CHAPTER 2000 Community Residential Alternative (CRA) Services

CHAPTER 2000
SPECIFIC PROGRAM REQUIREMENTS
FOR
COMMUNITY RESIDENTIAL ALTERNATIVE (CRA) SERVICES
SCOPE OF SERVICES
2001 General
Community Residential Alternative (CRA) services are targeted for participants who require intense levels of support. These services are a range of interventions with a particular focus on training and support in one or more of the following areas: eating and drinking, toileting, personal grooming and health care, dressing, communication, interpersonal relationships, mobility, home management, and use of leisure time. CRA Services are individually planned and tailored to meet the specific needs of the participant and to accommodate fluctuations in his or her needs for various services.
CRA services include assistance with and/or training in activities of daily living, such as bathing, dressing, grooming, other personal hygiene, feeding, toileting, transferring, and other similar tasks. These services also include training and/or assistance in household care, such as meal preparation, clothes laundering, bed-making, housecleaning, simple home repair, yard care, and other similar tasks. CRA services consist of medically related services, such as basic first aid, arranging and transporting participants to medical appointments, assisting with therapeutic exercises, and assisting with or supervising self-administration of medication. These services also consist of implementing behavioral support plans designed for participants to reduce inappropriate and/or maladaptive behaviors and to acquire alternative adaptive skills and behaviors. CRA Services include transportation to all other waiver services specified in the Individual Service Plan and as needed to facilitate the individual’s participation in personal shopping, recreation and other community activities.
Participants receive CRA services in small group settings of four or less,
in host home/life sharing situations for adults 19 years and above, or
foster home for participants under the age of 19 years through an
approved foster home operating under a licensed Child Placing Agency.
CRA Services may not be provided to persons living in their own or
family homes. CRA Services Providers offer any of the standard services
listed in section 2006 – Covered Services that are needed by the
participants served and specified in the participants’ Individual Service
Plans.
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2002 Special Requirements of Participation
The Department of Community Health limits enrollment to agencies and not individual homes. In addition to those conditions of participation in the Medical Assistance Program as outlined in Part I, Policies and Procedures for Medicaid/PeachCare for Kids Manual applicable to all Medicaid providers, Section 106 (General Conditions of Participation), and PART II, Chapter 600 Policies and Procedures for the COMP Program, Community Residential Alternative Services providers must meet the following requirements:
1. Staffing Qualifications and Responsibilities
Provider agencies rendering Community Residential Alternative Services must have staffing that meets the following requirements in addition to any applicable licensure requirements:
a. A designated agency director who must:
 Have either a bachelor’s degree in a human service field (such as social work, psychology, education, nursing, or closely related field) and five years of experience in service delivery to persons with developmental disabilities, with at least two of the years serving in a supervisory capacity; or
 Have an associate degree in nursing, education or a related field and six years of experience in service delivery to persons with developmental disabilities, with at least two of these years serving in a supervisory capacity; or
b. Duties of the Agency Director include, but are not limited to:
 Oversees the day-to-day operation of the agency;
 Manages the use of agency funds;
 Ensures the development and updating of required policies of the agency;
 Manages the employment of staff and professional contracts for the agency;
 Designates another agency staff member to oversee the agency, in his or her absence.
c. At least one agency employee or professional under contract
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with the agency must:
 Be a Developmental Disability Professional (DDP) (for definition, see Part II Policies and Procedures for COMP, Appendix I);
 Have responsibility for overseeing the delivery of Community Residential Alternative Services to participants.
d. The same individual may serve as both the agency director and the Developmental Disability Professional;
e. Duties of the DDP include, but are not limited to:
 Overseeing the services and supports provided to participants;
 Supervising the formulation of the participant’s plan for delivery of Community Residential Alternative Services;
 Conducting functional assessments; and
 Supervising high intensity services.
f. Direct Care Staff must:
 Be 18 years or older;
 Has high school diploma/equivalent (General Educational Development or GED)
 Meet transportation requirements in COMP Part II Chapter, Section 905 if transporting participants.
 Be provided with a basic orientation prior to direct contact with participants and show competence in:
1) The purpose and scope of Community Residential Alternative Services, including related policies and procedures;
2) Confidentiality of individual information, both written and spoken;
3) Rights and responsibilities of individuals;
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4) Requirements for recognizing and reporting suspected abuse, neglect, or exploitation of any individual:
i. To the DBHDD;
ii. Within the organization;
iii. To appropriate regulatory or licensing agencies; and
iv. To law enforcement agencies
g. Duties of the Direct Care Staff include, but are not limited to:
 Provides participant-specific assistance and training in activities of daily living, such as bathing, dressing, grooming, other personal hygiene, feeding, toileting, transferring, and other similar tasks;
 Accompanying participants and facilitating their participation in visits for medical care, therapies, personal shopping, recreation and other community activities;
 Training or assistance in household care, such as meal preparation, clothes laundering, bed-making, housecleaning, shopping, simple home repair, yard care, and other similar tasks;
 Assisting with therapeutic exercises, supervising self-administration of medication and performing other medically related services;
 Implements the behavioral support plans of participants to reduce inappropriate and/or maladaptive behaviors and to acquire alternative adaptive skills and behaviors.
h. The agency has adequate direct care staff with First Aid and CPR certifications to assure having at least one staff person with these certifications on duty during the provision of Community Residential Alternative Services.
i. CRA nursing staff must:
 Hold current Georgia professional license as a Licensed Practical Nurse if providing CRA LPN services and
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provide services under the supervision of a registered nurse, licensed to practice in the State of Georgia.
 Hold current Georgia professional license as a Registered Nurse if providing CRA RN services.
j. Duties of CRA nursing staff include CRA nursing services as defined in Section 2006.
k. CRA nursing services rendered by a CRA enrolled provider agency are provided by individual nurses employed by OR under professional contract with the CRA enrolled provider agency OR by subcontract with another provider agency. When CRA nursing services are provided by subcontract with another provider agency, the CRA enrolled provider agency must meet ALL of the following:
(1) Maintenance of a personnel file on each nurse providing CRA nursing services, including any PRN nurses, that includes all information required as if the individual nurse was an employee
(2) Provision of oversight and supervision equal to that for its own employees
(3) Documentation of the nurse’s qualifications, five year employment history or a complete employment history if the person has not been employed five years, and any health testing and examination as required for other employees (including TB testing upon employment and annually thereafter)
(4) Provision and documentation of orientation, training prior to direct contact of participants, and annual training as provided for an employee
(5) Written specification detailing nursing services to be provided in subcontracted agreement
(6) Documentation of at least an annual performance evaluation
(7) Personnel file readily available for review
l. The type and number of all other staff associated with the
organization (such as contract staff, consultants) are:
 Properly trained or credentialed in the professional field as required;
 Present in numbers to provide services and supports to participants as required;
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 Experienced and competent in the services and support they provide.
m. National criminal records check (NCIC) documentation for all employees and any volunteers who have direct care, treatment, or custodial responsibilities for participants served by the
agency.
2. Agency Policies and Procedures: Each provider agency must develop written policies and procedures to govern the operations of Community Residential Alternative Services, which follow the Standards for the Georgia Department of Behavioral Health and Developmental Disabilities refer to Part II Policies and Procedures for COMP.
3. Documentation Requirement: Providers must document the following in the record of each participant receiving Community Residential Alternative Services:
a. Specific activity, training, or assistance provided;
b. Date and the beginning and ending time when the service was provided;
c. Location where the service was delivered;
d. Verification of service delivery, including first and last name and title (if applicable) of the person providing the service and his or her signature;
e. Progress towards moving the participant towards independence by meeting the participant ISP, which includes person-centered goals, desired outcomes in the participant’s action plan, and the amount/type of assistance/support in the Current Service Summary and the Health and Safety sections of the ISP.
4. DBHDD Contract/LOA and DBHDD Community Service Standards: Agency providers must adhere to DBHDD Contract/LOA, DBHDD Community Service Standards and all other applicable DBHDD Standards, including accreditation by a national organization (CARF, JCAHO, The Council, Council on Accreditation) or certification by DBHDD (see Part II Policies and Procedures for COMP, Chapter 603).
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5. Community Residential Alternative Facility Capacity Limit:
a. Community Residential Alternative Services can only occur in a facility that serves no more than four (4) individuals at a time.
b. Exceptions to the facility capacity may be granted through the DBHDD Division of Developmental Disabilities (see Part II Policies and Procedures for COMP, Chapter 607). No exceptions to the facility capacity are granted for any site that began CRA service delivery October 2010 or later.
6. Host Home/Life Sharing Arrangement Requirements:
a. Providers (i.e., the individual/family providing the participant the host home/life sharing arrangement) rendering Community Residential Alternative Services to participants 19 years of age or older in host homes/life sharing arrangements must abide by the DDBHDD Operational Standards for Host Home/Life Sharing for adults in host homes/life sharing homes (Operational standards are located on the DBHDD website at www.dbhdd.georgia.gov)
b. Community Residential Alternative Services can only occur in a host home/life sharing arrangement that serves no more than two adult participants.
c. Host home/life sharing for a participant under the age of 19 years can only occur in an approved foster home operating under a licensed Child Placing Agency. These foster homes can only serve a maximum of two (2) individuals under the age of 19 years at a time and can only serve individuals receiving services through the COMP Waiver.
d. Only one provider agency can subcontract with a specific host home/life sharing, Community Residential Alternative Services site.
e. Administrative Costs and Payment to Host Home Provider. The following are requirements for administrative costs of the CRA provider agency and the agency’s payment to the host home individual/family (i.e., the individual/family providing the participant the participant the host home/life sharing arrangement):
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 The CRA provider agency maintains documentation on the actual administrative costs of the provider agency and the agency’s payment to the host home provider.
 The documentation of the CRA provider agency must support that the amount of payment to the host home provider allows for the provision of the CRA services specified in the ISP of the participant and ensures the health and safety of the participant in the host home/life sharing arrangement.
 The host home individual/family of participants with exceptional rates receive a higher payment if the host home provider provides enhanced services due to the exceptional support needs of the participant, with the amount of the higher payment based on any enhanced services based on any enhanced services provided by the host home provider.
f. When the host home individual/family initiates termination and ends its subcontract with the CRA provider agency, the following applies:
 The host home individual/family must relinquish CRA service provision to the CRA provider agency and support movement of the participant(s) to another home.
Host home individual/family may not manage the day to day operations of another residential location.
7. Termination of Contract between the Host Home/life Sharing Site and CRA Provider Agency
1. When a Host Home/Life Sharing provider no longer wants to provide services to the individual and/or wants to end its subcontract with the DBHDD provider agency, they must give at least thirty (30) days written notice to:
a. The individual(s) served)
b. The DBHDD provider agency under contract
2. When DBHDD Provider Agency initiates termination of a contract with a Host Home/Life Sharing Provider for good cause, the following applies:
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TRANSFERRANCE OF HOST HOME/LIFE SHARING SITES
The DBHDD provider agency and Host Home/Life-Sharing provider cooperate as requested by DBHDD to effectuate the smooth and reasonable transition of the care and services for individuals as directed by DBHDD. This includes, but is not limited to, the transfer of the individual records, personal belongings and funds of all individuals as directed by DBHDD.
DBHDD reserves the right under all Host Home/Life-Sharing agreements to transfer a Host Home/Life-Sharing site to another DBHDD provider agency on the following grounds:
 DBHDD termination of the contract/letter of agreement, or agreement with the DBHDD provider agency.
 DBHDD provider agency termination of the contract/letter of agreement.
The individual or Family/Representative’s termination of the relationship with an identified contracting provider agency (which requires the termination of the site specific Medicaid Provider Number by the contracting provider agency).
In either case above, the Host Home/Life-Sharing provider must be in agreement to contract with another DBHDD provider agency if they want to serve the same individual(s).
Prior approval for the transfer of the transfer of the Host Home/Life-Sharing site to an alternative DBHDD provider agency must be given by the designated DBHDD, Regional Coordinator.
8. Relocation of Participant: A participant must not be relocated without documented prior approval from the DBHDD regional office, a minimum of thirty (30) days prior to the move except in documented and regionally approved emergencies, and with subsequent adjustments to the ISP and Prior authorization (PA) prior to relocation except with confirmed regional approval. The relocation of a participant after a disaster damages or destroys a CRA site must be according to the disaster plan for that CRA site. The disaster plan for that site must be available for review by DBHDD and DCH.
9. Individual Site Enrollment: Each individual Community Residential Alternative site must be individually enrolled.
10. Actions Due to Critical Health and Safety Risks: If a CRA service site is determined by DBHDD to have critical health and
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safety risk, DBHDD will take immediate action to remove the participant(s).
11. Requirements for Employees Residing at Employer’s CRA Site: The provider agency must abide by the Fair Labor Standards Act requirements for sleep time when employees reside at the employer’s CRA site.
12. Requirements to Accompany Participants to Emergency Rooms or Hospitals: CRA provider agency staff must accompany participants who are transported to an emergency room or hospital.
2003 Licensure
Provider agencies that render CRA Services in a regulated setting must hold the applicable license from the Department of Community Health (DCH), Healthcare Facilities Regulation Division (HFR) as follows:
A. For CRA services, rendered in a Community Living Arrangement, the provider agency must have a Community Living Arrangement license for each individual residential site from HFR (State of Georgia Rules and Regulations 290-9-37).
B. For CRA services rendered in foster care settings for participants under the age of 19 years, the provider agency must have a Child Placing Agencies license from HFR in accordance with the therapeutic foster care section (State of Georgia Rules and Regulations 290-9-2).
C. For CRA, nursing services rendered in a home/life sharing arrangement, or an approved foster home operating a licensed Child Placing Agency, the provider agency must have a private Home Care License from HFR (State of Georgia Rules and Regulations 290-4-54.)
2004 Special Eligibility Conditions
A. CRA services are provided to participants who require intense levels of supports.
B. CRA services are not provided to persons living in their own or family homes.
C. The need for CRA services must be reflected in the Intake and Evaluation Team approved Individual Service Plan (ISP).
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D. Participants who receive CRA services in a group setting live in small group settings of four or less.
E. Participants who receive Community Residential Alternative services must receive a minimum of one face-to face contact with their support coordinator per month in the home where the supports are provided. Some participants may require additional contacts; the number of contacts is determined by the ISP team.
2005 Prior Approval
Community Residential Alternative Services must be authorized prior to service delivery by the applicable DBHDD Regional Office at least annually in conjunction with the Individual Service Plan development and with any ISP revisions.
2006 Covered Services
Reimbursable Community Residential Alternative Services include the following based on the assessed need of the participant and as specified in the approved ISP:
A. Assistance with, and/or training in, activities of daily living, such as bathing, dressing, grooming, other personal hygiene, feeding, toileting, transferring and other similar tasks.
B. Accompanying participants and facilitating their participation in visits for medical care, therapies, personal shopping, recreation and other community activities. This category includes staff to serve as interpreters and communicators and transportation costs to provide the service.
C. Training or assistance in household care, such as meal preparation, clothes laundering, bed-making, housecleaning, shopping, simple home repair, yard care and other similar tasks.
D. Assisting with therapeutic exercises, supervising self-administration of medication, basic first aid, arranging and transporting participants to medical appointments, documenting a participant’s food and/or liquid intake or output, reminding participants to take medication, assisting with therapeutic exercises, supervising self-administration of medication and performing other medically related services including health maintenance activities.
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E. Training and support in the areas of social, emotional, physical and special intellectual development. This category includes mobility training and programming to reduce inappropriate or maladaptive behaviors.
F. Transportation is required to and from all waiver services specified in the Individual Service Plan.
G. Implementation of behavioral support plans to reduce inappropriate behavior and to acquire alternative skills and behaviors.
H. CRA RN services defined as only routine nursing services that are integral to meeting the daily needs of the participant in his or her own or family home, such as routine administration of medications by nurse or tending to the needs of a participant who is ill or requires attention to his or her medical needs on an ongoing basis.
I. CRA LPN services defined as only routine nursing services that are integral to meeting the daily needs of the participant in his or her own or family home, such as routine administration of medications by a nurse or tending to the needs of a participant who is ill or requires attention to his or her medical needs on an ongoing basis.
2007 Non-Covered Services
A. Services delivered in the participant’s own or family home or in any residence in which Community Living Support services are provided to a participant including any family owned licensed personal care home, licensed community living arrangement, or host home/life sharing arrangement.
B. Services in a facility/home that does not meet capacity limit requirements.
C. Temporary absences including, but not limited to, absences of the participant from his or her residential facility due to overnight hospitalization or vacations for any of the up to 27 days billed per month, with the exception of a participant in a host home/life sharing arrangement who chooses to go on a host family vacation as the vacation billing for a participant does not exceed thirty (30) days in a calendar year.
D. An extended overnight visit with family or friends that exceeds 12 hours in a 24 hour period.
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E. Medically related services that are not allowable by State law, rules, and regulations.
F. Restrictive behavioral interventions, including chemical or mechanical restraints and seclusion, prohibited by state law or regulations.
G. Payment is not made, directly or indirectly, to members of the individual’s immediate family, except as approved as indicated in Part II Policies and Procedures for COMP, Chapter 900.
H. Participants receiving CRA services cannot receive Behavioral Supports Consultation Services, Adult Physical Therapy Services, Adult Occupational Therapy Services, Adult Speech and Language Therapy Services, Environmental Accessibility Adaptation Services, Vehicle Adaptation Services, and Transportation Services.
I. Exceptions to the authorization of a combination of Community Residential Services and Community Living Support Services may be granted through the DBHDD Division of Developmental Disabilities (see Part II COMP Policies and Procedures, Chapter 600, Section 607). Participants receiving Community Residential Alternative services cannot receive Community Living Support Services. Exceptions to the authorization of a combination of Community Residential Alternative Services and Community Living Services may be granted through DBHDD Division of Developmental Disabilities (see Part II COMP Policies and Procedures, Chapter 600, Section 607. Such exceptions will only be considered for participants who are in the process of transitioning from Community Living Support Services to Community Residential Alternative Services due to the participant’s transition to adulthood, the aging of the participant’s caregivers, and/or to allow the participant to remain in his or her family home for as long as possible. These exceptions are granted on an individual participant basis and justification. The provision of Community Living Support Services and Community Residential Alternative Services on the same day is never allowed. (A copy of this waiver of standards must be maintained in the participant’s record).
J. CRA nursing services that are not provided in accordance with State law, rules, and regulations.
K. Non-covered health maintenance activities as defined in
the Rules and Regulations for Proxy Caregivers Used in Licensed Heathcare Facilities, Chapter 111-8-100.
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L. Payment is not made for those goods and services covered by the State Medicaid Plan except where a participant’s need exceeds State Plan coverage limits and exceptions to the coverage limits are not available.
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2008 Basis for Reimbursement
Reimbursement rates for CRA services, including nursing services, are found in Appendix A. Note: Reimbursement for all CRA services, including nursing, cannot exceed the annual maximum for this service or any annual amount associated with an exceptional rate.
Transportation is included in the rate for CRA services.
A. The unit of service is daily for CRA services and 15-minutes for CRA nursing services.
B. The monthly maximum number of CRA daily units is 27. Reimbursement rates for CLA daily services are calculated based on 27 days of service to be equal to a full month of service. Agencies that render services for 27 days or more during any month only bill for 27 days. Agencies that render services for less than 27 days during any month bill only for those days those services were actually rendered.
C. The annual maximum number of CRA daily units is 324 daily per year.
D. CRA nursing services may be billed daily in fifteen minute increments for up to 365 days as authorized for the participant within the annual maximum for all CRA services or any annual amount associated with an exceptional rate as indicated in Appendix A.
2009 Participant-Direction Options
A. Community Residential Alternative Services are not eligible for the self-direction option.
B. For details on participant-direction, see Part II Policies and Procedures for COMP, Chapter 1200.
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