CHAPTER 1200 PARTICIPANT-DIRECTION

1201. General
The Comprehensive Supports Waiver (COMP) Program promotes personal choice and control over the delivery of waiver services by affording opportunities for participant-direction that are available to participants who live in their own private residence or the home of a family member.
The Participant or his or her Representative (Participant/Representative), assisted by the Support Coordinator, chooses services that meet their needs from among the allowable participant-directed services. The Participant/Representative exercises Employer Authority and has decision-making authority over the support workers who provide waiver services. The Participant/Representative may function as the employer of record (common law employer) of support workers or may be the co-employer with a traditional provider agency, which functions as the employer of record.
The Participant/Representative also exercises Budget Authority and has decision-making authority over a budget for participant-directed waiver services. The amount of the participant-directed budget is the amount of the waiver allocation minus any costs for provider-managed services.
The policies, procedures and the conditions related to participation in Georgia’s Comprehensive Supports Waiver (COMP) Program, Participant-Direction Option, to provide home and community based waiver services for persons with mental retardation/developmental disabilities (MR/DD) are authorized by a waiver renewal from the Centers for Medicare and Medicaid Services (CMS) pursuant to Section 2176 of Public Law 97-35. The COMP provides for services to eligible individuals with I/DD who resides in or are at risk of an institutional placement, and opts to self-direct their COMP Services.
1202. Participant Eligibility
The COMP provides every Participant/Representative, the opportunity to elect to direct up to (16) waiver services. Should the Participant/Representative choose to direct allowable waiver services, the election must be specified in the Individual Service Plan (ISP).
The participant enrolled in Participant-Directed COMP Services may receive other COMP waiver services through Traditional Agency Providers except for the exclusions specified in the Part III, Policies and Procedures Manual for the COMP Program. Traditional Agency Provider services must be specified in the Individual Service Plan (ISP) in accordance with provider requirements and
Rev 01 2013
Rev 01 2013
Rev 01 2013
January 1, 2015 Comprehensive Supports Waiver Program XII-2
qualifications specified for each respective service in the Part III, Policies and Procedures for the COMP Program.
1203. Participant-Direction by a Representative
Waiver services may be directed by:
1) A legal representative of the participant, or
2) A non-legal representative freely chosen by an adult participant.
A representative assists with participant-direction responsibilities on behalf of the participant. Representatives must follow all requirements related to the direction of waiver services, including signed documentation of their understanding of their role and responsibilities as a representative. Support Coordinators assist the representative in the development of the Individual Service Plan and the Individual Budget for Participant Direction.
An adult waiver participant’s Support Coordinator may assist him or her in choosing an appropriate, qualified representative who will serve in his or her best interests. Whenever an adult waiver participant chooses a non-legal representative, his or her Support Coordinator assures at least an annual review of whether the continued direction of waiver services by the non-legal representative is in the best interests of the adult waiver participant.
Community Guides provide, if needed, direct assistance to the representative on ISP and Individual Budget development that support community connections. Support Coordinators assure that representatives direct the inclusion of items in the Individual Budget that tie to specific ISP goals, which are based on the individual needs of the waiver participant. Under no circumstances may a representative for an individual in Participant-Direction be approved to be the provider of service. The Financial Support Service only pays for services specified in the Individual Service Plan, and Support Coordinators additionally monitor the provision of these services in relation to ISP goals, the health and safety of the waiver participant, and the meeting of all participant-direction responsibilities.
1204. Eligibility Criteria
The Department of Behavioral Health and Developmental Disabilities (DBHDD) uses the criteria below to determine whether a participant is appropriate for COMP Participant-Directed Services. Home and Community-Based Services included under the waiver may be provided only to persons who are not inpatients of a hospital, Skilled Nursing Facility (SNF), Intermediate Care Facility (ICF), or Intermediate Care Facility for the Mentally Retarded (ICF/MR), with the exception of the personal assistance retainer for Community Living Support Services (see COMP Part III, Policies and Procedures, Chapter 1900 for personal
January 1, 2015 Comprehensive Supports Waiver Program XII-3
assistance retainer details), and who:
I. Are categorically eligible Medicaid recipients; and
B. Are mentally retarded and/or developmentally disabled (a diagnosis of developmental disability includes mental retardation or other closely related conditions such as cerebral palsy, epilepsy, autism, or neurological impairments which result in impairments of general intellectual functioning or adaptive behavior requiring treatment and services similar to those needed by persons with mental retardation, with eligibility determined as specified in Chapter 700 of this manual); and,
C. Are currently receiving the level of care provided in an ICF/MR which is reimbursable under the State Plan, and for whom home and community-based services are determined to be an appropriate alternative; or,
D. Are likely to require the level of care provided in an ICF/MR which would be reimbursable under the State Plan in the absence of home and community-based services which are determined to be an appropriate alternative; and,
E. Are enrolled in or eligible for COMP Services and are capable of demonstrating that he/she is able to direct his or her COMP services and follow all policies and procedures for the participant-direction option applicable to the Participant, or has a designated Representative with the demonstrated ability to assist with this responsibility; and,
F. Are able to communicate effectively with the Support Coordinator and, if applicable, any caregiver of COMP services eligible for Participant-Direction, or has a designated representative with the demonstrated ability to assist with this responsibility; and,
G. Are able to understand and perform, if applicable, the tasks required to employ providers of COMP services (including recruitment, hiring, scheduling, training, supervision, and termination) or has a designated representative with the demonstrated ability to assist with this responsibility; and,
H. Are able to complete and submit all required timesheets/invoices and manage the individual budget for COMP Participant-Directed services or has a designated representative with the demonstrated ability to assist with this responsibility.
Prior to enrollment in participant-directed services, the ability of the participant/representative to participant-direct COMP services shall be confirmed.
January 1, 2015 Comprehensive Supports Waiver Program XII-4
An individual participant’s/representative’s ability to participant-direct COMP services may be reassessed at any time, as determined by the Support Coordinator, in response to objective evidence indicating changes in capacity or supports.
1205. Special Consideration for Eligibility for Participant-Direction
Participants, who do not receive the COMP Participant-Directed services but express a desire to self-direct allowable waiver services, will have their request reviewed. The Interdisciplinary Team, including the Intake and Evaluation Team, the Support Coordinator, provider(s), and the participant and their support network, will review the individual’s current services to determine if Participant-Direction is appropriate for the participant. If these services are determined to meet the participant’s needs and all other eligibility requirements for the participant-direction are met, the participant will be allowed to enroll in Participant-Directed COMP Services.
1206. Notification of Participant Approval/Disapproval
COMP applicants will be notified in writing of approval or disapproval for COMP services by the Regional DBHDD Office.
1207. Denial of Eligibility
Reasons for denial of eligibility for services under the Comprehensive Supports Waiver include those specified in Chapter 700. In addition, participants/representatives may be deemed ineligible to self-direct COMP Services because of insufficient demonstration of the ability of the participant or adequate supports by a designated representative to perform the responsibilities of the participant-direction.
1208. Grounds for Appeal
The right to appeal of denial of COMP funded services is specified in Chapter 700. A participant denied eligibility for Participant-Directed COMP services shall be informed of his/her rights to appeal by the Support Coordinator. The denial of eligibility for participant-direction of services due to a participant’s or family’s/representative’s inability to direct the COMP Services may be reassessed at any time, as determined by the Support Coordinator, in response to objective evidence indicating changes in capacity or supports.
Specific requirements, conditions and procedures for screening COMP applicants for services, Level of Care determinations and denials are detailed in Chapter 700 of this manual.
January 1, 2015 Comprehensive Supports Waiver Program XII-5
1209. Requirements for Enrollment in Participant-Direction
Once a participant or representative meets the eligibility for the Participant-Direction of COMP services, and voluntarily chooses to self-direct eligible COMP Services, the Support Coordinator must provide the following to initiate enrollment of the participant:
I. Documentation of willingness and ability of participant or representative to direct COMP services;
II. Documentation of a viable individual emergency back-up plan;
III. Completed Participant-Direction Memorandum of Understanding, with signature of Participant and/or Representative;
IV. Provision of a minimum of thirty (30) days written notice by the Support Coordinator to the COMP (traditional) provider;
V. Documentation of choice, where available, of Financial Support Services (FSS) Provider by the Participant/Representative and agreement by the Participant/Representative to remain with the chosen FSS provider for one year prior to an FSS change request.. In addition, after that year, to provide a minimum thirty (30) days written notice to the FSS provider prior to a change request.
For new enrollees, Participant-Directed COMP Services may only initiate on the first (1st) of the month.
1210. Eligible Waiver Services
COMP Services eligible for Participant-Direction are as follows:
1. Adult Occupational Therapy Services
Adult Occupational Therapy Services address the occupational therapy needs of the adult participant that result from his or her developmental disabilities.
Details on service specifications, provider requirements and licensure, covered and non-covered services, and reimbursement units and rates, can be found in Part III, COMP Policies and Procedures, Chapter 1300.
2. Adult Physical Therapy Services
Adult Physical Therapy Services address the physical therapy needs of the adult participant that result from his or her developmental disabilities.
Details on service specifications, provider requirements and licensure, covered
January 1, 2015 Comprehensive Supports Waiver Program XII-6
and non-covered services, and reimbursement units and rates, can be found in Part III, COMP Policies and Procedures, Chapter 1400.
3. Adult Speech and Language Therapy Services
Adult Speech and Language Therapy Services address the speech and language therapy needs of the adult participant that result from his or her developmental disabilities.
Details on service specifications, provider requirements and licensure, covered and non-covered services, and reimbursement units and rates, can be found in Part III, COMP Policies and Procedures, Chapter 1500.
4. Behavioral Supports Consultation Services
Behavioral Supports Consultation Services are the professional level services that assist the participant with significant, intensive challenging behaviors that interfere with activities of daily living, social interaction, work or similar situations
Details on service specifications, provider requirements and licensure, covered and non-covered services, and reimbursement units and rates, can be found in Part III, COMP Policies and Procedures, Chapter 1600
5. Community Access Services
Community Access Services are designed to assist the participant in acquiring, retaining, or improving self-help, socialization, and adaptive skills required for active participation and independent functioning outside the participant’s home or family home.
Note: With the exception of Co-Employer Services, participant-directed Community Access Group Service provided by an individual employee for one or more participants cannot exceed a ratio of one (1) employee to three (3) participants.
Details on service specifications, provider requirements and licensure, covered and non-covered services, and reimbursement units and rates, can be found in Part III, COMP Policies and Procedures, Chapter 1700
6. Community Guide Services
Community Guide Services are only for participants who opt for Participant- Direction and assist these participants with defining and directing their own services and supports and meeting the responsibilities of Participant-Direction.
Details on service specifications, provider requirements and licensure, covered and non-covered services, and reimbursement units and rates, can be found in Part III, COMP Policies and Procedures, Chapter 1800.
Rev. 07 2011
Rev. 10 2013
January 1, 2015 Comprehensive Supports Waiver Program XII-7
7. Community Living Support Services
Community Living Support Services are individually tailored supports that assist with the acquisition, retention, or improvement in skills related to a participant’s continued residence in his or her family home.
Details on service specifications, provider requirements and licensure, covered and non-covered services, and reimbursement units and rates, can be found in Part III, COMP Policies and Procedures, Chapter 1900.
8. Environmental Accessibility Adaptation Services
Environmental Accessibility Adaptation Services consist of physical adaptations to the participant’s of family’s home which are necessary to ensure the health, welfare, and safety of the individual, or which enable the individual to function with greater independence in the home.
Details on service specifications, provider requirements and licensure, covered and non-covered services, and reimbursement units and rates, can be found in Part III, COMP Policies and Procedures, Chapter 2100.
9. Individual Directed Goods and Services
Individual Directed Goods and Services are not otherwise provided through the COMP or Medicaid State Plan but are services, equipment or supplies identified by the participant who chooses Participant-Direction and his or her Support Coordinator or interdisciplinary team.
Details on service specifications, provider requirements and licensure, covered and non-covered services, and reimbursement units and rates, can be found in Part III, COMP Policies and Procedures, Chapter 2300.
10. Natural Support Training Services
Natural Support Training Services provide training and education to individuals who provide unpaid support, training, companionship or supervision to participant.
Details on service specifications, provider requirements and licensure, covered and non-covered services, and reimbursement units and rates, can be found in Part III, COMP Policies and Procedures, Chapter 2400.
11. Respite Services
Respite Services provide brief periods of support or relief for caregivers or individuals with disabilities and include maintenance respite for planned or scheduled relief or emergency respite for for a participant requiring a short period of structured support (typically due to behavioral support needs) or due to a family emergency.
Rev. 10 2011
Rev. 10 2011
Rev. 10 2011
Rev. 01 2012
January 1, 2015 Comprehensive Supports Waiver Program XII-8
Details on service specifications, provider requirements and licensure, covered and non-covered services, and reimbursement units and rates, can be found in Part III, COMP Policies and Procedures, Chapter 2600.
12. Specialized Medical Equipment
Specialized Medical Equipment consists of devices, controls or appliances specified in the Individual Service plan, which enable participants to increase their abilities to perform activities of daily living and to interact more independently with their environment.
Details on service specifications, provider requirements and licensure, covered and non-covered services, and reimbursement units and rates, can be found in Part III, COMP Policies and Procedures, Chapter 2700.
13. Specialized Medical Supplies
Specialized Medical Supplies consist of food supplements, special clothing, diapers, bed wetting protective chunks, and other authorized supplies that are specified in the Individual Service Plan.
Details on service specifications, provider requirements and licensure, covered and non-covered services, and reimbursement units and rates, can be found in Part III, COMP Policies and Procedures, Chapter 2800.
14. Supported Employment Services
Supported Employment Services are only supports that enable participants, for who competitive employment at or above the minimum wage, is unlikely absent the provision of supports, and who, because of their disabilities, need supports to work in a regular work setting.
Details on service specifications, provider requirements and licensure, covered and non-covered services, and reimbursement units and rates, can be found in Part III, COMP Policies and Procedures, Chapter 3000.
15. Transportation Services
Transportation Services enable participants to gain access to waiver and other community services, activities, resources, and organizations typically utilized by the general population but do not include transportation available through Medicaid non-emergency transportation or as an element of another waiver service.
January 1, 2015 Comprehensive Supports Waiver Program XII-9
Details on service specifications, provider requirements and licensure, covered and non-covered services, and reimbursement units and rates, can be found in Part III, COMP Policies and Procedures, Chapter 3100.
16. Vehicle Adaptation Services
Vehicle Adaptation Services include adaptations to the participant’s or family’s vehicle approved in the Individual Service Plan, such as a hydraulic lift, ramps, special seats and other modifications to allow for access into and out of the vehicle as well as safety while moving
Details on service specifications, provider requirements and licensure, covered and non-covered services, and reimbursement units and rates, can be found in Part III, COMP Policies and Procedures, Chapter 3200.
1211. Participant-Direction Opportunities
All waiver services eligible for participant-direction provide the following decision-making authorities for participants/representatives:
a. Participant – Employer Authority
The Participant/Representative has decision-making authority over workers who provide waiver services. The Participant may function as the common law employer or the co-employer of workers.
i. Participant/Common Law Employer Model
The Participant/Representative is the common law employer of workers who provide waiver services. Financial Support Services (FSS) are mandatory and the FSS functions as the participant’s agent in performing payroll and other employer responsibilities that are required by federal and state law.
The cost of the FSS is included in the individual budget. FSS services are not eligible for Participant-Direction.
The Participant-Employer Authority Responsibilities for this model are:
Note: Participant Directed Transportation Services are billed as employee and vendor payments as follows: (1) Commercial Carrier Transportation Services are billed as vendor payments; (2) regularly scheduled One Way and Round Trip Transportation Services provided by individual Georgia licensed drivers are billed as employee payments; and (3) one time and short-term, intermittent One Way and Round Trip Transportation Services are billed as vendor payments.
Rev. 07 2010
January 1, 2015 Comprehensive Supports Waiver Program XII-10
a. Recruit staff in accordance with specific service requirements as specified in the Part III, Policies and Procedures Manual for the COMP Program.
b. Hire staff (common law employer).
c. Verify staff qualifications.
d. Obtain criminal history and/or background investigation of staff.
e. The Financial Support Services conducts criminal records checks of support workers hired by the participant or
representative acting as the employer of recorder.
f. Determine staff duties consistent with service specifications.
g. Determine staff wages and benefits subject to applicable State
limits.
h. Determine staff duties consistent with service specifications in the ISP.
i. Determine staff wages and benefits subject to applicable State
limits.
j. Schedule staff.
k. Orient and instruct staff in duties.
l. Supervise staff.
m. Evaluate staff performance.
n. Verify time worked by staff and approve time sheets.
o. Discharge staff (common law employer).
p. Select vendors in accordance with specific service requirements as specified in the Part III, Policies and Procedures Manual for the COMP Program.
2. Participant/Co-Employer Model
The participant (or the participant’s representative) functions as the co-employer (managing employer) of workers who provide waiver services. An agency is the common law employer of participant-selected/recruited staff and performs necessary payroll and human resources functions.
The types of agencies that serve as co-employers of participant-selected staff are limited to enrolled co-employer providers of the following waiver services:
1.Community Access
2.Community Guide
3.Community Living Support
4.Supported Employment
5.Transportation
The Participant/Representative and the Agency share these Co-Employer Responsibilities:
A. Recruit staff.
January 1, 2015 Comprehensive Supports Waiver Program XII-11
B. Determine staff duties consistent with service specifications.
C. Determine staff wages and benefits subject to applicable State limits.
D. Schedule staff.
E. Orient and instruct staff in duties.
F. Supervise staff.
G. Evaluate staff performance.
The Participant/Representative Co-Employer Responsibilities, in addition to the responsibilities shared with the Agency, are:
1) Refer staff to agency for hiring
2) Verify time worked by staff and approve time sheets.
3) Recommend discharging staff from providing services.
The Agency Co-Employer responsibilities, in addition to the responsibilities shared with the Participant/Representative, are:
a. Verify staff qualifications
b. Obtain criminal history and/or background investigation of co- employees.
c. Conducts criminal records checks of co-employees.
d. Hire staff
e. Process payroll, withholding, filing and payment of applicable federal, state and local employment-related taxes and insurance for co-employees.
f. Conducts skills training and provides technical assistance to participants and/or their representatives on employer-related responsibilities.
g. Process and bill for services approved in the service plan.
b. Participant – Budget Authority
The participant or the participant’s representative has decision-making authority over a budget for waiver services.
The Participant-Budget Authority Responsibilities are:
a. Reallocate funds among services included in the budget.
b. Determine the amount paid for services within the State’s
established limits.
c. Substitute service providers.
d. Schedule the provision of services.
e. Authorize payment for waiver goods and services.
f. Review and approve provider invoices for services rendered.
Rev. 07 2009
Rev. 07 2009
January 1, 2015 Comprehensive Supports Waiver Program XII-12
1212. Supports for Participant-Direction
The COMP provides for three (3) distinct support services for participants who elect to direct their own services and manage the budget allocated for their support needs. These support services are designed to assist participants in assuming their management responsibilities:
A. Financial Management Services
B. Support Coordination (Case Management) Services, and
C. Community Guide Services
1212.1 Financial Management Services o Services Overview: Financial Management Services are mandatory and integral to Participant-Direction designed to perform fiscal and related finance functions for the participant or representative who elects the participant-direction option for service delivery and supports. Financial Management Services are provided by a Fiscal Intermediary Agency (FIA) established as a legally recognized entity in the United States, qualified and registered to do business in the state of Georgia, and approved as a Medicaid provider by the Department of Community Health (DCH.).
Financial Management Services are covered as a distinct waiver service entitled Financial Support Services (FSS) as specified in the COMP Part III, Policies and Procedures Manual, Chapter 2200. FSS are mandatory for Participants who elect to direct their eligible waiver services, and to exercise the Participant-Budget Authority. Costs for FSS are included in and paid from the Participant’s individual budget.
Financial Support Services (FSS) assist the participant or representative who elects Participant Direction by performing customer-friendly, fiscal support functions or accounting services. FSS also assures that funds to provide participant-directed services and supports outlined in the ISP are managed and distributed as authorized.
The Department of Community Health is responsible for monitoring the performance of Financial Support Services (FSS) providers. DCH monitors, reviews and evaluates participants’ expenditure activity to ensure the integrity of the financial transactions performed by FSS providers. DCH utilizes reports from Participants, their Representatives, Support Coordinators, Community Guides, and DBHDD agency staff to identify any issues with the adequacy of
January 1, 2015 Comprehensive Supports Waiver Program XII-13
supports provided by FSS providers to participants exercising the employer and/or budget authority.
Financial Support Services are not available to participants or representatives who choose the Co-Employer model for self-directed services and supports. The Co-Employer provider agency processes payroll, withholding, filing and payment of applicable federal, state and local employment-related taxes and insurance for co-employees. This agency also processes and bills for services approved in the service plan.
B. Responsibilities of FSS Providers:
1. Process payroll, withholding, filing and payment of applicable federal, state and local employment-related taxes and insurance for participants or representatives who elect to be the employer of record of support workers.
2. Conduct skills training and provides technical assistance to participants and/or their representatives on submission of all required employer-related documents.
3. Track and report on income, disbursements and balances of participant funds
4. Process and pay invoices for goods and services approved in the service plan
5. Provide the participant or representative with twice a month reports of expenditures and the status of the participant-directed budget for Participant/Representative who elects to exercise the Budget Authority.
6. Conduct skills training and provide technical assistance to participants and/or their representatives on budget management, including the process of reviewing the reports of expenditures and budget status.
C. Employment/Vendor Enrollment and Financial Reporting Requirements:
1) A participant or representative acting as a common law employer must complete the employer enrollment process;
January 1, 2015 Comprehensive Supports Waiver Program XII-14
2) All new employees must complete the employment enrollment process prior to receiving any paychecks. There are no exceptions to this policy;
3) All employee timesheets must be completed correctly and timely
4) Any vendors must complete the vendor enrollment process prior to receiving any payment;
5) All invoices for vendor payments must be completed correctly and timely;
6) All timesheets and invoices must be in accordance with the approved Individual Service Plan;
7) DBHDD, DCH and FSS provider are not responsible for delays in payment caused by late submissions, incomplete or illegible forms, or neglect of the participant or his or her representative or employee, or failure to inform the FSS provider of changes in address, etc.;
8) Timesheets and invoices may be returned to the participant or representative due to error. The participant or representative must complete or correct the identified error, and re-submit the timesheet and/or invoice to the FSS provider. The timesheet and/or invoice will be processed and paid in the next pay period following receipt of the corrected timesheet or invoice by the FSS provider;
9) Other reasons an employee may not get paid include: late time sheets, lack of, or incomplete, employer enrollment forms, lack of, or incomplete, employer enrollment forms, and lack of authorized Individual Service Plan;
10) The FSS provider will generate paychecks and invoices at least twice per month and, according to the established payment schedule;
11) The pay rate for employees is established during the development of the Individual Service Plan and may not exceed the authorized rate.
12) Information on unemployment benefits, workers’ compensation coverage, and tax withholding is available from the FSS provider.
Rev. 04/2014
January 1, 2015 Comprehensive Supports Waiver Program XII-15
13) Participant/Representative and their employees should first attempt to resolve payroll problems by directing contacting the FSS provider. If problems persist, the participant or representative may contact the Support Coordinator for assistance;
14) Participants, representatives and their employees should be knowledgeable about Medicaid fraud. Medicaid fraud is committed when an employer or employee is not untruthful regarding services provided to Medicaid Waiver participants in order to obtain improper payment. The Medicaid Fraud and Abuse Unit of Georgia investigates and prosecutes people who commit fraud against the Medicaid Program.
1212.2 Support Coordination (Case Management) Services
Support Coordination (Case Management) Services consist of information and assistance in support of Participant-Direction. These services are performed primarily by Support Coordinators, in addition to Planning List Administrators and Intake and Evaluation staff. Case Management Services are covered as a distinct waiver service entitled Support Coordination Services as specified in the COMP Part III, Policies and Procedures Manual, Chapter 2600.
Responsibilities of Support Coordinators
1. Informing the participant or representative of the benefits, risks and responsibilities of Participant-Direction.
2. Assessing the participant or representative who request Participant- Direction to determine the ability to assume the responsibilities of Participant-Direction, consisting of, where applicable, being the employer of support workers.
3. Informing the participant that a representative may assist him or her with participant direction.
4. Informing the participant or representative about freedom of choice of providers, individual rights, and the grievance process.
5. Assisting the participant or representative with the development of the individual emergency back-up plan.
6. Assisting the participant or representative with the development of risk management agreements.
January 1, 2015 Comprehensive Supports Waiver Program XII-16
7. Arranging Community Guide services to provide direct assistance with Participant-Direction responsibilities, including participant-directed budget development, training to be effective employers of support workers (if applicable), and brokering of available community resources.
8. Providing the participant or representative with the process for changing the Individual Service Plan and the individual budget, as well as and the reassessment and review schedules.
9. Informing the participant or representative of state policies and procedures for Participant-Direction.
10. Assisting the participant or representative with recognizing and reporting critical events and with identifying and managing known and/or potential risk.
11. Linking the participant or representative to the training and technical assistance provided by the Financial Support Services provider.
12. Monitoring participant-directed services, in conjunction with the employer supervision provided by the participant or representative (if applicable), in order to ensure quality of care and to protect the health and safety of the participant.
1212.3 Community Guide Services
Community Guide Services provide information and assistance in support of participant-direction and are provided through the distinct waiver service called Community Guide Services as specified in the COMP Part III, Policies and Procedures Manual, Chapter 1800.
Community Guide Services are individualized services designed to assist participants in meeting their responsibilities in the participant-direction option for service delivery. Information provided by the Community Guide helps the participant’s understanding of provider qualifications, record keeping, and other participant-direction responsibilities. The intended outcome of these services is to improve the participant’s knowledge and skills for Participant-Direction.
Responsibilities of Community Guides
Based on the assessed need of the participant and as specified in the approved ISP, Community Guides provide the following information and assistance services:
January 1, 2015 Comprehensive Supports Waiver Program XII-17
1. Assist these participants with defining and directing their own services and supports as well as meeting the responsibilities of Participant- Direction.
2. Provide information, direct assistance, and training to participants in support of Participant-Direction.
3. Assist and train participants to build the skills required for Participant Direction, to include, but not limited to:
1. Direct assistance to participants in exploring and brokering available community resources.
2. Direct assistance to participants in meeting their participant-direction responsibilities.
3. Information and assistance that helps the participant in problem solving and decision-making.
4. Information and assistance that helps the participant in developing supportive community relationships and other resources that promotes implementation of the Individual Service Plan.
5. Assistance with developing and managing the individual budget.
6. Assistance with recruiting, hiring, training, managing, evaluating, and changing employees.
7. Assistance with scheduling and outlining the duties of employees.
8. Training the participant to be an effective employer of support workers.
9. Information and assistance in understanding provider qualifications, record keeping and other participant-direction requirements.
1212.4 Health Maintenance Activities
Under certain conditions as specified below, a proxy caregiver, without the requirement for licensure as a registered professional nurse, can perform health maintenance activities for a participant who is self-directing waiver services. Health maintenance activities are those activities that allow a participant to function and maintain his or her health status and are activities or skills that can be taught to a proxy caregiver to maintain the individual in a community setting. Participants who are self-directing their services may hire individuals to perform health maintenance activities under the conditions specified below.
January 1, 2015 Comprehensive Supports Waiver Program XII-18
Note: This section is not applicable to Participant-Direction through a co-employer agency.
Health Maintenance Activities Definition: Health maintenance activities, which are limited to those activities that, but for a disability, a person could reasonably be expected to do for himself or herself. Such activities are typically taught by a registered professional nurse, but may be taught by an attending physician, advanced practice registered nurse, physician assistant, or directly to a person and are part of ongoing care. Health maintenance activities are those activities that do not include complex care such as administration of intravenous medications, central line maintenance (i.e., daily management of a central line, which is intravenous tubing inserted for continuous access to a central vein for administrating fluids and medicine and for obtaining diagnostic information)., and complex wound care; do not require complex observations or critical decisions; can be safely performed and have reasonably precise, unchanging directions; and have outcomes or results that are reasonably predictable. Any activity that requires nursing judgment is not a health maintenance activity. Health maintenance activities are specified for an individual participant in written orders of the attending physician, advanced practice registered nurse, or physician assistant.
a. Written Plan of Care Requirements: Health maintenance activities are as defined in the written plan of care that implements the written orders of the attending physician, advanced practice registered nurse, or physician assistant and specifies the frequency of training and evaluation requirements for the individual employee, including additional training when changes in the written plan of care necessitate added duties for which such proxy caregiver had not previously been trained. The written plan of care is established by a registered professional nurse, or by an attending physician, advanced practice registered nurse, or physician assistant. This written plan of care for health maintenance activities must be maintained by the participant or representative and available for the proxy caregiver.
b. Written Informed Consent: A participant or individual legally authorized to act on behalf of the participant must complete a written informed consent designating a proxy caregiver and delegating responsibility to such proxy caregiver to receive training and to provide health maintenance activities to the participant pursuant to the written orders of an attending physician, or an advanced practice registered nurse or physician assistant working under a nurse protocol agreement or job description.
c. Individual Employee Requirements: Individuals hired by a participant or representative self-directing waiver services to provide health maintenance activities in accordance with the above conditions must meet the following:
January 1, 2015 Comprehensive Supports Waiver Program XII-19
a. Be selected by the participant or a person legally authorized to act on behalf of the participant to serve as the participant’s proxy caregiver.
b. Receive training by a registered nurse, attending physician, advanced practice registered nurse, or physician assistant that teaches the individual provider the necessary knowledge and skills to perform the health maintenance activities documented in the participant’s written plan of care as defined above. The training must include the knowledge and skills to perform any identified specialized procedures for the participant.
c. Demonstrate to the trainer (i.e., registered nurse, attending physician, advanced practice registered nurse, or physician assistant) the necessary knowledge and skills to perform the health maintenance activities documented in the participant’s written plan of care as defined above. The training must include the knowledge and skills to perform any identified specialized procedures for the participant.
d. Meet employee eligibility requirements specified in Section 1213.
E. Non-Covered Health Maintenance Activities: Health maintenance activities that meet any of the following are non-covered:
a. Complex care such as administration of intravenous medications, central line maintenance, and complex wound care.
b. Provided by an individual employee without written informed consent designating that individual as a proxy caregiver and delegating responsibility to such proxy caregiver to receive training.
c. Provided without the written orders of an attending physician, or an advanced practice registered nurse or physician assistant working under a nurse protocol agreement of job description, respectively, pursuant to Georgia Code Section 43-34-25 or 43-34-23.
d. Provided without a written plan of care as defined above.
e. Provided by individual employees who do not meet the requirements specified above.
1213. Employee Eligibility
Participants/Representatives who opt to participant-direct Community Access, Community Guide, Community Living Support, Supported Employment, or Transportation Services are the common law employer or co-employer of employees who provide these services. These employees must meet the
January 1, 2015 Comprehensive Supports Waiver Program XII-20
following, in addition to the specific provider requirements, specified for these services in the Part III, Policies and Procedures Manual for the COMP Program:
A. Are at least 18 years of age or older.
B. Are U.S citizens or legally authorized to work in the United States.
C. Have a valid Social Security Number.
D. Are legally eligible for employment under state and federal laws; and must have demonstrated the experience, training, education or skills necessary to meet the participant’s needs, consistent with the requirements for the specific services.
E. Are prohibited from working overtime and shall not work in excess of 40 hours per week.
F. Agree to a criminal records check, prior to employment, to ensure that the employee has no history of a felony conviction.
G. Are willing to attend training (e.g., safety training) at the participant’s or representative’s request.
H. Sign affidavits regarding: incident reporting, abuse/neglect/exploitation; confidentiality; person-centered planning; and respect and rights.
I. Understand and agree to comply with the Participant-Direction Option requirements, including confidentiality requirements.
1214. Hiring Family/Relatives to Provide Participant-Directed Waiver Services
Payment directly or indirectly for waiver services provided to participants in the COMP Participant-Direction Option by legally responsible relatives, such as spouses, parents to minor children, or court-appointed legal guardians, is prohibited.
Other family members or relatives of the participant may be compensated for providing participant-directed COMP services if there are documented extenuating circumstances. Under these circumstances, family members may be considered to provide the following participant-directed COMP services: Community Access, Community Living Support, Supported Employment, or Transportation Services. A family member or relative who is serving as the participant’s representative may not be approved to provide COMP services for the participant.
In situations with extenuating circumstances, prior approval is obtained through
January 1, 2015 Comprehensive Supports Waiver Program XII-21
the Department of Behavioral Health and Developmental Disabilities, according to the protocol outlined below. Extenuating circumstances include:
A. A lack of qualified providers in remote areas;
B. The presence of extraordinary and specialized skills or knowledge by approvable family/relatives in the provision of services and supports in the approved Individual Service Plan (ISP); and/or
C. A clear demonstration of the use and compensation of family/relatives being the most cost effective and efficient means to provide the services.
1214.1 Steps for Approval of Extenuating Circumstances
A. The individual or representative must work with the Support
Coordinator on any letter requesting extenuating circumstances.
B. Requests for consideration of extenuating circumstances are to be made in writing and submitted to the designated regional Intake and Evaluation Team member.
C. The designated regional Intake and Evaluation Team member reviews the request and notifies in writing the individual or representative of the decision. The Support Coordinator is copied on this decision.
1214.2 Appeals of Denials of Requests
The individual or representative must work with the Support Coordinator on any letter requesting an appeal for denial of a request to hire family/relative. The written request for an appeal is sent to the regional Intake and Evaluation Manager. If the request is denied by the Intake and Evaluation Manager, a written appeal of this denial may be sent to the Regional Coordinator or designee. If the Regional Coordinator or designee denies the request, the final level of appeal may be made in writing to the Division of Developmental Disabilities in the Georgia Department of Behavioral Health and Developmental Disabilities. The responsible party will receive written notification at each level of appeal, including the Division of DD final decision, if applicable.
1215. Special Requirements and Conditions of Participation of Employees
A. A participant’s spouse or parent, if the participant is a minor, may not be paid
January 1, 2015 Comprehensive Supports Waiver Program XII-22
for COMP Participant-Directed services.
B. The utilization of other family members/relatives of the Participant as providers of COMP Participant-Directed services must be approved by the Department of Behavioral Health and Developmental Disabilities and documented in the ISP.
C. A participant’s legal guardian (appointed by a probate court) may not be paid to provide services under the Participant-Directed Option.
D. An individual who is employed to provide COMP Participant-Directed services for the participant and paid by the FSS provider may not also serve as the participant’s representative.
E. Individuals employed by the Participant/Representative to provide COMP Participant-Directed services are prohibited from working overtime and shall not work in excess of 40 hours per week.
F. Employees are not paid to provide services while the individual is admitted to a hospital or nursing facility, except where approved with the provision of a personal assistance retainer for Community Living Services (see COMP Part III, Policies and Procedures, Chapter 1900 for personal assistance retainer details).
G. Persons with a history of abuse, neglect, or exploitation may not be paid to provide any services under the Participant-Direction Option.
H. Persons with a history of felony conviction as evidenced in the criminal records check may not be hired as an employee.
I. Individuals convicted of child, client, or patient abuse, neglect or mistreatment, regardless of date, may not be hired as an employee.
J. Employees are not paid for vacation time or any other services not rendered according to COMP policies and procedures.
1216. Participant-Directed Services Documentation and other Requirements
Key documentation required for Participant-Directed Services consist of:
1) Employee timesheets.
2) Vendor payments.
3) Written summaries of the participant’s progress on ISP goals.
January 1, 2015 Comprehensive Supports Waiver Program XII-23
1216.1 Participant-Direction through a FSS Provider
The participant/representative who opts for participant-direction through a FSS Provider must:
1. Maintain copies of timesheets and vendor payments for documentation of date and time of service delivery.
2. Maintain copies of CLS Personal Assistance Retainer Timesheet for any claims of this retainer for Community Living Support Services.
Note: see Part III, COMP Policies and Procedures, Chapter 1900 and Appendix C for additional information on the personal assistance retainer.
3. Require employees and professional vendors to provide a written summary of the participant’s progress on the ISP goals for the applicable service ninety (90) days prior to the formal ISP meeting.
1216.2 Participant-Direction through a Co-Employer Agency
The Co-Employer agency of any participant/representative who opts for participant-direction through a Co-Employer Agency must:
1) Maintain copies of timesheets and vendor payments for documentation of date and time of service delivery.
2) Document the following in the record of each participant for whom a personal assistance retainer is a component of Community Living Support Services;
1. Beginning and end date of absence.
2. Reason for absence.
3. Scheduled days and units per day for Community Living Support Services as specified in the ISP.
Note: see Part III, COMP Policies and Procedures, Chapter 1900 and Appendix C for additional information on the personal assistance retainer.
January 1, 2015 Comprehensive Supports Waiver Program XII-24
3) Require employees and professional vendors to provide a written summary of the participant’s progress on the ISP goals for the applicable service ninety (90) days prior to the formal ISP meeting.
4) Meet all documentation requirements for any co-employer service that requires a license in accordance with the specified documentation requirements of the license.
1217. Maintenance of Records
A. Co-Employer Agency Requirements
Co-employer agency providers must maintain written documentation of all level of care evaluations and reevaluations in the individual’s case record for a period of six (6) years. Copies of these evaluations must be made available to the State upon request.
B. Requirements for Participant-Direction through a FSS Provider
Level of care evaluations and reevaluations for participants/representatives who opt for participant-direction through a FSS provider are maintained in the Case Management Information System (CIS) for a period of six (6) years. Copies of these evaluations must be made available to the Department upon request.
1218. Exclusions and Special Conditions
A. An individual serving as a representative for a waiver participant in self- directed services is not eligible to be a participant-directed provider of eligible services.
B. Payment directly or indirectly for COMP services provided to recipients in the Participant-direction Option by legally responsible relatives such as spouses, parents to minor children, or court-appointed legal guardians is prohibited in this waiver. Other family members or relatives of the participant may be compensated for some COMP services as indicated in Section 1214 of this manual.
C. Services provided by relatives or friends, except as noted above, may be covered only if:
o The family member or friend must meet the provider qualifications and training standards specified in the waiver for that service (see COMP Part III, Policies and Procedures for these requirements);
January 1, 2015 Comprehensive Supports Waiver Program XII-25
o The family member or friend must meet the training qualifications prior to rendering services to a COMP participant;
o An agreement must be in place between the participant and employee before services are rendered;
o The participant must pay the employee at a rate that does not exceed that which would otherwise be paid to a provider of a similar service;
o The service must not be an activity that the family would ordinarily perform or is responsible to perform;
o An individual employee may not provide more than 40 hours of paid COMP services in a seven-day period.
o The employee must maintain and submit timesheets and other required documentation for hours paid.
D. Provider agencies enrolled to provide NOW/COMP services cannot be vendors for self-directed services
1219. Termination of Participant-Direction
A. A participant or representative may voluntarily decide to terminate Participant-Direction and return to provider-managed services.
B. Involuntary termination of Participant-Direction occurs due to the failure of the participant or representative to meet the responsibilities of Participant Direction or because of identified health and safety issues for the participant.
C. The Support Coordinator is responsible for a timely revision of the ISP, ensuring continuity in services by linking the participant to alternate waiver providers, and assuring the participant’s health and welfare during the transition period.
D. A period of twelve (12) months must elapse prior to consideration for re-enrollment in the participant-directed option

Comments are closed.