Categories of Service must bill the lowest possible level ICD-10 diagnosis code. There may be services and/or procedures that do not have a specified code or procedure and warrants billing an unspecified code. However, providers must bill the most detailed ICD-10 code available for the service rendered. Claims billed with unlisted and/or unspecified codes will be denied if determined that a more appropriate code is available. The physician’s clinical documentation should support the specificity of the code(s) being billed.
11. Prior authorization (PA) requests already approved prior to the ICD-10 transition on October 1, 2015, will not need to be resubmitted. If the PA request is submitted for approval on or after October 1, 2015, the request form must have ICD-10 diagnosis (CM) codes for claim processing. Any PA renewals or requests submitted on or after October 1, 2015, will need to have ICD-10 diagnosis (CM) codes.
January 1, 2015 Comprehensive Supports Waiver Program T-3
NOTE: The PA start date is the key to which code set (ICD-9 or ICD-10) to submit on a PA. The correct diagnosis code set must be used on the claim to be adjudicated in GAMMIS.
12. Some ICD-10 diagnosis codes are restricted such as those related to age, gender, and sex. The GAMMIS is configured to accept these restrictive types of ICD-10 diagnosis codes.
13. ICD-10 procedure (PCS) codes must be used on all inpatient (admit) facility or hospital claims. The GAMMIS is configured for ICD-10 transition to auto-deny any UB-claims that have missing or inappropriate ICD-10 procedure codes. The ICD-10-PCS codes are associated to the appropriate anatomic sites related to each Major Diagnostic Category (MDC).
DOCUMENTATION REQUIREMENTS UNDER ICD-10
Implementation of ICD-10 on October 1, 2015, will affect the clinical documentation of providers to payer organizations. ICD-10 coding provides the opportunity for greater accuracy in creating standardized data that describes the patient’s condition and supports the billing and payment based on the physician’s documentation. Increased code detail contained in ICD-10-CM (diagnosis codes) means that documentation requirements will change substantially. ICD-10-CM (diagnosis) includes a fuller definition of severity, comorbidities, complications, sequelae, manifestations, causes, and a variety of other important parameters that characterize the patient’s condition.
A large number of the ICD-10-CM (diagnosis) codes are the same except for indicating laterality of a patient’s body part: RIGHT, LEFT, BILATERAL, UNILATERAL, or UNSPECIFIED SIDE. Thousands of other codes differ only in the way they distinguish “initial encounter [first visit= A],” versus “subsequent encounter [second or follow-up visit= D],” versus “sequelae [secondary codes produced by an acute phase of illness or injury and cannot be billed without the initial code= S].”
RESOURCES AVAILABLE TO EASE THE ICD-10 TRANSITION
There are a number of industry resources available to assist all HIPAA entities in the ICD-10 transition.
Below are several resources that provide a wealth of ICD-10 information:
 General Equivalence Mappings (GEMs) attempt to include all valid relationships between the codes in the ICD-9-CM diagnosis classification and the ICD-10-CM diagnosis classification. The tool allows coders and providers to look up an ICD-9 code and be provided with the most appropriate ICD-10 matches and vice versa. GEMs are not a “crosswalk”; they are merely meant to be a guide. Visit the CMS website at www.cms.gov/ICD10 for more information on GEMs.
January 1, 2015 Comprehensive Supports Waiver Program T-4
 Centers for Medicare & Medicaid Services (CMS) website:. www.cms.gov/ICD10
 Georgia Department of Community Health ICD 10 Project website: http://dch.georgia.gov/icd-10
January 1, 2015 Comprehensive Supports Waiver Program U-1
APPENDIX U
Georgia Families 3600 SM,
Information for Providers Serving Medicaid Members
in the Georgia Families 3600 SM Program
Georgia Families 3600 SM, the state’s new managed care program for children, youth, and young adults in Foster Care, children and youth receiving Adoption Assistance, as well as select youth in the juvenile justice system, launched Monday, March 3, 2014. Amerigroup Community Care is the single Care Management Organization (CMO) that will be managing this population.
DCH, Amerigroup, and partner agencies — the Department of Human Services (DHS) and DHS’ Division of Family and Children Services (DFCS), the Department of Juvenile Justice (DJJ) and the Department of Behavioral Health and Developmental Disabilities (DBHDD), as well as the Children’s and Families Task Force continue their collaborative efforts to successfully rollout this new program.
Amerigroup is responsible through its provider network for coordinating all DFCS, DJJ required assessments and medically necessary services for children, youth and young adults who are eligible to participate in the Georgia Families 3600SM Program. Amerigroup will coordinate all medical/dental/trauma assessments for youth upon entry into foster care or juvenile justice (and as required periodically). Georgia Families 3600 SM members will also have a medical and dental home to promote consistency and continuity of care. Providers, foster parents, adoptive parents and other caregivers will be involved in the ongoing health care plans to ensure that the physical and behavioral health needs of these populations are met. Electronic Health Records (EHRs) are being used to enhance effective delivery of care. The EHRs can be accessed by Amerigroup, physicians in the Amerigroup provider network, and DCH sister agencies, including the DFCS, regardless of where the child lives, even if the child experiences multiple placements. Ombudsman and advocacy staff are in place at both DCH and Amerigroup to support caregivers and members, assisting them in navigating the health care system. Additionally, medication management will focus on appropriate monitoring of the use of psychotropic medications, to
January 1, 2015 Comprehensive Supports Waiver Program U-2
include ADD/ADHD medications.
Providers can obtain additional information by contacting the Provider Service Line at 1-800-454-3730 or by contacting their Provider Relations representative.
To learn more about DCH and its dedication to A Healthy Georgia, visit www.dch.georgia.gov

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