CHAPTER 2900 Support Coordination Services

CHAPTER 2900
SPECIFIC PROGRAM REQUIREMENTS
FOR
SUPPORT COORDINATION SERVICES
SCOPE OF SERVICES
2901 General
Support Coordination services are a set of interrelated activities for identifying, coordinating, and reviewing the delivery of appropriate services for participants. Support Coordination services include the following:
1. Assessment and Periodic Reassessment
2. Development and Periodic Revision of the Individual Service Plan
3. Referral and Related Activities
4. Monitoring and Follow-up Activities
See Section 2905 for additional information on covered services.
Support Coordination services assist participants in coordinating all services, whether Medicaid reimbursed services or services provided by other funding sources. These services include completing the Individual Service Plan (ISP) document and any revisions, and monitoring the implementation of the ISP and the health and welfare of participants. The frequency of Support Coordination services is based on the individual needs of the participant and as required to address any identified health and safety risks or service provider issues.
Support Coordination services are provided by agencies that employ a sufficient number of Support Coordinators to meet the Support Coordination services needs of participants served by the agency. Support Coordinators assure the completion of the written ISP document and any revisions. Support Coordinators are also responsible for monitoring the implementation of the ISP, the health and welfare of participants, and the quality and outcome of services. Monitoring includes direct observation, review of documents, and follow up to ensure that services plans have the intended effect and that approaches to address challenging behaviors, medical and health
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needs, and skill acquisition are coordinated in their approach and anticipated outcome. Support Coordinators are also responsible for the ongoing evaluation of the satisfaction of participants and their families with the ISP and its implementation. Support Coordinators assist participants and their families or representatives in making informed decisions about the participant-direction option and assist those who opt for participant-direction with enrollment in this option.
2902 Special Requirements of Participation
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, Support Coordination Services agency providers must meet the following requirements:
1. Agency Experience
Provider agencies rendering Support Coordination services must:
a. Have at minimum two (2) years experience in providing home and community based case management services for individuals with disabilities or the aging populations, and demonstrate success in supporting individuals in community inclusion and person centered planning;
b. Have established or will establish working relationships with local advocacy groups, experience advocating for individuals in the community, and preparing individuals for self advocacy;
c. Have experience and demonstrated success with outcome based planning, and developing plans based on the individual’s goals, choices and direction;
d. Have experience with measuring quality of services and satisfaction with services, ensuring that the services that are provided are consistent with quality measures and expectations of the individual;
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2. Staffing Qualifications and Responsibilities
Provider agencies rendering Support Coordination Services must have staffing the meets the following requirements:
a. One individual may perform one or more of the following functions for the agency.
b. 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) or business management and two years of experience in service delivery to persons with developmental disabilities, with at least one year in a supervisory capacity.
c. 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 for the agency; and
 Designates another agency staff member to oversee the agency, in his or her absence.
d. At least one agency employee with the agency must:
o Be a Developmental Disability Professional (DDP) (for definition, see Part II Policies and Procedures for COMP, Appendix I);
o Have responsibility for overseeing the delivery of Support Coordination Services to participants.
e. Duties of the DDP include, but are not limited to:
 Overseeing the Support Coordination services provided to participants;
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 Ensuring the completion of Supports Intensity Scale (SIS) assessments 90 to 120 days before the expiration of participants’ Individual Service Plans;
 Assuring the completion of inter-rater reliability reviews of SIS assessments;
 Reviewing Individual Service Plans for quality;
 Document and report on any identified health and safety issues for participants ; and
 Providing training and support to support coordinators.
f. Have sufficient number of supervisory staff whose duties include, but are not limited to, training, support, and supervision of support coordinators.
g. Have sufficient number of quality assurance staff whose duties include, but are not limited to:
 Reviewing Individual Service Plans for quality;
 Completing SIS inter-rater reliability reviews; and
 Providing oversight of any identified health and safety issues for participants.
h. Support Coordinators must:
1) Be at least 18 years of age;
2) Meet the QMRP education and experiential standards of a minimum of a bachelor’s degree in a human service field;
3) Have at least one year’s experience in serving persons with developmental disabilities;
i. Duties of Support Coordinators include, but are not limited to, the covered services in 2905.
j. The agency has adequate Support Coordinator staffing to provide the covered services in 2905 to all participants served.
k. Have for each DBHDD region served a designated on-call agency employee whose duties include, but are not limited to,
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serving as the primary liaison to the DBHDD Regional Office 24 hours a day, 7 days a week.
l. Must have an Organization Chart that is kept up to date showing lines of authority and responsibility for all staff within the agency and includes position descriptions for all staff.
3. Staff Hiring, Assignment, and Training Requirements
Support Coordination Providers must meet the following staff hiring, assignment, and training requirements:
a. Document the review of each support coordinator’s qualifications by DBHDD Regional Office prior to provision of waiver services.
b. Track changes in assignment of support coordinators. If an assignment changes, the provider must notify the participant and family or representative in writing with name, telephone number and other contact information within 10 days of change.
c. Provide required DBHDD orientation training to all new hires prior to contact with waiver recipients.
d. Document the participation of each support coordinator in a minimum of 20 hours per year of additional DBHDD sponsored or other training in the area of developmental disabilities.
e. Document attendance of all support coordinators, quality staff, and supervisors at DBHDD mandated training.
f. Maintain documentation of required training in staff personnel files and make available for quarterly review by the Department of Behavioral Health and Developmental Disabilities, Division of Developmental Disabilities staff.
4. Assessment and Individual Service Plan Requirements
Support Coordination Providers must meet the following assessment and Individual Service Plan (ISP) requirements:
a. The Supports Intensity Scale (SIS) is completed 90 to 120 days before the expiration of an individual’s ISP for any
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participant 16 years or older that requires a SIS assessment as follows:
(1) The first two years a participant 16 years or older receives waiver services (Note: The Planning List Administrator (PLA) completes the Support Intensity Scales (SIS) assessment 90 to 120 days prior to services starting for anyone 16 years or older new to waiver services. The SIS findings for any participant who has a SIS completed within the 12 months prior to entry into the waiver may be reviewed by the DBHDD Regional Intake and Evaluation staff and PLA 90 to 120 days prior to waiver services starting for an individual, and when the clinical review indicates no change in support needs, the I&E staff and PLA provide written, signed documentation that the clinical review confirmed the findings of the SIS completed within the calendar year reflect the current support needs of the individual.) The SIS findings for any participant from his or her entry into the waiver may be reviewed by the DBHDD Regional Intake and Evaluation staff and Support Coordinator 90 to 120 days prior to beginning of the second year of the waiver, and when the clinical review indicates no change in support needs, the I&E staff and Support Coordinator provide written, signed documentation that the clinical review confirmed the findings of the SIS completed at entry into the waiver reflect the current support needs of the individual;
(2) The year of the 16th and 22nd birthday;
(3) Regression of a participant during the past year determined by assessment findings available 90 days prior to the Individual Service Plan development. Regression includes: having a stroke, diagnosis of Alzheimer’s, a new diagnosis or behavior change that severely impacts functioning or any medical diagnosis that results in regression of functioning or need for specialized medical care or services as indicated by an increase in the HRST to Level 3 or above from prior year, when the last SIS does not reflect the changes in the individual’s health risk.
(4) Any participant 16 years or older with a current or continued exceptional rate request if the HRST does not support approval of the exceptional rate. SIS findings that substantiate an initial request for an exceptional rate in the absence of substantiation through the Health Risk Screening Tool must be reviewed by the Support Coordinator and DBHDD Regional clinical staff within 120 days prior to the
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expiration of an existing exceptional rate in order to validate continued need for an exceptional rate.
b. Re-evaluate annually each participant’s Level of Care (LOC) and re-certify the LOC by signing and dating the complete DMA-7 form no more than 30 calendar days prior to the LOC approval date (see COMP Part II, Chapter 700, Sections 707 and 708 for level of care re-evaluation requirements).
c. Assemble both professionals and non-professionals who provide individualized supports and whose combined expertise and involvement ensures plans address what is important to and for the participant and identifies the supports necessary to address issues of health, behavior, and safety.
d. Hold the Individual Service Plan (ISP) meeting at least 45 days before expiration of the ISP;
e. Document action plans or team discussion on record that address issues of conflict between preferences and issues of health and safety in ISP development.
f. Submit ISP document to DBHDD Regional Office for approval within 14 business days of the ISP meeting.
g. Convene an ISP amendment meeting and coordinate the revision of a participant’s ISP as indicated due to circumstances, including but not limited to, change of provider(s), changes in medical, social or behavioral statuses, family crisis, and reduction in funding.
h. Request additional services for a participant due to the following circumstances, including but not limited to, emergency services are required to address change in individual service or support needs (e.g., caregiver dies), the individual is turning 22 years of age and has a SIS completed, or regression of the individual occurred (e.g., had a stroke, diagnosed with Alzheimer’s Disease, or needs have significantly changed and caregiver needs immediate assistance). Develop requests for additional services based on the changing need(s) of the participant either assessed with the annual development of the Individual Service Plan or during the year due to changing circumstances. Review current allocation and determine if changing the authorized services within the available funding addresses the changing need(s) of the participant prior to submitting a request for additional services. When review indicates the need for additional funding, complete SIS if recent SIS does not reflect current support needs of the individual and submit request for additional services to the DBHDD Regional Office. Prior
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Approval by the DBHDD Regional Office is required through the additional service request process before new funded services can be listed in the participant’s ISP.
5. Documentation Requirement
Support Coordination Providers must document the following in the record of each participant receiving Support Coordination Services:
 Specific activity, assessment, or assistance provided;
 Date and the beginning and ending time when the service was provided effective September 1, 2009;
 Location where the service was delivered;
 Verification of service delivery, including first and last name and title (if applicable) of the person providing the service and his or her signature;
 Type of contact (face-to-face, ancillary). Ancillary contacts are any contact made to or on behalf of the participant and may include the following:
1) Telephone contacts made to the participant;
2) Person-to-person or telephone contact made to another individual/company/social entity on a participant’s behalf to secure needed services/benefit or such contacts otherwise necessary to provide appropriate and sufficient Support Coordination services;
 Completed progress report for ancillary contact;
 Completed monitoring report for face-to-face contact;
 Any findings on ISP goals’ progress or identified health and safety issues for the participant.
6. Contact Requirements
Support Coordination Providers must meet the following contact requirements:
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a. Contact all participants based on individual needs and service mix and as specified in the ISP;
b. Increase the frequency of participant contacts based on identified health and safety risks and/or identified issues with the service provider; including but not limited to the following required increased frequency of contact:
 Person has an exceptional rate for Community Access Group. Visits are made monthly to day program, in addition to other requirements.
 Person lives in a home with identified health and safety issues that resulted in the Regional Office or Certification Team placing the provider under a moratorium on new placements. Site visits are made at least twice monthly to all individuals who receive services in a home with identified health and safety issues until a Technical Assistance is completed by the DBHDD Regional Intake and Evaluation staff. If the issue is with a day support provider, the visits are increased to monthly until a Technical Assistance is completed by the DBHDD Regional Intake and Evaluation staff.
 Person has a critical incident that may have included medical hospitalization for unexplained injuries, abuse, chemical restraint, or neglect. Visits are made at least twice monthly or more frequently until a Technical Assistance is completed by the DBHDD Regional Intake and Evaluation staff. If the DBHDD Regional Intake & Evaluation staff supports that the situation is resolved, Support Coordinator may go back to regularly scheduled visits.
c. Contact participants receiving Community Residential Alternative Services and Community Living Support services at minimum one face-to-face contact per month;
d. Contact all other participants at minimum one face-to-face contact per quarter, with ancillary contact in the intervening months;
e. Contact the participant’s family or representative, if applicable, by phone no less than quarterly;
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f. Contact each participant’s service providers no less than quarterly to discuss current status to include health and safety, ISP implementation, and any other issues;
7. Monitoring Requirements
Support Coordination Providers must meet the following monitoring requirements:
a. Support Coordinators complete the monitoring report for required each face-to-face contact and provide a summary rating of the services provided according to the following scale:
 Summary Rating – 1: No health, safety or service deficiencies;
 Summary Rating – 2: Minor deficiencies that do not cause or have the potential to cause actual harm to the participant and are addressed informally by the service provider;
 Summary Rating – 3: Serious deficiencies that require the service provider to develop a formal corrective action plan with specified timeframes;
 Summary Rating – 4: Critical deficiencies that require immediate corrective action. Participant may need to be moved to another site and/or with another service provider on the day of the review or on the next day if corrections cannot be made immediately;
b. Support Coordinators inform the DBHDD Regional Office of problems identified with service providers or with participant-directed services and progress in addressing these problems;
c. Support Coordinators assist the participant and the DBHDD Regional Office in identifying alternative service providers when necessary;
8. Incident Reporting Requirements: In addition to the incident reporting requirements for all providers specified in Part II Policies and Procedures for COMP, Support Coordination Providers must require Support Coordinators to complete a critical incident report whenever it is questionable that a service provider completed the necessary report.
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9. Fair Hearings Notification Requirements: Support Coordination Providers must require Support Coordinators to provide notification to participants of their rights to request a Fair Hearing whenever there are any denials, suspensions, reductions or terminations of waiver services.
10. Reporting Requirements
Report monthly to the DBHDD Division of DD the following:
1) Number of contacts of participants made by the Support Coordination Agency;
2) Number of participants seen at a greater frequency than once per month;
3) Number of Supports Intensity Scale (SIS) assessments due and number completed;
4) Number of DMA-6s due and number submitted by birthday;
5) Number of Individual Service Plans due and number completed; and
6) Number of monitoring reports with scores of 1, 2, 3, 4; report on follow up of 3s and 4s and critical incidents; number of unannounced look behind visits made during the month.
11. Agency Policies and Procedures – Support Coordination Providers must develop written policies and procedures to govern the operations of Support Coordination services in accordance with all requirements for these services. These policies and procedures must address how the agency assures Support Coordination services meet participant and family preferences.
12. DBHDD Contract/LOA and DBHDD Community Service Standards: Support Coordination Providers must adhere to DBHDD Contract/LOA, all applicable DBHDD Community Service Standards and other DBHDD Standards, including certification by the DBHDD (see Part II Policies and Procedures for COMP, Chapter 603).
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2903 Participant Flexibility
In a number of different situations, some flexibility in Support Coordination is required. Some participants or families may desire to assume more control in coordinating services for themselves or their family member. Participants and their families may consider flexibility in Support Coordination Services if the following criteria are met:
a. The participant or family desires to assume more control over coordination and services;
b. The participant has been receiving waiver or state funded services for a minimum of one year;
c. The participant has a stable life situation, as evidenced by living with a family member at least one year and having no significant health and safety problems noted;
d. The participant lives in his/her family home; and
e. The participant/family has had no involvement in allegations of abuse or neglect.
f. Participants who receive Community Living Support services are not eligible for flexible case management.
When a participant and/or his or her family are interested in this flexibility, they need to notify the DBHDD Regional Office of their interest. If the above criteria are met, an ISP meeting is scheduled with the participant and/or family member to amend the ISP outlining what Support Coordination Services will be provided and what responsibilities will be assumed by the participant or family and at what frequency. The responsibilities may include the following:
1) Monitoring of progress in working towards goals;
2) Monitoring the satisfaction of services;
3) Follow-up on any medical or dental goals;
4) Completion of the “Personal Profile” part of the ISP.
2904 Prior Approval
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Support Coordination 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.
2905 Covered Services
Reimbursable Support Coordination Services include the following based on the assessed need of the participant and as specified in the approved ISP:
1. Assessment and Periodic Reassessment
a) Scheduling Supports Intensity Scale (SIS) assessment for any participant as required by Section 2902 4.a. of this chapter.
b) Conducting SIS assessment for any participant as required by Section 2902 4.a. of this chapter to determine individual service needs.
c) Completes the annual DMA-7 level of care re-evaluation for each participant.
2. Development and Periodic Revision of the Individual Service Plan
i. Updating Personal Profile and holding any pre-meetings with participant, support network, and service providers for development of the annual Individual Service Plan (ISP) to respond to the assessed needs of the participant.
ii. Convening ISP development/amendment meetings and facilitating the development of the written ISP document and any revisions to include the goals and actions to address the specific waiver services and other services needed by the participant.
iii. Coordinating and facilitating ISP development among both professionals and non-professionals who provide individualized supports.
iv. Documenting action plans or ISP team discussion on record addressing issues of conflict between preferences and issues of health and safety.
v. Request additional services for a participant due to the following circumstances, including but not limited to, emergency services are required to address changes in
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individual service or support needs (e.g., caregiver dies), the individual is turning 22 years of age and has a SIS completed, or regression of the individual occurred (e.g., had a stroke, diagnosed with Alzheimer’s Disease, or needs have significantly changed and caregiver needs immediate assistance).
3. Referral and Related Activities
i. Assisting each participant in coordinating all services, whether Medicaid reimbursed services or services provided by other funding sources.
ii. Linking the participant to needed services to address identified needs and to achieve goals specified in the ISP.
iii. Providing information and assistance that help the participant and his or her family or representative in making informed decisions about the participant-direction option.
iv. Assisting each participant who opts for participant-direction with enrollment in this option.
4. Monitoring and Follow-up Activities
5. Contacting participants based on individual needs and service mix as specified in the ISP.
6. Contacting participants as needed to address any identified health and safety risks and/or identified issues with the service provider.
7. Contacting the participant’s family or representative by phone.
8. Making ancillary contacts to another individual/company/ social entity on a participant’s behalf to secure needed services/benefits or such contacts otherwise necessary to provide appropriate and sufficient Support Coordination services.
9. Contacting the participant’s service providers.
10. Monitoring implementation of the ISP and the health and welfare of the participant, which includes direct observation, review of documents, and follow up to ensure that service plans have the intended effect and that approaches to address challenging behaviors, medical and health needs, and skill acquisition are coordinated in their approach and anticipated outcome.
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11. Reviewing the quality and outcome of services.
12. Evaluation of the satisfaction of participants and their families with the ISP and its implementation.
2906 Non-Covered Services
1. Support Coordinators cannot provide other direct waiver services, including Community Guide Services, to any waiver participant.
2. 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.
3. Services provided to individuals during full-month periods of institutionalization may not be billed. Discharge planning during periods of institutionalization must continue in order to safely and effectively transition individuals from institutions back into community settings.
4. Counseling services.
5. The provision of services to enrolled participants in Institution for Mental Diseases (IMD) units.
6. Services that duplicate case management services provided to an eligible participant through a Targeted Case Management Program as prohibited by Medicaid.
7. 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.
2907 Basis for Reimbursement
A. The unit of service is monthly.
B. Flexible Support Coordination is billed at the established rate for Support Coordination Services but only for months in which the flexible Support Coordination Services are provided.
C. Reimbursement Rate: The reimbursement rate for Support Coordination Services is found in Appendix A.
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2908 Participant-Direction Options
A. Support Coordination Services are not eligible for any participant-direction options.
B. For details on participant-direction, see Part II Policies and Procedures for COMP, Chapter 1200.

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