NEW OPTIONS WAIVER PROGRAM (NOW)

PART II
CHAPTERS 600 – 1200
POLICIES
AND
PROCEDURES
FOR
NEW OPTIONS WAIVER PROGRAM (NOW)
FORMERLY MENTAL RETARDATION WAIVER PROGRAM (MRWP) SERVICES
GENERAL MANUAL

COMMUNITY HEALTH SEAL

GEORGIA DEPARTMENT OF COMMUNITY HEALTH

DIVISION OF MEDICAID

Published January 1, 2015

PART II
POLICIES AND PROCEDURES
FOR
NEW OPTIONS WAIVER PROGRAM
(NOW)
GENERAL MANUAL

CONTENTS

CHAPTER 600 SPECIAL CONDITIONS OF PARTICIPATION VI

Section 601 General
Section 602 Organization and Administration
Section 603 Other Provider Information

Section 604 Provider Enrollment
Section 605 Changes in Enrollment Information
Section 606 Staffing Requirements
Section 607 Waiver of Standards

CHAPTER 700 SPECIAL ELIGIBILITY CONDITIONS VII

Section 701 Eligibility Criteria
Section 702 Notification of Participant
Approval/Disapproval
Section 703 Denial of Eligibility
Section 704 Grounds for Appeal
Section 705 Screening for Services
Section 706 Initial Level of Care Determination
Section 707 Level of Care Reevaluation
Section 708 Level of Care Approval Requirements (DMA-6/ DMA-6A/DMA-7)
Rev. 04 2014
Section 709 Reevaluation of Participant
Section 710 Assurances
Section 711 Eligibility Determination for Medical Assistance Only (MAO)
Section 712 Eligibility Determination for TEFRA/Katie Beckett
Section 713 Georgia Pediatric Program (GAPP)

CHAPTER 800 PRIOR APPROVAL VIII

Section 801 General
Section 802 Obtaining Prior Approval

CHAPTER 900 GENERAL SERVICES REQUIREMENTS IX

Section 901 Services Overview
Section 902 Exclusions and Special Conditions
Section 903 Duplication of Services
Section 904 Hospice Services
Rev. 4/2009
Section 905 Transportation Requirements
Rev. 7/2009 Section 906 Day Services Requirements
Section 907 Developmental Disability Professional Requirements
Rev. 10 2011
Section 908 Termination of Participant Services Requirements
Section 909 Proxy Caregivers and Health Maintenance Activities

CHAPTER 1000 BASIS FOR REIMBURSEMENT X

Section 1001 General
Section 1002 Reimbursement Methodology
Rev 07 2013
Section 1003 General Claims Submission Policy for Ordering, Prescribing, or Referring (OPR) Providers
Section 1004 Limitations for Case Management
Rev 04 2014
Section 1005 CMS 1500 Claim Form Overview

CHAPTER 1100 DOCUMENTATION AND RECORDS XI

Section 1101 General
Section 1102 Individualized Service Planning and Implementation
Section 1103 Provider Intake
Section 1104 Individual Service Plan (ISP) Goal
Progress Documentation
Section 1105 Maintenance of Records
Section 1106 Management and Protection of Participant
Funds
Section 1107 Monitoring
Section 1108 Multi-Purpose Information Consumer Profile

CHAPTER 1200 PARTICIPANT-DIRECTION XII

Section 1201 General
Section 1202 Participant Eligibility
Section 1203 Participant-Direction by a Representative
Section 1204 Eligibility Criteria
Section 1205 Special Consideration for Eligibility for
Participant-Direction
Section 1206 Notification of Participant
Approval/Disapproval
Section 1207 Denial of Eligibility
Section 1208 Grounds for Appeal
Section 1209 Requirements for Enrollment in
Participant-Direction
Section 1210 Eligible Waiver Services
Section 1211 Participant-Direction Opportunities
Section 1212 Supports for Participant-Direction
Section 1213 Employee Eligibility
Section 1214 Hiring Family/Relatives to Provide
Participant-Directed Waiver Services
Section 1215 Special Requirements and Conditions of
Participation of Employees
Section 1216 Participant-Directed Services Documentation and Other Requirements
Section 1217 Maintenance of Records
Section 1218 Exclusions and Special Conditions
Section 1219 Termination of Participant-Direction

APPENDIX A Regional Office of DBHDD Contact List

APPENDIX B Application for Developmental Disabilities/Mental
Retardation Services

Rev. 01 2009 Rev.10 2010
APPENDIX C Physician’s Recommendation Concerning Nursing Facility Care or
Intermediate Care for the Mentally Retarded
(DMA-6)

Physician’s Recommendation Concerning Nursing Facility Care or Intermediate Care for Pediatric Care (Pediatric DMA 6(A)

Rev. 04 2013
Level of Care Re-Evaluation Form (DMA-7)

Rev. 10 2010
APPENDIX D I & E Screening Tool for Chronic Medical Conditions

APPENDIX E Freedom of Choice (Statement of Informed Consent)

APPENDIX F MAO Communicator

APPENDIX G Prior Authorization Form

Rev. 10 2012
APPENDIX H Documentation for Exceptional Rate Request

Rev. 10 2010
APPENDIX I Glossary of Terms

APPENDIX J Georgia Health Partnership (GHP)

APPENDIX K Medical Assistance Eligibility Certification

APPENDIX L Medicaid Provider Application Process for DBHDD
Services

Rev 04 2014

APPENDIX M Georgia Families

APPENDIX N Non-Emergency Transportation Broker System

Rev. 10 2010
APPENDIX O Person Centered Planning

Rev. 10 2010
APPENDIX P Letter of Intent to Provide Services Form

Rev. 10 2010
APPENDIX Q MR/DD New Site Inspection Checklist

APPENDIX R Antipsychotic and Mood Stabilizer Medications
Rev. 01 2011

Rev. 07 2011
Rev. 04 2013
APPENDIX S Documentation Progress Note and Summary Example

Rev. 04 2014
APPENDIX T ICD-10 Overview

APPENDIX U Georgia Families 3600 SM,
Rev. 04 2014

PART II – CHAPTER 600

SPECIAL CONDITIONS OF PARTICIPATION

601. General

The State of Georgia believes it is critical that services and supports respect the vision of the individual. Each agency or organization must incorporate this belief into their service delivery to support individuals with intellectual and developmental disabilities in living a meaningful life in the community. Specifically, the provider must ensure:

Rev. 10 2010
. Person-centered service planning and delivery that address what is important to and for individuals

. Capacity and capabilities, including qualified and competent providers and staff

. Participant safeguards

. Satisfactory participant outcomes

. Systems of care that have the infrastructure necessary to provide coordinated services, supports, treatment and care

. Participants rights and responsibilities

. Participant access

601.1 OUTCOMES FOR PERSONS SERVED

Rev. 10 2010
The Standards that follow are applicable to the Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD) or organizations that provide services to individuals that are financially supported in whole or in part by funds authorized through DBHDD, regardless of the age or disability of the individual served and therefore applicable to providers of NOW services.

Participant self-determination includes freedom, authority and responsibility and is considered key to achieving the vision of a satisfying, independent life with dignity and respect for everyone.

Services supports, care or treatment approaches assist the individual in:
1. Living in the most integrated community setting appropriate to their individual requirement, preferences and level of independence:

2. Exercising meaningful choices about their living environments, providers of services received, the types of supports, and the manner by which services are provided; and

3. Obtaining quality services in a manner as consistent as possible with community living preferences and priorities and

4. Inclusion and active community integration are supported and evident in documentation.

Rev 01 2013

Individualized services supports, care and treatment determinations are made on the basis of an assessment of needs with the individual. The purpose of the
assessment is to determine the individual’s hopes, dreams or vision, for their life and to determine how best to assist the individual in reaching those hopes, dreams or vision including determining appropriate staff to deliver these services.
Assessments should include but are not limited to the following:
a) The individual’s:

i) Hopes and dreams, or personal life goals;

ii) Perception of the issue(s) of concern;

iii) Strengths;

iv) Needs;

v) Abilities; and

vi) Preferences.
b) Medical history;

c) A current health history status report or examination in cases where:

i) Medications or other ongoing health interventions are required;

ii) Chronic or confounding health factors are present;

iii) Medication prescribed as a part of DBHDD services has research indicating necessary surveillance of the emergence of diabetes, hypertension, and/or cardiovascular disease;

iv) Allergies or adverse reactions to medications have occurred; or

v) Withdrawal from a substance is an issue
d) Appropriate diagnostic tools such as impairment indices, psychological testing or laboratory testing;

Rev. 10 2010
Rev 01 2013
Rev 01 2013
e) Social history;
f) Family history;
g) School records (for school-aged individuals);
h) Collateral history from family or persons significant to the individual if available.

NOTE: When collateral history is taken, information about the individual may not be shared with the person giving the collateral history unless the individual has given specific written consent; and

i) Review of legal concerns including:
i. Advance Directives;
ii. Legal Competence;
iii. Legal Involvement of the courts; and
iv. Legal status as adjudicated by a court

2. Additional assessments should be performed or obtained by the provider if required to fully inform the services, support, care and treatment provided. These may include but not limited to:

a. Assessment of trauma or abuse;

b. Suicide risk assessment;

c. Functional assessment;

d. Cognitive assessment;

e. Behavioral assessments;

f. Spiritual assessment;

g. Assessment of independent living skills;

h. Cultural assessment;

i. Recreational assessment;

j. Educational assessment;

k. Vocational assessment; and

l. Nutritional assessment.

The policies, procedures and the conditions related to participation in Georgia’s New Options Waiver Program (NOW) to provide home and community-based waiver services for persons with intellectual and developmental disabilities (I/DD) are authorized by an approved waiver from the Centers for Medicare and Medicaid Services (CMS) pursuant to Section 2l76 of Public Law 97-35. The waiver provides for services to eligible individuals with I/DD who resides in or are at risk of an Intermediate Care Facility for Persons with Intellectual disabilities (ICF/ID) placement.

In addition to the policies and procedures in this manual, providers must adhere to the following:

. Those conditions for participation in the Medical Assistance Program, which are, outlined in Part I Policies and Procedures for Medicaid/PeachCare for Kids Manual applicable to all Medicaid providers;

. Any policies and procedures specific to the NOW services rendered by the provider in the Part III NOW Manual; and

. All applicable Standards for Department of Behavioral Health and Developmental Disabilities (DBHDD) in the DBHDD provider manual.

The NOW Program provides the following services to participants:
(1) Adult Occupational Therapy
(2) Adult Physical Therapy
(3) Adult Speech and Language Therapy
(4) Behavioral Supports Consultation
(5) Community Access
(6) Community Guide
(7) Community Living Support
(8) Environmental Accessibility Adaptation
(9) Financial Support Services
(10) Individual Directed Goods and Services
(11) Natural Support Training
(12) Prevocational Services
(13) Respite
(14) Specialized Medical Equipment
(15) Specialized Medical Supplies
(16) Support Coordination
(17) Supported Employment
(18) Transportation
(19) Vehicle Adaptation

See Chapter 900, Section 901 of this manual for a definition of each service.

602. Organization and Administration

Providers enrolled in the New Options Waiver Program (NOW) services may be a local public or private agency or an individual provider that meets the Department of Community Health (DCH) and the Georgia Department of Behavioral Health and Departmental Disabilities (DBHDD) enrollment criteria.

Faith or Denominationally Based Organizations who receive Federal or State Monies address issues specific to being a Faith or Denominationally Based Organization in their Policies and Practice must include the following information and how it is shared with individuals:
. Its religious character;

. The individual’s freedom not to engage in religious activities;

. Their right to receive services from an alternative provider;

. The organization shall, within a reasonable time after the date of such
objection, refer the individual to an alternative provider.
. If the organization provides employment that is associated with religious
criteria, the individual must be informed.
. In no case may federal or state funds be used to support any inherently
religious activities, such as but not limited to:
o Inherently religious activities;

o Religious instruction; or

o Proselytization.

. Organizations may use space in their facilities to provide services,
supports, care and treatment without removing religious art, icons, scriptures or other symbols.
. In all cases, rules found at 42 CFR Parts 54, 54a and 45 CFR Parts 96, 260
and 1050 Charitable Choice Provisions and Regulations: Final Rules shall apply.

603. Other Provider Information

603.1 Core Requirements
Providers serving NOW Program participants must be in compliance with applicable DBHDD Community Service Standards and Policies.

When Program Integrity or other focused audits are conducted by the Department of Community Health, the Department of Behavioral Health and Departmental Disabilities,
Rev 01 2011
Rev 01 2012
Rev 01 2013

and/or other regulatory agencies, and it is determined that there are unmet standards under any of the ‘critical function’ areas, the Department of Community Health authorizes the Department of Behavioral Health and Departmental Disabilities (DBHDD) to recommend adverse action that requires enrolled providers to correct deficiencies. DBHDD may recommend a suspension on new admissions, new services or new sites or termination of the provider.

Noncompliance determinations in critical function areas may be cause for further adverse actions to be implemented, including suspension, recoupment of paid claims, and/or termination from the program. Additionally, failure to submit a Corrective Action Plan (CAP) will result in adverse action recommendations of suspension on new admission, new services, new sites and/or recoupment of paid claims.

Critical function areas include:
. Violation of Individual Rights, Responsibilities and Protections

. Inadequate Behavioral Support Practices

. Violation of Adequate and Competent Staff (including Inadequate Staff to Participant Ratios and Service Provision)

. Inadequate Medications and Healthcare Management

. Violation of Respectful Service Environment (including Environmental Health and Safety)

603.2 Provider Information Documentation Requirements

Unless otherwise specified, materials cited below need not be submitted to the Department of Community Health, Division of Medicaid (DMA). They must be available for review at the agency or individual provider site.

A. Disclosure of Ownership – If the provider organization is a corporation, information on all ownership interests of five percent or more (direct or indirect) must be available for review.

B. Governing Body – The provider agency organization must have a governing body (or designated person(s) so functioning) which assumes full authority and responsibility for the operation of the NOW and for assuring compliance with all conditions of participation. A subdivision or subunit, which is required to meet independently the conditions of participation, must have its own governing body.

C. Bylaws – The provider agency must have written dated bylaws which are periodically reviewed and updated, as appropriate, by its governing body.

D. Reports – The provider shall furnish service reports to the DBHDD in such form and at such times as may be specified, which accurately and fully disclose all NOW activities.

E. Licensure – Licensure and other permits, when applicable, must be available at the agency or by the individual provider and open to view by the public.

F. Records Management – All required records pertaining to the provision of NOW services shall be maintained in accordance with standards specified in this manual, DBHDD Provider Manual, and with accepted professional standards and practices. Such records shall be subjects to inspection and review by the Department and its agents, and must be made available during the provider’s normal business hours (7:30 am – 5:00 pm).

G. Each provider must participate in Georgia Department of Behavioral Health and Developmental Disabilities’ statewide participant data reporting system.

H. Each provider must participate in revenue and expenditure reporting on the Uniform Accounting System (UAS), maintenance of subsidiary expense ledgers, and specialized records for cost accounting purposes.
Rev 01 2013

603.3 Provider Requirements for Accreditation and DBHDD Standards Quality Review.

A. General Information:
Rev 04 2011
Rev 04 2010
Rev 01 2013
1. Providers of NOW services must meet requirements related to Accreditation and Quality Review of Service Standards for Providers of Developmental Disabilities Services outlined in the DBHDD Provider Manual, Policy Section. The manual is accessed as follows: www.dbhdd.georgia.gov.
Rev. 04 2010
Rev. 04 2011
Rev. 01 2013

2. There are some DD services that are not required to be accredited or to complete the Standards Quality Review process. These include:

a. Support Coordination
b. Specialized Services which includes Specialized Medical Equipment, Specialized Medical Supplies, Environmental Accessibility Adaptation when one or more of these specialized services are the only service(s) being delivered by the organization.

B. Standards Quality Review for DD Providers authorized to receive less than $250,000
Rev. 04 2011
Rev. 01 2013

1) Standards Quality Review: The DBHDD Provider Performance Unit conducts reviews regarding compliance with the Community Service Standards. Providers receive from DBHDD a Certificate of Standards Compliance for a period not to exceed two years. DD providers must maintain a current Certificate of Standards Compliance to provide
Rev. 04 2011
Rev. 01 2013
services.

2) Additional Expectations related to Standards Quality Review:
Rev. 01 2013

a. Compliance must be maintained for all DBHDD approved services.
b. Providers must be providing DD community services for a minimum of 12 months and have completed the DBHDD Standards review or be accredited to add new services/sites.
c. If new services are approved, they will be included in the subsequent Standards Quality Review.
d. At any time, DBHDD may request a special Standards Quality Review to assess a Provider’s compliance with the Community Service Standards. .
e. Providers terminated due to failure to comply with the Standards Quality Review may not make application to become a provider for a period of one (1) year.
f. If during the standards quality review or a special standards quality review, critical function areas are identified, then the contracting regional office(s) has the option to relocate the individual(s) immediately.
C. Accreditation for DD Providers Authorized to Receive an Amount Equal to or more than $250,000 annually.
Rev. 04 2010
Rev. 04 2011
Rev. 01 2013

1. General expectations regarding Accreditation:
a) It is the responsibility of the Provider to select an accrediting agency from the list listed in Appendix I and submit an application for accreditation. This must occur within 30 days after the Provider has crossed the threshold and is authorized to receive funding in an amount more than $250,000 per year regardless of expiration date of existing standards compliance certificate.

b) The Provider is responsible for paying accreditation fees and providing to DBHDD Regional Coordinator a copy of the Accrediting body’s letter confirming the date of the survey.

c) The Provider must be accredited within 12 months of application for accreditation.

d) The provider must submit to DBHDD Regional Coordinator results of accrediting body’s visit within seven (7) working days
of receipt.

e) The provider is expected to ensure that the specific services approved by DBHDD are properly accredited.

f) If DBHDD approves the Provider to offer a new service, the Provider must be accredited for the new category of service at the time of their next accreditation survey. If the provider’s next accreditation survey is not due for longer than twelve (12) months from the time that the additional services are initiated by the provider, DBHDD may require the following:
i. that the Provider Performance Unit conducts a Special Standards Quality Review,
OR
ii. that the Provider verifies compliance with their accrediting body’s requirements related to accrediting the new service.
2. Maintenance of Accreditation and Requests for Waiver: If an accredited provider loses accreditation, fail to reapply for accreditation, or comes under a corrective action requirement with the Accrediting body, the provider must notify DBHDD within 7 working days; this notification is done in writing via a letter sent to:
Rev. 01 2013
a. DBHDD Regional Office
b. DBHDD, Provider Network Management, Suite 23-427, 2 Peachtree Street, Atlanta, GA 30303 AND

c. DBHDD Contracts Section, Suite 23-173, 2 Peachtree Street, Atlanta GA 30303

3. Action related to each of the following situations
a. Loss of Accreditation: Loss of accreditation results in termination of the DBHDD relationship with the provider.
b. Failure to reapply will result in actions being taken against the provider. The provider will be given sixty (60) calendar days, during which the agency makes application to the accrediting body and must submit written proof of application payment and a scheduled visit by the accreditation body. Failure to meet this time frame results in termination of the DBHDD relationship with the provider.

604. Provider Enrollment

604.1 To Enroll to Become a Provider
Rev 04 2011
A. To enroll to become a provider agency or individual must complete DBHDD Policy and Procedure on becoming a Provider of Developmental Disabilities Services. The Policy is found in Recruitment and Application to
Become a Provider of Developmental Disabilities Services, 02-701 located at the following website: http://gadbhdd.policystat.com.

B. The Medicaid Provider Enrollment packet is obtained from the following website: www.mmis.georgia.gov or by calling (800) 766-4456 for assistance.

Rev. 04 2009
Rev. 04 2011
Rev. 10 2011
Rev. 01 2013
Both applications are submitted to the address listed in the DBHDD provider application.

C. Questions regarding licensure requirements should be directed to the Department of Community Health, Healthcare Facility Regulation Division (HFR), formerly known as the Office of Regulatory Services, at 1-800-Georgia or the website: www.dch.georgia.gov.
Rev. 04 2011
Rev. 07 2012

1. The Department requires proof of licensure or permit for the following
services:

Adult Occupational Therapy Services
Adult Physical Therapy Services
Adult Speech Language Therapy Services
Community Living Support Services
Respite Services

2. A proof of licensure is required from individual providers as defined for specific services in the Part III NOW Manual at the website: www.mmis.georgia.gov

D. Individual professionals making application to provide any of the following services should follow the information provided in Section 604.1 in submitting an individual provider application:
Rev. 07 2009
Rev. 04 2011

Adult Occupational Therapy Services
Adult Physical Therapy Services
Adult Speech and Language Therapy Services
Behavioral Supports Consultation Services
Community Living Support LPN Services
Rev. 04 2010
Rev. 01 2011
Community Living Support RN Services

Individuals applying to be enrolled Medicaid Provider must have provided the waiver service for a least one year as an individual hired by a participant or representative through self-direction prior to submission of a provider application. The individual provider must provide evidence of satisfactory performance of self-directed waiver service through documentation from the support coordination agency (such as support
Rev.10 2011
coordination monitoring notes) and other sources (such as no evidence of substantiated critical incidents against the individual in the provision of self-directed services or required correction actions related to the provision of self-directed services by the individual). Policies and procedures related to self-direction are in Chapter 1200 of this manual.

Rev. 10 2009
E. Providers must be providing DD community services for a minimum of 12 months and have completed the DBHDD Standards review or be accredited to add new services/sites.

F. Provider agencies that apply or are enrolled to provide Financial
Support Services (FSS) can not apply or be enrolled to provide any other
waiver service. Application for enrollment for FSS are submitted directly
to the Department of Community Health.

G. Provider agencies that apply or are enrolled to provide Support
Coordination Services can not apply or be enrolled to provide any
other waiver service.

Rev. 04 2011
Rev. 01 2013
H. The Georgia Department of Behavioral Health and Developmental Disabilities Regional Office staff conducts preliminary site visits as required.

License(s) (as applicable)

1. Private Home Care License (for agency providing

community living support and in-home respite services)
Or
Home Health Agency License (for home health agency
providing adult therapy services)
Or

Individual Professional Licenses (for individuals and
agencies for nursing, occupational therapy, physical therapy,
speech and language therapy, and other professional services
as required for specific NOW services).

2. Personal Care Home Permit, Community Living Arrangement Permit, Child Caring Institutions for 4 beds and Child Placing Agencies (for the provision of Respite Services only)

I. Current Secretary of State Registration
Rev. 04 2011
Rev. 01 2013

J. Current Business License or Permit

Rev. 04 2011
Rev. 01 2013
604.2 Approval of New Providers

1. HP Enterprise (HPES) reviews and sends an approval letter with a provider number and corresponding approved service name(s) to the provider.

2. DBHDD issues a Letter of Agreement to agencies approved by DCH to provide NOW services.

Rev. 04 2011
Rev. 01 2013
605. 605 Changes in Enrollment Information

Enrolled providers are required to provide written notice to the DCH, DBHDD, Healthcare Facility Regulation (as applicable), and Support Coordination.

A. Notification of Updated Information
1. Should the information submitted during enrollment (e.g. office location, the payee, etc.) change, the provider must report those changes within ten (10) calendar days of the changes in writing to the following:

Provider Enrollment Unit
Office of Provider Network Management
Georgia Department of Behavioral Health and Developmental Disabilities
2 Peachtree Street, Suite 23-247
Atlanta, Georgia 30303

AND

Program Specialist, NOW/COMP Waivers
Department of Community Health
2 Peachtree Street, 37th Floor
Atlanta, GA 30303

2. The Department of Community Health will verify information as needed and provide notification to HP Enterprise for claims system updates. Notice of a change of information is not accomplished by simply including the updated information on claims submitted for payment. These claims will be made to the payee on file. Checks returned to the Division by the Post Office will be voided.

Reported changes should include all of the following applicable items or any other pertinent information:

a. Address of the provider agency, administrative or business office
b. Address of the service location
c. Request to deactivate provider number
d. Request to reactivate suspended provider number
e. Request to terminate provider number
f. Telephone numbers
g. Changes in permit/license issued by Healthcare Facility Regulation
h. Other changes as outlined in Part I, Chapter 100, Section 105.7.

605.1 Process for Provider Enrollment Application for Facilities

Effective September 1, 2014, DCH will only accept online Medicaid enrollment applications for facilities, including additional locations. In extreme hardships cases, DCH may waive this requirement for the New Options Waiver Program providers; this request must be in writing and submitted to the Department of Behavioral Health and Developmental Disabilities (DBHDD) Provider Network Unit. DBHDD will submit the request to DCH Provider Enrollment for consideration. Facility applicants must enroll online by clicking on Provider Enrollment/Enrollment Wizard. The Enrollment Wizard will assist with the completion of an application. Facilities eligible to enroll using an additional Location must first log onto the web portal. A web base training module is located on the website @ www.mmis.georgia.gov. The training module is located under the Provider Information link.
Rev. 10 2014

606. Staffing

Rev. 01 2013
Individuals are provided Services and Supports by Staff who are properly Licensed, Credentialed, Trained, and who are Competent.

606.1 Agency Staffing
A. Organizational policy and practice demonstrates that appropriate professional staff conducts the following services and supports, including but not limited to:
1. Overseeing the services, supports, care and treatment provided to individuals;

2. Supervising the formulation of the individual service plan;

3. Conducting diagnostic, behavioral, functional, and educational assessments;

4. Designing and writing behavior support plans;

5. Implementing assessment, care and treatment activities as defined in professional practice acts; and

6. Supervising high intensity services such as screening or evaluation, assessment, and residential behavior support services.

B. The type and number of professional staff and all other staff attached to the organization are:
1. Properly trained, licensed or credentialed in the professional field as required;

2. Present in numbers to provide adequate supervision to staff

3. Present in numbers to provide services, supports, care and treatment to individuals as required;

4. Experienced and competent services, supports, care and treatment and/or supervision as required;

5. In 24 hour or residential care settings, at least one staff trained in Basic Cardiac Life Support (BCLS) and first aid is on duty at all times on each shift and;

6. DD providers using Proxy Caregivers must receive training that includes knowledge and skills to perform any identified specialized health maintenance activity.

Rev. 10 2010
C. The organization must have procedures and practices for verifying licenses, credentials, experience and competence of staff:

a. There is documentation of implementation of these procedures for all staff attached to the organization; and

b. Licenses and credentials are current as required by the field.

D. When medical and/or psychiatric services involving medication are provided, the organization receives direction for that service from a professional with experience in the field, such as medical director, physician consultant, or psychiatrist.

E. Federal law, state law, professional practice acts and in-field certification requirements are followed regarding:
1. Professional or non-professional qualifications are required to provide the services offered. If it is determined that a service requiring licensure or certification by State Law is being provided by unlicensed staff, it is the responsibility of the organization to comply with DBHDD Policy regarding Licensing and Certification Requirements and the Reporting of Practice Act Violations;

2. Laws governing hours of work such as but not limited to the Fair Labor Standards Act

F. Job descriptions are in place for all personnel that include:
1. Qualifications for the job;

2. Duties and responsibilities;

3. Competencies required;

4. Expectations regarding quality and quantity of work; and
5. Documentation that the individual staff has reviewed understands and is working under a job description specific to the work performed within the organization.

G. a) There is evidence that a national criminal records check (NCIC) is completed for all employees, to include contractors/subcontractors and their employees, and volunteers who work directly with the individuals, who provide services, supports, care and treatment to persons served within the organization. The applicant should submit fingerprints prior to employment or if circumstances justify delay within 10 business days of employee’s start date. See DBHDD Criminal History Records Checks for Contractors Policy 04-104 https://gadbhdd.policystat.com/policy/201763/latest/.
b) There is mandatory disqualification from providing services for DBHDD for a minimum of five (5) years from the date of conviction, a plea of nolo contendere, or release from incarceration or probation, whichever is later. Refer to DBHDD Policy 04-104, Criminal History Records Checks for Contractors for a list of crimes that restricts employment as a DBHDD contractor or contractor’s employee.

H. The organization has policies, procedures and documentation practices detailing all human resources practices, including but not limited to:
a. Process for determining staff qualifications including:
i. License or certification status;

ii. Training;

iii. Experience; and

iv. Competence.

b. Processes for managing personnel information and records which should include but not be limited to:

i. Criminal records checks (including process for reporting CRC status change);

ii. Drivers license checks; and

iii. Annual TB testing (for all staff providing direct support).

c. Provisions for and documentation of:

i. Timely orientation of personnel;

ii. Periodic assessment and development of training needs;

a) Development of activities responding to those needs; and

iii. Annual work performance evaluations.

d. Provisions for sanctioning and removal of staff when:

1.Staff are determined to have deficits in required competencies;

2.Staff is accused of abuse, neglect or exploitation.

e. Administration of personnel policies without discrimination.

I. All staff, direct support volunteers, and direct support consultants shall be trained and show evidence of competence in the following:
a. Orientation requirements are specified for all staff and are provided prior to direct contact with individuals and are as follows:
i. The purpose, scope of services, supports, care and treatment offered including related policies and procedures;

ii. HIPAA and Confidentiality of individual information, both written and spoken;

iii. Rights and responsibilities of individuals;

iv. Requirements for recognizing and mandatory reporting suspected abuse, neglect or exploitation of any individual:
a) To the DBHDD;
b) Within the organization;
c) To appropriate licensing agencies (Healthcare Facility Regulation) and for in home services (Adult Protective Services); and
d) To law enforcement agencies.

J. Within the first sixty (60) days from date of hire, all staff having direct contact with participants shall receive training in the following which shall include, but not be limited to:
1. Person centered values, principles and approaches;
2. A Holistic approach for providing care, supports and services for the individual;
3. Medical, physical, behavioral and social needs and characteristics of the persons served;
4. Human rights and responsibilities (*);
5. Promoting positive, appropriate and responsive relationships with persons served, their families and stakeholders;
6. The utilization of:
i. Communication Skills (*);
ii. Behavioral Support and Crisis Intervention techniques to de-escalate challenging and unsafe behaviors (*);
iii. Nationally benchmarked techniques for safe utilization of emergency interventions of last resort (if such techniques are permitted in the purview of the organization)
iv. The Georgia Crisis Response System (GCRS) (*);
;
7. Ethics, cultural preferences and awareness;

8. Fire safety (*);

9. Emergency and disaster plans and procedures (*);

10. Techniques of standard precautions, including:
i. Preventative measures to minimize risk of HIV;
ii. Current information as published by the Centers for Disease Control (CDC); and
iii. Approaches to individual education.
11. BCLS including both written and hands on competency training is required;
12. First aid and safety;

13. Specific individual medications and their side effects (*);

14. Suicide Prevention Skills Training (such as AIM, QPRP); and

15. Ethics and Corporate Compliance is evident.

16. A minimum of 16 hours of training must be completed annually to include the trainings noted by asterisk (*) in items 4, 6, 8, 9, and 13 above.

17. The organization details in policy by job classification:
i. Training that must be refreshed annually;
ii. Additional training required for professional level staff;
iii. Additional training required for all other staff.
18. Regular review and evaluation of all staff is evident at least annually
i. The evaluation should occur annually;

ii. Managers who are clinically, administratively and experientially qualified conduct evaluations.

19. It is evident that the organization demonstrates administration of personnel policies without discrimination.

607. WAIVERS TO STANDARDS

The organization may not exempt itself from any of these standards or any portion of the DBHDD provider manual applicable to DD service provision. Individual standards and provider manual requirements may be requested to be waived by written request to the Regional Coordinator for the DBHDD. For any request, approval must be given, in writing, by the:
Rev. 07 2011
Rev. 01 2013
1. DBHDD Regional Coordinator or designee;

2. Assistant Commissioner of Developmental Disabilities or designee

607.1 Procedures for Requests of Waivers of Standards

The Georgia Department of Behavioral Health and Departmental Disabilities (DBHDD) has a standard process for review and approval of requests for waivers of standards that are listed in this section and throughout the Part II and Part III NOW Manuals.

A service provider may request that the facility capacity limit be waived when the standard creates an undue hardship or barrier for participants to access a needed service.

A service provider may not request the waiving of any standards that pertain to Healthcare Facility Regulation (HFR) licensing requirements or the definition of a Developmental Disability Professional (DDP). Requests to waive these standards will not be reviewed by DBHDD.
Rev 07 2013

Rev 07 2013
A service provider, individual, family member, advocate, or other interested party may request that a standard be waived when the standard creates an undue
hardship or barrier for individuals to access a needed services. Waiver requests are sent to the DBHDD Regional Coordinator or designee, accompanied by a completed Request for Waiver of Standards Form and other applicable Waiver of Standards Requests form(s) for the specific request (available online at DBHDD PolicyStat, http://gadbhdd.policystat.com). The Request for Waiver of Standards Form includes relevant information related to the request for a waiver of standards:
. Justification of the reason for a waiver of standards due to an undue hardship or barrier for participants to access a needed service;

. Plan for improvement or changes needed in order for services to be available in accordance with the standards;

. A recommendation and affirmation of the identified need for a waiver signed by the Director of the provider organization.

607.2 Process for Review and Approval of Waivers of Standards

1. Providers are required to submit all NEW waiver of standard requests to the DBHDD Regional Office no later than forty-five (45) days prior to projected start date.

2. Providers are required to submit RENEWAL waiver of standard requests to the DBHDD Regional Office no later than sixty (60) days prior to the expiration date.

3. The Regional Office completes an initial review to determine if the request falls within DBHDD guidelines. Requests for WOS are reviewed by the Regional Coordinator or the Regional Service Administrator (RSA) for Developmental Disabilities as the designee.

4. Within ten (10) business days after receiving a waiver request, the DBHDD Regional Coordinator or designee submits the request, along with his/her recommendations, to the appropriate DBHDD State Disability Office. The recommendation is documented on the Tracking Form for Request for Waiver of Standards (available online at DBHDD PolicyStat, http://gadbhdd.policystat.com) and submitted to the Division of Developmental Disabilities with the request.

5. The Division of Developmental Disabilities approves or disapproves the requested waiver within thirty (30) calendar days after involving appropriate DBHDD staff in the review of the request.

6. Should the Provider fail to submit the information needed to review the request or the Regional Office and/or Division of Developmental Disabilities requires more information from the Provider and there is a delay in additional or resubmission of information, this will cause a delay in response by the Regional Office and/or Division of Developmental Disabilities.

7. The Division of Developmental Disabilities is responsible for notifying the provider (or other requesting party) by letter of the decision that has been made. The letter outlines the decision regarding the waiver request; if the request is approved, the expectations for the provider (or other requesting party) are outlined.

Rev 07 2013
The letter created by the Division is forwarded to the Regional Coordinator for distribution to the Provider.

8. The Division of Developmental Disabilities maintains a record of the information regarding the waiver request using the Tracking Form for Request for Waiver of Standards (available online at DBHDD PolicyStat, http://gadbhdd.policystat.com) which is then stored in the DBHDD Shared Drive or using a database created by the Disability Office for this purpose.

9. In extraordinary circumstances, the Regional Office may request an expedited review of a NEW waiver of standard due to a situation impacting the health and safety of an individual.

10. All approved DD waivers expire at the end of the specified approved time period, not to exceed one (1) year following approval.

11. If the petitioner believes there are special circumstances justifying an extension beyond one year, they may apply again prior to the expiration date, completing another Request for Waiver of Standards form with updated documentation.
607.3 Provider Responsibilities Following Approval of a Waiver Request

1. The provider must maintain on file a copy of all approved waiver requests and have such waiver(s) available for review by the State.

2. The provider must notify the Regional Coordinator or designee when there is any change to services for which the waiver was requested.

3. For waivers of standards for services that are audited/monitored by DBHDD or Department of Community Health contracted entities, the provider must produce a copy of the waiver letter at the time of the audit in order for the DBHDD reviewer;

4. External Review Organization or other contracted entity is to appropriately incorporate the approved waiver into the audit/monitoring activity.
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Rev 07 2013

Waiver Requests for More than One Year

All approved waivers expire at the end of one year following their approval. If the petitioner believes there are special circumstances justifying an extension beyond one year, they may apply again prior to the expiration date, completing another Request for Waiver of Standards Form with updated documentation.
PART II – CHAPTER 700

PARTICIPANT ELIGIBILITY CONDITIONS

701. Eligibility Criteria

The Georgia Department of Behavioral Health and Departmental Disabilities Intake and Evaluation Team (I&E Team) use the criteria below to determine whether a participant is appropriate for New Options Waiver Program (NOW) 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), Intermediate Care Facility for Persons with Intellectual Disability (ICF/ID), with the exception of the personal assistance retainer for Community Living Support Services (see NOW Part III, Policies and Procedures, Chapter 1900 for personal assistance retainer details), and who:

A. Are categorically eligible Medicaid recipients; and

Rev. 10 2010
Rev. 01 2011
B. Have a diagnosis of an intellectual disability and/or a closely related condition (see Section 706.2); and

C. Are currently receiving the level of care provided in an ICF/ID 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/ID that would be reimbursable under the State Plan in the absence of home and community-based services that are determined to be an appropriate alternative.

702. Notification of Participant Approval/Disapproval

NOW applicants are notified in writing of approval or disapproval for NOW services by the Regional DBHDD Office.

703. Denial of Eligibility

Eligibility for services under the waiver may be denied for the following reasons:

A. A participant fails to meet the eligibility criteria specified in this chapter.

B. The participant or his or her representative has not supplied information needed to complete the eligibility process.

C. The participant or his or her representative has not signed the Freedom of Choice form.

D. The Individual Service Plan costs are prohibitive because they exceed the NOW individual cost limit of $25,000 (which does not include Support Coordination Services) or a time-limited, no more than 12 months, approval of additional funding up to $6,000 above the NOW individual cost limit due to increased needs for services by the participant.

704. Grounds for Appeal

A participant denied service or terminated from service because he/she does not meet the level of care requirement is informed of his/her rights to appeal or to a hearing. The DBHDD authorized representative sends the participant a Denial of Level of Care letter that outlines the procedure to appeal the decision and to request a hearing.

705. Screening for Services

All persons requesting institutional or community services in the developmental disability service system do so through the Department of Behavioral Health and Developmental Disabilities (DBHDD) Regional Office. An individual or family participant applies for DD services by completing an Application for Developmental Disabilities Services (see Appendix B). The Regional Office requests the individual or family participant to provide copies of any previous psychological evaluations or adaptive behavior testing. The Regional Office will maintain copies of the application and related documentation.
Rev 01 2010

The Intake and Evaluation (I&E) Team is responsible for the screening process. The team composition and qualifications are defined in the Official Codes of Georgia Annotated 37-4 and 37-5. An I&E Team participant from the DBHDD Regional Office meets with the individual and/or his or her family participant/representative to complete the Intake Screening Tool within 14 business days of the receipt of the application. Information gathered includes background information, functional abilities, developmental milestones, and behavioral and health issues.

All supporting documentation is reviewed to determine whether the individual meets the established eligibility criteria. To determine eligibility, the Intake and Evaluation Team participants review available copies of prior psychological evaluations and adaptive behavior testing and determine whether additional testing is required. The I&E psychologist reviews and signs off on all determinations. Once an eligibility determination is made, a person receives services or is placed on the region’s Planning. A Planning List Administrator will be assigned to anyone placed on the short-term planning list.

For persons recommended by the DBHDD Regional Office for enrollment in NOW funded services, a comprehensive evaluation is to be completed by the DBHDD Regional Office, including a DMA-6 or DMA-6A form (see Appendix C) signed and dated by a physician, nurse practitioner, or physician assistant and
approved by the DBHDD Regional Office. The DBHDD Regional Office determines whether the individual’s needs place him or her at risk of institutionalization in an ICF/ID. The Initial Comprehensive Evaluation, the Individual Service Plan (ISP), and a DMA-6 or DMA-6A form are used to document this determination of eligibility and are reviewed by the Regional Office for level of care determination.

Prior to the comprehensive evaluation process at enrollment in service, an individual is determined by the DBHDD Regional Office to likely require the level of care provided in an ICF/ID through the administration of functional assessment instruments, the review of presenting documentation, and application eligibility standards as defined in Section 701. The participant and his or her legal representative are: (1) provided a brief explanation of the NOW and informed of alternatives available under the waiver and (2) given the choice of either institutional or home and community-based services. The participant and/or his or her representative must sign the Freedom of Choice Form. In those cases where the beneficiary is unable to comprehend fully the options or consequences of his or her choice, a duly authorized representative of the beneficiary may act on his or her behalf. See Appendix E for Freedom of Choice Form.

706. Initial Level of Care Determination

The DBHDD Regional Office reviews copies of the following documents for the initial level of care determination:

706.1 The Initial Individual Service Plan (ISP)

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Rev 01 2013
Information is gathered from a variety of assessment tools to include the Health Risk Screening Tool (HRST), Supports Intensity Scale (SIS), and any assessments completed by the Intake and Evaluation Team. The ISP should also contain any known medical documentation and any documented health history as additional sources for health information. The Planning List Administrator or an Intake and Evaluation Team member completes the initial Supports Intensity Scale (SIS). for individuals who are 16 years or older.

The I&E nurse completes the initial Health Risk Screening Tool (HRST). The HRST assesses where the individual is likely to be most vulnerable in terms of potential health risks. If the Health Care Level is a 3 or greater on the HRST or an individual scores a “2” or two “1’s” on the SIS Exceptional Medical Needs Section, a nursing assessment is completed as part of the initial level of care determination.

DBHDD Regional Office staff, comprised of the Intake and Evaluation Team participants and the Planning List Administration staff, review all documents prior to facilitating the initial ISP meeting. The ISP addresses what is important to and for the individual. This information includes the support need areas
identified in the Supports Intensity scale for individuals 16 years or older, and any health and safety issues identified in the screening process, SIS ( for individuals 16 years or older), or HRST. The Planning List Administrator, in conjunction with the individual, and his or her family and/or support network develop a written Individual Service Plan that includes the services to be provided, the frequency of services, and the type of provider to deliver the service. The physician’s signature is required on the ISP when the individual has a chronic medical condition defined as a Level 2 and above on the Intake and Evaluation Screening tool.

Rev. 01 2010
Known medical conditions, allergies and medication summaries are also included in the ISP. Diagnoses are indicated to ensure treatment of medical conditions such as obesity and diabetes. Behavioral Health conditions are noted and connections made to community mental health services as appropriate. Needed connections to primary care physicians and specialty medical providers are incorporated into the ISP. It is the responsibility of the primary care physician to ensure all appropriate health screenings and treatment.
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Rev 01 2013
No service will be reimbursed that is not listed on the approved Individual Service Plan. Assurance is made that goods and services provided by the waiver are not covered under the Medicaid State Plan when applicable. The individual cost limit for the NOW is $25,000, not including the costs of Support Coordination Services. The cost of service for some individual participants may be approved to exceed this cost limit by up to $6,000 on a time-limited basis not to exceed 12 months due to documented increased needs for services. Please see protocol for physician’s signature in Appendix C.

Please see Appendix C, page C-12 (Protocol for Physician Signature) and Appendix D (I & E Screening Tool for Chronic Medical Condition).

706.2 Comprehensive Evaluation

The comprehensive evaluation for initial level of care determination includes:

A. A complete DMA-6/ DMA-6A form signed by a licensed physician, nurse practitioner, or physician assistant and the participant.

Rev 10 2014
B. A social work assessment that must be current within one (1) year when submitted to the DBHDD Regional Office for the initial level of care determination.

C. A psychological assessment for intellectual functioning and adaptive behavior based on a standardized instrument(s) recognized by professional organizations (American Psychological Association, American Association on Intellectual and Developmental Disabilities). The psychological assessment must document:

. Diagnosis of an intellectual disability defined by the following three criteria:
Rev. 01 2011

(1) Age of Onset: Onset before the age of 18 years;

(2) Significantly Impaired Adaptive Functioning: Significant limitations in adaptive functioning (two or more standard deviations below the mean) in at least two of the following skill areas: self-care, communication, home living, self-direction, functional academic skills, social/interpersonal skills, use of community resources, work, leisure, health, and safety; and

(3) Significantly Sub-average General Intellectual Functioning: Significantly sub-average general intellectual functioning defined as an intelligence quotient (IQ) of about 70 or below (approximately two standard deviations below the mean). Individuals with an IQ of 70 to 75 with appropriately measured, significant impairments to adaptive behavior that directly relate to issues of an intellectual disability may be considered as having an intellectual disability; or
Rev 10 2013

Note: A diagnosis of mental retardation according to current diagnostic manuals is the same as a diagnosis of intellectual disability defined above (see Rosa’s Law, Federal S. 2781, signed October 2010)
Rev. 01 2010

Rev. 01 2011
Rev. 07 2012
Rev. 01 2014
. Diagnosis of a condition found to be closely related to an intellectual disability and attributable to: (a) cerebral palsy or epilepsy; or (b) any other condition, other than mental illness, found to be closely related to an intellectual disability because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of persons with an intellectual disability and requires treatment or services similar to those required for these persons; and that meets the following criteria (Code of Federal Regulations, Title 42, Section 435.1010 and align with the definition of ICF/MR now known as ICF/ID as defined in title 42 Section 440.150):

. Assessment findings that meet the diagnostic criteria in the Pediatric Level of Care criteria for individuals 18 years or less (see Appendix C).

(1) Age of Onset: Onset before the age of 22 years;

(2) Service Needs: The individual must require an ICF/ID level of care without home and community-based treatment or services similar to those required for individuals with a diagnosis of an intellectual disability.
Rev. 07 2012
(3) Substantially Impaired Adaptive Functioning: Substantial
limitations in adaptive functioning (two or more standard deviations below the mean) in three or more of the following areas of functioning: self-care, receptive and expressive language, learning, mobility, self-direction, and capacity for independent living; and the adaptive impairments must be directly related to the developmental disability and cannot be primarily attributed to mental/emotional disorders, sensory impairments, substance abuse, personality disorder, specific learning disability, or attention-deficit/hyperactivity disorder; and

(4) Continued Disability: The disability is likely to continue indefinitely.

(5) Participants Aged 18 Years or Less: Assessment findings meet the diagnostic criteria in the Pediatric Level of Care for individuals 18 years or less (see Appendix C.)

Rev 07 2012
The psychological assessment must be current within one (1) year. A psychological consultation report is acceptable when submitted with a copy of the referenced evaluation (s). Psychological consultation report must include a summary of the previous testing scores in the referenced evaluation (s) and must confirm an intellectual disability or other closely related condition.

706.3 Additional Assessment and Planning Requirements

A. The individual or his or her representative is informed of the findings of the assessments in language he or she can understand.

Rev 01 2013
B. The Support Coordinator discusses service options with the participant, his/her family and others as appropriate in order to identify social, education, and other needs. These needs may indicate Medicaid and non-Medicaid covered services.

C. Individuals direct decisions that impact their life.

Rev 10 2013
D. Others assisting in the development of the individualized plan are persons who:
a) Are significant in the life of the individual;
b) Have a historical perspective of the desires of the individual;
c) The individual gives consent to have input from family and friends, if desired; and
d) Will deliver the specific services, supports, care and treatment identified in the plan:
For individuals with coexisting, complex and confounding needs, cross disciplinary approaches to planning should be used;
Planning should be facilitated by professional(s) qualified to plan or provide services to persons with this level of complexity; and
Representatives of other agencies outside of DBHDD or providers affecting the daily life of the individual should be present and participating.

E. Each individualized plan should be:
Rev 01 2013
Rev 10 2013
1. Driven by the individual and focused on outcomes the individual desires to achieve;

2. Fully explained to the individual using language/communication he or she can understand and agreed to by the individual;

3. Identify and prioritize the needs of the individual and include a page for signatures of the individual or guardian or other members to indicate who participated in the planning of services. Subsequent addendums must also document individual/guardian’s signature;

4. A page for signature, title and date by participants (including the individual and professionals) that is attached to the plan, to indicate all participants presence and involvement in the plan that provide services, supports, care and treatment to the individual.
F. Statement of goals or objectives of the individual are:
1. Each goal/objective is specific to the services provided:

a. Specific to the desired outcomes;

b. Measurable for progress;

c. Achievable skills;

d. Relevant to service provision;

e. Realistic to service provision; and

f. Time-limited with specified target dates.
2. The frequency or intensity that the specific service, support, care and treatment will be given or provided;
3. Identification of staff responsible to deliver or provide the specific service, support, care and treatment;
4. There is evidence of involvement in the formal individualized plan of all traditional service delivery providers of services and supports to the individual and specification of any participant-directed service delivery for the individual, as applicable;
5. Waiver participants or their families/representative who opt for participant direction and become the employer of record of support workers must specify specific support worker qualifications required to meet the exact medical, education, social and other support needs of the waiver participant.
Rev 01 2013
6. Clear authorization of the plan:
a. Refer to NOW Part III definitions of service to determine who must authorize the plan;
b. A physician must authorize the plan when it includes medical care and treatment (Please see protocol for physician’s signature in Appendix C);
c. When more than one physician is involved in individual care, there is evidence that an RN or MD has reviewed all in-field information to
assure there are no contradictions or inadvertent contraindications within the care and treatment orders or plan.

Note: A physician, nurse practitioner, or physician assistant must authorize the level of care of a participant as required by Georgia Department of Community Health Division of Medicaid, Part II Policies and Procedures for the NOW & COMP Waiver Program. No Medicaid reimbursement will be made for any service period of an individualized plan for which there is no level of care (DMA-6/DMA-6A or DMA-7) in effect.
Rev 04 2013

Rev. 10 2010
Rev. 01 2011
Rev. 10 2013
G. Behavior Support Practices

1. In policies, procedures and practices, the organization outlines and defines the adaptive, supportive, medical protection devices and the restrictive interventions that are implemented or prohibited by the organization and licensure requirements. These devices include but are not limited to:

a. Use of adaptive supportive devices or medical protective devises (devices which restrain movement but are applied for the protection of accidental injury, required for medical treatment or for corrective/supportive needs):

i. May be used in any service, support, care and treatment environment;

ii. Use is defined by a physician’s order (order not to exceed twelve calendar months);

iii. Written order to include rationale and instructions for the use of the device;

iv. Authorized in the individual service plan (ISP); and

v. Are used for medical and/or protection against injury and not for treatment of challenging behavior(s).

b. Time out (also known as withdrawal to a quiet area):

i. Under no circumstance is egress physically or manually restricted;

ii. Time out periods must be brief, not to exceed 15 minutes;

iii. Procedure for time out utilization is incorporated in the behavior support plan; and

iv. The justification for use and implementation details for time out utilization is documented.

c. Manual Hold/Restraint(also known as Personal Restraints): The application of physical force, without the use of any device, for the purpose of restricting the free movement of a person’s body:

i. May be used in all community settings except residential settings licensed as Personal Care Homes;

ii. Circumstances of use must represent an emergency safety intervention of last resort affecting the safety of the individual or of others;

iii. Brief handholding (less than 10 seconds) support for the purpose of providing safe crossing, safety or stabilization does not constitute a personal hold;
iv. If permitted, Manual/Personal Restraint (ten seconds or more), shall not exceed five (5) minutes and use of personal restraint is documented;

v. Use of manual/personal restraints must be outlined as an approved intervention in his/her safety plan; and

vi. If manual/personal restraints are implemented more than three (3) times in a six (6) month period, there must be corresponding procedures to teach the individual skills that will decrease/eliminate the use of personal restraints.

d. Mechanical Restraint (also known as Physical Restraints): A device attached or adjacent to the individual’s body that one cannot easily remove and that restricts freedom of movement or normal access to one’s body or body parts. Mechanical/Physical restraints are prohibited in community settings.

e. Seclusion: The involuntary confinement of an individual alone in a room or in any area of a room where the individual is prevented from leaving, regardless of the purpose of the confinement. The practice of “restrictive time-out” (RTO) is seclusion and may not be utilized except in compliance with the requirement related to seclusion. The phrase “prevented from leaving” includes not only the use of a locked door, but also the use of physical control or verbal threats to prevent the individual from leaving. Seclusion is not permitted in NOW services.

f. Chemical restraint may never be used under any circumstance. Chemical restraint is defined as a medication or drug that is:

i. Not a standard treatment for the individual’s medical or psychiatric condition;

ii. Used to control behavior; and

iii. Used to restrict the individual’s freedom of movement.
Examples of chemical restraint are the following:
i. The use of over the counter medications such as Benadryl for the purpose of decreasing an individual’s activity level during regular waking hours;

ii. The use of an antipsychotic medication for a person who is not psychotic but simply ‘pacing’ or agitated.

g. PRN anti-psychotic medications for behavior control are not permitted. See Appendix R for list of medications.

2. The approach to developing a positive behavior support plan (including a safety plan) and treatment for individuals demonstrating challenging behaviors should be consistent with the definitions and protocols in the Guidelines for Supporting Adults with Challenging Behaviors in Community Settings and Best Practice Standards for Behavioral Support Services found in Appendix B of the NOW Part III Policies and Procedures Manual. Behavior Support activities outlined in the PBSP is guided by an overall emphasis on not only decreasing target behaviors but also concurrently increasing skills in appropriate areas.

3. The PBSP and Safety Plan for challenging behaviors should be a collaborative effort among each provider providing services for the individual. The providers must work to develop and implement one plan that includes any modification for implementation for each service site and the modification must be
addressed and approved prior to finalizing the plan. The final approved PBSP is incorporated by reference into the ISP. A copy of the individual’s PBSP must be available at all service sites for implementation.

4. a) A behavior support plan should be developed and implemented for individuals with developmental disabilities who receive psychotropic medications for symptom management of challenging behavior that continues to pose a significant risk to the individual, others, or the environment (e.g., self-injury, physical aggression, property destruction) and is not specifically related to mental illness or epilepsy requiring treatment with psychotropic medications. The behavior support plan must minimally include:

1) An operationally defined behavior(s) for which the drug is intended to affect;

2) Measuring target behaviors which shall constitute the basis on which medication adjustments will be made; and

3) A focus on teaching replacement behaviors in an effort to replace the use of medication with behavioral programming.
b) A behavior support plan is not required for individuals receiving psychotropic medication to treat mental illness (e.g., schizophrenia, bi-polar disorder) or epilepsy when the record documents that the medication addresses the symptoms of the mental illness or epilepsy.
5. When positive behavior support plan is used to reduce challenging behaviors there must evidence that the following issues have been addressed. The plan is:

a. Individualized;

b. Based on a functional assessment;

c. One that has addressed potential medical causes;

d. Developed and overseen by a qualified professional (Refer to Appendix I for Developmental Disability Professional categories of Psychologist, Behavior Specialist, and Board Certified Behavior Analyst);

e. Inclusive of methods outlined to teach alternative appropriate behaviors that will achieve the same results as the challenging behavior(s);

f. Inclusive of rationale for the following:

i. Use of identified approaches;

ii. The time of their use;

iii. An assessment of the impact on personal choice of the individual;

iv. The targeted behavior; and

v. How the targeted behavior will be recognized for success.

g. Implemented by trained and competent staff as documented by individual who developed the BSP/Safety Plan and trained the staff.

h. Has monitoring plans for review, analyzing trends, and summarizing the effectiveness of the plan and termination criteria;

i. Consent provided by the individual and his or her legal guardian;

j. Discussed with the individual and family/natural supports (as permitted by the individual); and

k. Developed in accordance with Best Practice Standards for Behavioral Support Services for Providers of Developmental Disabilities Services (www.dbhdd.georgia.gov).
6. Intrusive or restrictive procedures must be clearly justified through documentation of less restrictive procedures ineffectiveness and/or the need for more intrusive procedures due to the safety or health risks presented by the targeted behaviors. These procedures are authorized, incorporated into the BSP and/Safety Plan, approved by ISP interdisciplinary team, reviewed by organization’s Rights Committee and supervised by qualified professional(s) and may not be in conflict with Federal or State Laws, Rules and Regulations, Clients Rights or Department standards to include but not limited to the document Guidelines for Supporting Adults with Challenging Behaviors in Community Settings and the Best Practice Standards for Behavioral Support when developing a behavior support/safety plan.

7. Providers must have processes in place to implement crisis intervention as needed. The staff must be trained to respond to a crisis situation that occurs at the service site and have an agency’s crisis plan, that at a minimum addresses:

a. Approved interventions to be utilized by staff;

b. Availability of additional resources to assist in diffusing the crisis;

c. If the acute crisis presents a substantial risk of imminent harm to self and others, that community based crisis services to include the Georgia Crisis Response System(GCRS) serves as an alternative to emergency room care, calling 911, institutional placement, and/or law enforcement involvement (including incarceration) is implemented;

d. Protocols to access community-based crisis services to include the Georgia Crisis Response System must be included in agency’s policy and procedures with staff trained to implement this protocol; and

e. Notification process by Direct Support Staff that includes informing the designated on-call management staff and/or Director.

8. All organizations must have the capacity to address individual’s behavioral needs. If the cause of the challenging behavior cannot be determined or satisfactorily addressed by the provider, there should be evidence of consultation with an outside professional who is licensed or qualified through education, supervised training and experience to address the behavior needs of the Individual. Those authoring such plans should minimally meet professional criteria as a Psychologist, Behavioral Specialist or a Board Certified Behavior Analyst (see Appendix I for Developmental Disability Professional qualifications for these professions).

9. If the need for behavior supports is identified, the individual or guardian is given a choice to select the qualified person to develop the BSP and /or Safety plan.

H. Documents Referenced in Individual Service Plan
Documents to be incorporated by reference into an individual service plan include, but are not be limited to:

1. Medical updates as indicated by physician orders or notes;

2. Known medical conditions, allergies and medication summaries

3. Medical documentation and any documented health history

4. Addenda as required when a portion of the plan requires reassessment;
Rev 01 2013
Rev 01 2013
5. A personal crisis plan which directs in advance the individual’s desires/wishes/plans/objectives in the event of a crisis;

6. A behavior support plan and/or a safety plan for individuals demonstrating challenging behaviors;

7. A behavior support plan and safety plan for individuals who receive psychotropic medications for symptom management;

8. Diagnoses are indicated to ensure treatment of medical conditions such as obesity and diabetes.
Rev 10 2013
Rev 01 2012
Rev 10 2013

I. Summary of progress toward goals

Rev 10 2013

There is evidence that the participant data from tracking sheets and /learning logs have been reviewed, and summarized against progress toward goals at least quarterly.

J. Individual Referrals Based on Assessment of Individual Need
Rev 10 2013

Policies, procedures and practice describe processes for referral of the individual based on ongoing assessment of individual need:
a. Internally to different programs or staff; or

b. Externally to services, supports, care and treatment not available within the organization including, but not limited to:

i. Health care for

1. Routine assessment such as annual physical examinations;

2. Chronic medical issues;

3. Ongoing psychiatric issues;

4. Acute and emergent needs;

1. Medical

2. Psychiatric

ii. Diagnostic testing such as psychological testing or labs; and

iii. Dental services.

707. Level of Care Re-Evaluation

A. The level of care re-evaluations are completed at a minimum of every 12 months. LOC service approval may not exceed 365 days.

B. Psychological/Behavioral Assessment Updates: The interdisciplinary team determines if there has been a change in the participant’s condition and recommends a psychological/behavioral assessment update as follows:
Rev 10 2013

. For participants below 18 years of age, a psychological assessment (or psychological consultation report as indicated in Section 706) will be conducted every three (3) years for any individual whose initial level of care determination was not based on a diagnosis of moderate to profound mental retardation or severe autism.

. For participants over 18 years of age, a behavioral assessment update will be conducted when the participant scores a “2” and a total greater than 5 on the SIS Exceptional Behavioral Support Needs Section.
Rev. 01 2009
Rev. 04 2010

Rev. 04 2009
C. Social Work Assessment Updates: The interdisciplinary team determines if there have been major changes in a participant’s home or family environment or other life circumstances, including but not limited to, loss or illness of caregiver, extended hospitalization (i.e., one month or more), or loss of home due to fire or natural disaster. Social work assessments are updated when the interdisciplinary team determines these changes have occurred.

D. Nursing Assessment Updates: If the Health Care Level of the participant is a 3 or greater on the HRST or the participant scores a “2” (Extensive Support Needed) on Lifting and/or Transferring, Turning or Positioning, or Seizure Management) or a total great then 5 on the SIS Exceptional Medical Needs Section, the nursing assessment is updated.
Rev. 01 2009

E. The participant’s support coordinator or service provider may request at any time technical assistance from the DBHDD Regional Office due to changing needs of a participant, including but not limited to, loss or illness of primary caregiver, extended hospitalization, deteriorating neurological functioning, mental illness, severe aberrant behaviors, and significant decline in functioning.

Rev 01 2013
F. The Support Coordinator submits to the DBHDD Regional Office the participant’s Level of Care Re-Evaluation form and Individual Service Plan, along with any required copies of updated psychological, social work, and/or nursing assessment(s) as indicated above.

Rev. 07 2010
Rev. 01 2013
Rev. 04 2013
G. The Level of Care Re-Evaluation (DMA-7) form must be signed by support coordinator and the participant or participant representative.

H. The I&E Level of Care RN reviews the Level of Care Re-Evaluation (DMA-7) form, the ISP, and any accompanying assessment updates to determine whether the person continues to meet the level of care requirement.
Rev. 01 2013
Rev. 04 2013

Rev. 01 2013
708. Level of Care Approval Requirements

1. Each participant approved for NOW services must have a level of care determination authorized by the DBHDD Regional Office (see Appendix A).
Rev. 04 2013

2. The DBHDD Regional Office will not approve any level of care or re-evaluation until all required documents submitted for approval are complete. The initial date the completed Level of Care Re-Evaluation (DMA-7) form is received by the DBHDD Regional Office with all additional required documentation for recertification will be the date that it is entered into
Rev. 04 2013
DBHDD Regional Office system and will constitute the earliest re-certification date once approved. The annual date of the participant’s current level of care is the date that the level of care is made effective by DBHDD Regional Office.

Rev 01 2013
Rev 04 2013
Rev 04 2014
3. The signatures of the physician, nurse practitioner, or physician assistant on the DMA-6/DMA-6A form for initial level of care determination must be no more than 30 days prior to the LOC approval date. The need for institutional care shall be considered to have been satisfied for persons who are currently receiving the level of care provided in an ICF/ID or SNF, unless otherwise indicated in the most recent utilization review of the participant.

Rev 01 2013
Rev 04 2013
4. The approved initial level of care (DMA-6/DMA-6A) or re-certification of level of care ( DMA-7 form) is uploaded to a web based system so that all providers have access. Initial services must begin within 60 days of DBHDD Regional Office approval. In the event services do not begin within 60 days, the DMA-6/DMA-6A form and assessment will be reviewed by the clinicians and physician and updated as needed.

Rev 01 2013
Rev 04 2013
5. Each participant must have a current level of care (DMA-6/DMA-6A for initial level of care and DMA-7 form for level of care re-evaluations) approved by the Regional DBHDD office and with required signatures. No Medicaid reimbursement will be made for any service period for which there is no level of care (DMA-6/DMA-6A or DMA-7) in effect.

Rev 01 2013
6. Each enrolled provider service type must maintain a copy of the current and approved DMA-6/DMA-6A or DMA-7 forms covering all periods of services rendered, in the participant’s record. Noncompliance to this program requirement will result in a request for refund from the Department.
Rev 04 2013

709. Re-Evaluation of Participants

The participant, his or her support network, and support coordinator as often as necessary, but no less frequently than annually will review each participant’s ISP. ISP reviews will also occur anytime there is a major life change for the individual. These reviews will explain in detail the reason for failure to achieve any anticipated outcomes. The ISP will be revised as needed to assure appropriate provision of services to each participant. All team participants in attendance will sign the new ISP or addendum. I & E Team participants’ signatures, for those not in attendance but who contributed to this annual ISP, can be found on the annual assessments or reviews included with the ISP. The revised start date listed on the ISP addendum is the approval date for any ISP addendum, but in no instance can the revised start date be prior to the date of the ISP addendum meeting.
Rev. 07 2010

709.1 Reduction or Termination of Services
Rev 01 2013
Rev 07 2013

1. Reduction of NOW Services: The participant and/or his/her representative (family member or legal guardian) will receive written notice of the rights to appeal any reduction of NOW services from the DBHDD regional office. The notice will outline the process for requesting a fair hearing.

2. Termination from the NOW Program due to Medicaid Eligibility Discontinuance: NOW Waiver Program eligibility is dependent upon Medicaid eligibility, and discontinuance of Medicaid eligibility for an individual results in his or her termination from the NOW Program. The participant and/or his/her representative will receive written notice of the rights to appeal discontinuance of Medicaid eligibility from the local Department of Family and Children Services (DFCS) Office. The notice will outline the process for requesting a fair hearing.

3. Termination from the NOW Program due to Department of Community Health Adverse Decision: Part I Policies and Procedures for Medicaid/Peachcare for Kids, Chapter 500, Section 508 provides procedures for the request of a fair hearing should a decision of the Department of Community Health be adverse to a participant.
4. Termination from the NOW Program due to DBHDD Adverse Decision: The participant and/or his/her representative (family member or legal guardian) will receive written notice from the DBHDD regional office of the rights to appeal any NOW Program termination resulting from a DBHDD adverse decision. The notice will outline the process for requesting a fair hearing.

710. Outcomes for Participants
710.1 Respect for the Dignity of the Individual
1. Access to appropriate services, supports, care and treatment is available regardless of:

a. Age;

b. Race, National Origin, Ethnicity;

c. Gender;

d. Religion;

e. Social status;

f. Physical disability;

g. Mental disability;

h. Gender identity; or

i. Sexual orientation.

2. There are no barriers in accessing the services, supports, care and treatment offered by the organization, including but not limited to:

a. Geographic;

b. Architectural;

c. Communication:

i. Language access is provided to individuals with limited English proficiency or who are sensory impaired;

Rev. 10 2010
ii. All applicable DBHDD policies regarding Limited English Proficiency and Sensory Impairment are followed.
d. Attitudinal;

e. Procedural; and

f. Organizational scheduling or availability.

3. There is evidence of organizational person-centered planning and service delivery that demonstrates:

a. Sensitivity to individual differences and preferences is evident;

b. Practices and activities that reduce stigma; and
c. Interactions that are respectful, positive and supportive.
4. The organization must have written policies and procedures regarding the visitation rights of individuals, including a requirement that any reasonable restrictions must be based on the seriousness of the individual’s mental or physical condition as ordered in writing by the attending physician. Such orders shall state the type and extent of the restriction. The order shall be reviewed for changes as needed and renewed at least annually. Additional orders shall follow the same procedure. The organization must meet the following requirements:

a. Inform each individual (or guardian, or parent or custodian of a minor, as applicable) of his or her visitation rights, including any clinical restriction of such rights, when he or she is informed of his or her other rights under this section;

b. Inform each individual (or guardian, or parent or custodian of a minor, as applicable) of the right, subject to his or her consent, to receive visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner (including a same sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time. However, the parent, guardian or custodian of a minor may restrict his or her visitation rights;

c. Not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identify, sexual orientation or disability;

d. Ensure that all visitors enjoy full and equal visitation privileges consistent with the preferences of the individual;

e. Not restrict visitation by an individual’s attorney or personal physician on the basis of the individual’s physical or mental condition;

f. Visitors/guardians are also expected to adhere to any reasonable restrictions as ordered in writing by the attending physician in the area of diet; and

g. If visitation facilitates/results in problematic behaviors, reasonable restrictions may be ordered and incorporated into the Safety Plan.

710.2 Human and Civil Rights
Rev 10 2013

1. The organization has policies and promotes practices that:

a. Do not discriminate;

b. Promote receiving equitable supports from the organization;

c. Provide services, supports, care and treatment in the least restrictive environment possible;

d. Emphasize the use of teaching functional communication, functional adaptive skills to increase independence, and using least restrictive interventions that are likely to be effective;

e. Incorporate Clients Rights or Patients Rights Rules found at www.dbhdd.georgia.gov, as applicable to organization; and

f. Delineates the rights and responsibilities of persons served.
2. In policy and practice the organization makes it clear that under no circumstances will the following occur:

a. Threats of harm or mistreatment (overt or implied);

b. Corporal punishment;

c. Fear-eliciting procedures;

d. Abuse or neglect of any kind;

e. Withholding basic nutrition or nutritional care; or

f. Withholding of any basic necessity such as clothing, shelter, rest or sleep.
3. Federal and state laws and rules are evident in policy and practice including, but not limited to:
a. For all community based programs, practices promulgated by DBHDD or the Rules and Regulations for Clients Rights, Chapter 290-4-9 are incorporated into the care of individuals served. Issues addressed include but are not limited to the right to:

i. Care in the least restrictive environment;

ii. Humane treatment or habilitation that affords protection from harm, exploitation or coercion.

iii. Unless adjudicated incompetent by a court of law, be considered legally competent for any purpose without due process of law, including to maintain

1) Civil;

2) Political

3) Personal; or

4) Property rights.
4. There is evidence of the individual or legal guardian’s signature on notification that all individuals are informed about their rights and responsibilities:
a. At the onset of services, supports, care and treatment;

b. At least annually during care;

c. Through written information that is well prepared in a language/format understandable by the individual; and
d. How confidentiality will be addressed including but not limited to who they wish to be informed about their services, supports, care and treatment.

Rev. 04 2010

710.3 Community Integration and Inclusion into the Larger Natural Community

Community integration and inclusion into the larger natural community is supported and evident. Terms “Integration and Inclusion” mean:
a. Use of community resources that are available to other citizens;

b. Providing the opportunity to actively participate in community activities and types of employment as citizens without disabilities;

c. The organization has community partnerships for capacity building and advocacy of activities to achieve this goal of integration;

d. The organization must provide supports and inclusion activities that show respect for the individual’s dignity, personal preference and cultural differences;

e. There is documentation of individualized preferences, person-centered integration and inclusion in the community;

f. Building of community relationships (natural/paid/unpaid); and

g. Supporting individual’s choice as measured by the amount of control an individual has over his/her life.

710.4 Participant Rights and Responsibilities
Providers must acknowledge that participants have rights and responsibilities regarding participation in the NOW. At the time of admission, the provider reviews participant rights and responsibilities with the participant and/or participant’s representative. After the participant or participant’s representative reads and signs a copy of the participant rights and responsibilities, the provider gives a copy of the rights and responsibilities to the participant and the participant’s representative if applicable. The provider places a copy in the participant’s record.
Participant rights recognized by the provider include:
1. The right of access to accurate and easy-to-understand information

2. The right to be treated with respect and to maintain one’s dignity and individuality

3. The right to voice grievances and complaints regarding services and supports that is furnished or not furnished, without fear of retaliation, discrimination, coercion, or reprisal

4. The right to a choice of approved service provider(s)

5. The right to accept or refuse services

6. The right to be informed of and participate in preparing the Individual Service Plan and any changes in the plan

7. The right to be advised in advance of the provider(s) who will furnish services and the frequency and duration of services

8. The right to confidential treatment of all information, including information in the participant’s record

9. The right to receive services in accordance with the current Individual Service Plan

10. The right to be informed of the name, business telephone number and business address of the person supervising the services and how to contact that person

11. The right to have property and residence treated with respect

12. The right to be fully and promptly informed of any cost share liability and the consequences if any cost share is not paid

13. The right to review participant’s records on request

14. The right to receive adequate and appropriate services without discrimination.

15. The right to be free from mental, verbal, sexual and physical abuse, neglect, exploitation, isolation, corporal or unusual punishment, including interference with daily functions of living

16. The right to be free from chemical or physical restraints

 

NOTE:
Providers must be aware of additional participant rights and responsibilities required under specific program licensure and must include signed copies of these rights and responsibilities in the participant’s record.

711. Eligibility Determination for Medical Assistance Only (MAO)

Participants who receive SSI are eligible for Medicaid. Participants whose income exceeds SSI eligibility may be considered to be Medicaid eligible as a
result of a Medical Assistance Only (MAO) determination. The county Division of Family & Children Services determines eligibility and cost share responsibility. The MAO determination will indicate a monthly cost share amount calculated from the participant’s income as the participant’s cost share or participant liability for services being rendered as determined by DFCS. The cost share is reassessed no less than annually, sometimes more frequently.

The Intake and Evaluation Team is responsible for initiating the eligibility process by completion of the initial MAO Communicator and the responsible provider will assist the participants in setting an appointment at the local DFCS office subsequent to DBHDD Regional Director/Designee authorization to serve the participant. The Support Coordinator is responsible for assisting providers in the timely completion of subsequent MAO renewals annually.

A. Persons currently residing in ICF/MRs or SNFs and receiving Medicaid reimbursed services but not receiving SSI, and who have been approved by the DBHDD Regional Director/Designee and the DBHDD designated agency (through a DMA-6/DMA-6A) as meeting the service need criteria for the NOW are to comply with the following procedures.

1. The MAO Determination Form (see Appendix F), the application for Medical Assistance and the approved DMA-6/DMA-6A should be submitted by the responsible provider to the local DFCS office in the county where the participant resides.

2. The responsible provider must contact the DFCS office by telephone to schedule an appointment with the eligibility worker and to obtain additional information regarding the MAO determination process.

3. Participants that are currently community residents must be receiving a service that is a defined NOW service but is not reimbursed under the NOW.

B. Persons who live in the community, but who do not receive Medicaid services or SSI payments, but have been identified by the DBHDD Regional Director/Designee and/or DBHDD designated agency as meeting the service need criteria for the NOW waiver, must comply with the procedures outlined in Section 708.

C. Division of Family and Children Services (DFCS) is responsible for determining the amount of cost share if any.

D. MAO status must be reviewed annually according to DFCS guidelines. The Support Coordinator is responsible for this process.

712. Katie Beckett
Rev. 07 2014

TEFRA/Katie Beckett is an eligibility category that is defined as a Medicaid service made available to certain children with disabilities. It allows states to make Medicaid services available to these children who would not ordinarily be eligible for Social Security Income (SSI) benefits because of their parents’ income.

A. Eligibility Determination for Katie Beckett

States are allowed, at their option, to make Medicaid benefits available to children (age 18 or under) at home who qualify as individuals with disabilities under the Social Security Act provided when certain conditions are met. TEFRA/Katie Beckett is defined as a Medicaid service made available to certain children with disabilities. It allows states to make Medicaid services available to children who would not ordinarily be eligible for Social Security Income (SSI) benefits because of their parents’ income.

In order for a child to establish Medicaid eligibility under this program, it must be determined that:

. If the child was in a medical institution, he/she would be eligible for medical assistance under the State plan for Title XIX;

. The child requires a level of care provided in a hospital, skilled nursing facility, or intermediate care facility (including an intermediate care facility for the mentally retarded);

. It is appropriate to provide the care to the child at home; and

. The estimated cost of caring for the child outside of the institution will not exceed the estimated cost of treating the child within the institution.

The criteria used to determine a child’s eligibility in the program is found in Title 42 Code of Federal Regulations. Medical necessity is not based on specific medical diagnoses. The reviewer must review all available medical information to determine whether services are medically necessary. In addition, the reviewer must determine whether the child requires the level of care provided in a hospital, nursing facility, or intermediate care facility (including an intermediate care facility for the mentally retarded).

Income qualifications for “Katie Beckett” are based solely on the child’s income, but a number of different factors are considered for approval. If approved, the same eligibility for health coverage will be available to the child as other Medicaid participants. Eligibility for Medicaid under “Katie Beckett” will only be approved if ALL of the following conditions are met:

. Child is 18 years of age or younger

. Child meets the federal criteria for childhood disability

. Child meets an institutional level of care criteria

. Even though the child may qualify for institutional care, it is appropriate to care for the child at home

. The Medicaid cost of caring for the child at home does not exceed the Medicaid cost of appropriate institutional care

B. Hearing and Appeals Process

Due process rights associated with the denial of admission to the “Katie Beckett” program are initially commenced after the level of care assessment by Georgia Medical Care Foundation (GMCF). Participants in the “Katie Beckett” program are subject to yearly assessments by GMCF. If the level of care assessment results in the denial of admission/continuation into the “Katie Beckett” program, GMCF will send an “Initial Denial of Admission/Continued Stay” to the family (with a copy to the DFCS care worker). This notice informs the parents of the reason for the denial and the administrative review rights. To ask for a hearing, the family must make the request in writing.
The Georgia Medical Care Foundation must receive requests for administrative review within the 30-day time limit. When counting days, the family has a two (2) day period for receipt of the letter. Then, beginning on the third day after the date of the letter, regardless of whether that day is a weekend or holiday, the count of the 30 days begins. However, if the 30th day falls on the weekend or holiday, the next full business day is counted as the 30th day. The family’s request must be submitted to the following address:

Department of Community Health
Legal Services Section
Two Peachtree Street, NW – 40th Floor
Atlanta, Georgia 30303-3159

713. Georgia Pediatric Program (GAPP)

The Georgia Pediatric Program (GAPP) is designed to serve eligible participants under the age of 20 years 11 months based on medical necessity determination(s). Eligible pediatric participants age out of the GAPP program on their 21st birthday. Participants must be medically fragile with multiple systems diagnoses and require continuous skilled nursing care or skilled nursing care in shifts in order to be considered for services in the Georgia Pediatric Program. A portion of the services in the GAPP operates under a Home and Community-Based Waiver [1915(c)] approved by the Center for Medicare and Medicaid Services. This pediatric program allows the Department of Community Health to use Title XIX
funds to provide approved services to medically fragile children in their homes and communities as well as in a ‘medical’ daycare setting as an alternative to placing children in a nursing care facility. Participants served by the GAPP are required to meet the same level of care as for admission to a hospital or nursing facility and must be Medicaid eligible.

The Georgia Pediatric Program (GAPP) offers the following services:

A. In-Home Skilled Nursing Services

Skilled nursing care is provided in the home. Nurses caring for GAPP participants must have a current background in pediatric critical care nursing within the past two years.

B. Medical Day Care Services

The medical day care service provides specialized pediatric services to medically fragile participants, with a current Individualized Family Service Plan, (IFSP) in a licensed medical day care facility.

There are services that a person can not receive through GAPP while receiving those same services through the MR/DD waiver services. Those services are:
Rev. 04 2010

. Community Living Supports Services (CLS)

. Natural Support Training

If the MR/DD provider bills a claim for services that are provided by GAPP, the claim will deny for duplication. Claims that deny as a result of apparent duplication of services may be reviewed on a case-by-case basis. When a claim denies providers may submit for review the denied TCN’s and address all submittals related to the TCN’s to the New Options Waiver and Comprehensive Supports Waiver (NOW/COMP) Program Specialist at the Department of Community Health at the following address: :

Department of Community Health
New Options Waiver/Comprehensive Supports Waiver (NOW/COMP)
Program Specialist
2 Peachtree Street, NW, 37th Floor
Atlanta, Georgia 30303

PART II – CHAPTER 800

PRIOR APPROVAL

801. General

The Department requires that all NOW services are approved prior to reimbursement being rendered. Prior approval does not guarantee reimbursement or participant eligibility. In order for an enrolled provider to be reimbursed for prior approved services, the participant must be Medicaid eligible at the time services are rendered and with a valid and current level of care determination.

Note: All requests to change prior authorizations for any state fiscal year must be submitted no later than the last day of the calendar year (December 31st) in which the state fiscal year ends. Changes to prior authorizations can not be made after this date.

802. Obtaining Prior Approval

The Regional DBHDD offices must complete a Prior Authorization Request as part of the enrollment process. The Prior Authorization must be submitted for approval to the Regional DBHDD Office. Once the prior authorization has been approved, it will be submitted to Medicaid electronically indicating the approved services, authorization periods in which services can be rendered, the provider of each service, and the procedure codes and rates for the services. The Regional DBHDD Office will distribute to all providers listed on the prior authorization a copy of the approved PA. A copy of the prior authorization can be found in Appendix G. The enrolled provider’s NOW participant record must include a copy of the approved Prior Authorization forms. Noncompliance to this program requirement will result in a request for refund from the Department.
PART II – CHAPTER 900

GENERAL SERVICE REQUIREMENTS

901. Services Overview
Rev. 07 2010
The New Options Waiver Program (NOW) services are based on the assessed need of the participant that includes consideration of what is important to and for the person, person-centered planning/thinking, and the use of person-centered tools (see NOW Part II, Appendix Q for information on person-centered planning). These reimbursable services include the following and are as specified in the approved ISP:

1) Adult Occupational Therapy – these services address the occupational therapy needs of the adult participant that result from his or her developmental disabilities.

2) Adult Physical Therapy – these services address the physical therapy needs of the adult participant that result from his or her developmental disabilities.

3) Adult Speech and Language Therapy – these services address the speech and language therapy needs of the adult participant that results from his or her developmental disabilities.

4) Behavioral Supports Consultation – these 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.

5) Community Access – these 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.

6) Community Guide – these 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.

7) Community Living Support – these 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.

8) Environmental Accessibility Adaptation – these 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.

9) Financial Support Services – these services are provided to assure that participant directed funds outlined in the Individual Service Plan are managed and distributed as intended.

10) Individual Directed Goods and Services – these services are not otherwise provided through the NOW or Medicaid State Plan but are services, equipment or supplies identified by the participant who opts for participant direction and his or her Support Coordinator or interdisciplinary team.

11) Natural Support Training – these services provide training and education to individuals who provide unpaid support, training, companionship or supervision to participants.

12) Prevocational Services – these services prepare a participant for paid or unpaid employment and include teaching such concepts as compliance, attendance, task completion, problem solving and safety.

13) Respite – these 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 structured support (typically due to behavioral support needs) or due to a family emergency.
Rev. 01 2010

14) Specialized Medical Equipment – this 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.

15) Specialized Medical Supplies – these supplies consist of food supplements, special clothing, diapers, bed wetting protective chunks, and other authorized supplies that are specified in the Individual Service Plan.

16) Support Coordination – these services are a set of interrelated activities for identifying, coordinating, and reviewing the delivery of appropriate services with the objective of protecting the health and safety of participants while ensuring access to needed waiver and other services.

17) Supported Employment – these 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.
18) Transportation – these 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; and

19) Vehicle Adaptation – these 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.

Part III, Policies and Procedures for the New Options Waiver (NOW) Program provides the service requirements specific to the individual NOW Services. Description of each service is discussed more fully in Part III Policies and Procedures for NOW, Chapters 1300-3100. The general service requirements for the NOW Program are specified in the section to follow.

Participants have the option to self-direct NOW services, with the exception of Financial Support Services, Prevocational Services, and Support Coordination. The Co-Employer Participant-Direction Option is available for Community Access, Community Guide, Community Living Support, Respite, Supported Employment, and Transportation Services. For details on participant-direction, refer to Part II Policies and Procedures for NOW, Chapter 1200.

902. Exclusions and Special Conditions

A. Payment directly or indirectly for any waiver services provided to participants by legally responsible relatives, such as spouses, parents of minor children, or legal guardians, when the services are those that these persons are already legally obligated to provide is prohibited in this waiver. Direct payment is defined as a payment made to the legally responsible individual without any diversion. Indirect payments occur when a payment is made to a recipient, a provider, or a third party, and then transferred to the legally responsible individual or approved family paid caregiver. Other participants’ family members, by blood or marriage, who are aged 18 years or older, may be reimbursed for providing services when there are extenuating circumstances (family is defined as a person who is related by blood within the third degree of consanguinity or by marriage, such as spouse, stepparents, or stepsiblings. Third degree of consanguinity means mother, father, grandmother, grandfather, sister, brother, daughter, son, granddaughter, grandson, aunt, uncle, great aunt, great uncle, niece, nephew, grand niece, grand nephew, 1st cousins, once removed, and 2nd cousins) Extenuating circumstances include the following:

1. lack of qualified providers in remote areas,

Rev. 07 2010
2. lack of a qualified provider who can furnish services at necessary times and places,

3. presence of extraordinary and specialized skills or knowledge by approvable relatives in the provision of services and supports in the approved ISP, and/or

4. clear demonstration of being the most cost effective and efficient means to provide the services.
NOTE: Approvable relatives meeting the extenuating circumstances criteria may provide Community Access, Community Living Support, Respite, Supported Employment, and/or Transportation Services in the NOW Program.

In the case of the request of a parent of an adult to provide waiver services, there must be a clear demonstration that the provision of the waiver services by the parent is in the best interests of the participant and that the above-required extenuating circumstances are met. In addition, whenever the parent of an adult is approved to provide waiver services under extenuating circumstances, the support coordinator for the participant assures at least an annual review of whether the continued provision of the waiver services is in the best interests of the participant.

The Division of Medicaid considers on a case-by-case basis if extenuating circumstances justify approval of family participants (other than spouses, parents of minor children, or legal guardians) as paid caregivers of traditional provider services. See Chapter 1200 of this manual for the policies on extenuating circumstances review for provision of participant-directed services by relatives.

Requests for consideration of extenuating circumstances are to be made in writing and submitted to the appropriate DBHDD Regional Office (see Appendix A). The responsible party will receive written notification of the Department of Community Health’s final decision for traditional provider services furnished by relatives.

B. Medical, home health, dental, and pharmacy services that are provided under the Medicaid State Plan are not included as NOW services; however, the provider along with the Support Coordinator is expected to ensure links with all needed services.

903. Duplication of Services

A. Waiver Programs include:
. New Options Waiver (NOW)
. Comprehensive Supports Waiver (COMP)
. Community Care Services Program (CCSP)
. Independent Care Waiver Program (ICWP)
. Waivered Home Care Services (Model Waiver)
. Shepherd Care Project 66
. Service Options Using Resources in Community Environments (SOURCE)
. GAPP (except skilled nursing)

B. NOW and other Waiver clients are not eligible to enroll in Medicaid HMOs.

904. Hospice Services

If an individual enrolled in the New Options Waiver Program is diagnosed with a terminal illness, he or she may elect to enroll in the Hospice program. He or she may continue to receive the following waiver services that are not duplicative of the hospice services:

. Community Access Services

. Prevocational Services

Request or claims for other waiver services while enrolled in the Hospice program will be denied.

Rev. 01/2014
When a NOW participant elects to enroll in the Hospice program, the hospice agency assumes full responsibility for the professional management of the individual’s hospice care in accordance with the hospice Conditions of Participation. When an individual enrolled in a waiver program elects hospice, the hospice agency, the waiver participant and the waiver participant case manager must communicate, establish, and agree upon a coordinated plan of care for both providers that reflects the hospice philosophy and is based on an assessment of the individual’s needs and unique living situation. The Hospice provider must coordinate care of the participant enrolled in other Medicaid programs, i.e. Home and Community-Based Waivers and Nursing Facilities, as evidenced in the participant’s hospice plan of care.
A participant may receive more than one service within a single waiver program, but a participant may not participate in more than one waiver program at any given time. Claims submitted for services rendered to the same participant under more than one Waiver Program will be denied.

. When a NOW participant elects Hospice services, a plan of care must be written and be consistent with the hospice philosophy of care. The plan of care must be written in accordance with the CFR and include the individual’s current medical, physical, psychosocial, and spiritual needs. The hospice must designate an RN from the hospice to coordinate the implementation of the plan of care.

. Evidence of the coordinated plan of care must be in the clinical records of both providers. The waiver provider and the hospice must communicate with each other when any changes are indicated to the plan of care and each provider must be aware of the other’s responsibilities in implementing the plan of care.

. All hospice services must be provided directly by hospice employees and cannot be delegated. The hospice agency may involve the waiver provider staff in assisting with the administration of prescribed therapies, included in the plan of care, only to the extent that the hospice would routinely utilize the service of the patient’s family/caregiver in implementing the plan of care.

The waiver provider must offer the same service to its participant who has elected the hospice benefit to remain consistent with participants who have not elected the hospice benefit. The participant receiving hospice services should not experience any lack of these services because of his or her status as a hospice program participant.

905. Transportation Requirements

Individual and agency providers that provide transportation as a part of a waiver service specified in the NOW Part III manual must meet the following requirements:

A. Be legally licensed in the State of Georgia with the class of license appropriate to the vehicle operated if transporting participants as follows:
1) Have a valid, Class C license as defined by the Georgia Department of Driver Services for any single vehicle with a gross vehicle weight rating not in excess of 26,000 pounds.

2) Have valid, Commercial Driver’s License (CDL) as defined by the Georgia Department of Driver Services if the vehicle operated falls into one of the following two classes:

i. If the vehicle has a gross vehicle weight rating of 26,001 or more; or

ii. If the vehicle is designated to transport 15 or more passengers, including the driver.
B. Have no more than two chargeable accidents, moving violations, or any DUIs in a three (3) year period within the last five (5) years of the seven (7) year Motor Vehicle Record (MVR) period if transporting participants.

NOTE: The Department will allow an exception to Out-of-State Driver’s License and MVP record under the following circumstances: (1) the individual is on active duty in Georgia; (2) the individual is a college student enrolled at a Georgia college or university; or (3) the individual’s place of residence is a neighboring state on the border of Georgia. For individual to be granted this exception, he or she must:
. Have a valid, Class C license

. Have no convictions for substance abuse, sexual crime or crime of violence for five (5) years prior to providing the service

. Have current, valid insurance

906. Day Services Requirements

The delivery of day services to include Community Access, Prevocational, and Supported Employment services must be based on the participant’s needs and outlined in the Individual Services Plan. Any variation from the Individual Service Plan should be considered noncompliance and will be reported as such.
Rev 07 2009

907. Developmental Disability Professional Requirements
Rev. 10 2010

DDP services rendered by a provider agency must be provided by a qualified individual DDP employed by, or under professional contract with, the provider agency.

At least one agency employee or professional under contract with the agency must:

. Be a Developmental Disability Professional (DDP)

. Have responsibility for overseeing the delivery of waiver services to participants.

The same individual may serve as the agency director, nurse and/or DDP,
provided the employee meets the qualifications and/or designation of each position. However, the duties of shared roles for each position must be separately delivered and documented. Reporting of change in approved and designated DDP (addition or termination) is as indicated in the current state fiscal year DBHDD Provider Manual, Part II Standards for Developmental Disabilities Providers located at www.dbhdd.georgia.gov (For Providers Community Provider Manuals, Provider Manual for Community Developmental Disabilities Providers).

Rev 10 2013
Each Development Disability Professional (DDP) has a specified schedule or contract with sufficient hours per week to meet the duties of the DDP and level of need for individuals receiving services, which include but are not limited to:

. 1. Overseeing the services and supports provided to participants that include:
a. The agency DDP monitors and/or participates in the implementation and delivery of the Individual Service Plan (ISP).
b. The agency DDP supervises the delivery of service and ensures the strategies reflect the goals and objectives of the ISP.
c. The agency DDP monitors the progress toward achievement of goals in the ISP, and makes recommendations for modifications to the ISP, as appropriate.

2. Supervising the formulation of the participant’s plan for delivery of all waiver services provided to the participant by the provider, on an annual basis subsequent to ISP development and after any ISP addendum that includes, but is not limited to:
a. Ensuring the implementation strategies reflect the ISP and the needs of the participant
b. The agency DDP participates in the development of the ISP as indicated by signature of the ISP.

3. Conducting or overseeing functional assessments to support formulation of the participant’s plan for delivery of all waiver services as indicated by the DDP signature:
Rev 10 2013
a. The Health Risk Screening Tool;
b. The Supports Intensity Scale;
c. Functional Behavioral Analysis, if qualified;
d. And others as needed or required.

4. Supervising high intensity services that address health and safety risks for the participants as indicated by the DDP signature:
a. The agency DDP is involved in reviewing and/or writing, and the implementation and effectiveness of the Behavior Support Plan
b. The agency DDP is involved in reviewing and/or writing, and the implementation and effectiveness of the Crisis Plan
c. The agency DDP is involved in identifying ongoing supports as needed (medical and/or behavioral) in collaboration with appropriate personnel

The provider will be responsible for monitoring and ensuring the DDP meets his/her above assigned responsibilities utilizing the below performance indicators.

Performance indicators of the responsibilities listed above (1-4) are as follows:
a. Active participation in the planning meeting documented in either the meeting minutes/notes and/or progress notes prior to ISP meeting.
b. Documented contact with the SC prior to the ISP date.
c. Consulted with, supervised, and provided guidance to direct support staff regarding implementation of the services.
d. The DDP will complete documentation in any individual’s record for any of the above responsibilities. This documentation shall include the signature, title/credentials, timed (start and end time of delivery of service) and date.
Rev 10 2013
e. The DDP will complete, or assure the completion of required agency assessments, including but not limited to, HRST and SIS, within the given time frame.

For additional details regarding documentation requirements, refer to Chapter 1100 of this manual.

Hours scheduled and worked must be sufficient to meet the individual needs of each participant served by the provider. The provision of DDP oversight and service provision must be documented in the participant’s record. A DDP is not scheduled to work only on a PRN (pro re nata) basis.

The DDP personnel file must include the following:
Rev 10 2013
a. A signed DDP job functions that meet the DDP requirements;

b. A specified schedule for each site and sufficient contract hours per week (not a PRN staff) to meet the individual’s needs of the assigned caseload must be maintained on site;

c. There is documentation of attestation by the DDP that the scheduled or contracted hours do not conflict with his/her work with another provider agency;

d. There is documentation to verify the DDP’s face to face visits of specified scheduled and contact hours in the individual’s record;

e. At a minimum, the DDP for residential services must document on a monthly basis, a review of each individual’s health, safety, ISP goals progress and any recommendations identified. Where applicable, the adequacy of high intensity services should be included;
f. For services other than residential such as Community Living Support Services and Community Access Services, DDP visits are documented as indicated in ISP; and

g. For individuals on exceptional rate, there is documentation of additional direct service provision and oversight by the DDP, if applicable.

NOTE: DDP direct service provision and oversight for a participant with an approved exceptional rate is in addition to the above requirements and as specified in the letter of approval for the exceptional rate.

Required Training for Developmental Disabilities Professional

The provider agency must also show participation and document the participation of each DDP in a minimum of eight (8) hours per year of DBHDD sponsored or other training in the area of developmental disabilities in addition to initial orientation requirements for new employees listed in Chapter 600, Section 606. . Other required trainings for DDPs in their first year of employment include:
Rev 10 2012
Rev 10 2013
. Individual Service Planning

. Support Intensity Scale overview

. Health Risk Screening Tool on line training

908. Termination of Participant Services Requirements

The provider must provide a minimum of a 30 days notice when terminating NOW services to a participant. The provider must agree to be a part of the transition process with the support coordinator and DBHDD Regional Office and continue to provide NOW services until a new provider is identified and transition to this provider occurs in order to assure continuity of care and maintenance of health and safety for the participant.

909 Proxy Caregivers and Health Maintenance Activities
Rev 10 2011

Licensed provider agencies, including co-employer agencies, must abide by the Rules and Regulations for Proxy Caregivers Used in Licensed Healthcare Facilities, Chapter 111-8-100. Proxy Caregivers may be used under the following licensure categories:

. Private Homecare

. Personal Care Home

. Community Living Arrangements

. Assisted Living Communities

. Residential Drug Abuse Treatment Programs

. Traumatic Brain Injury Facilities

PART II – CHAPTER 1000

BASIS FOR REIMBURSEMENT

1001. General

Reimbursement for NOW services is made by the Division of Medicaid to providers who have completed the enrollment process and rendered services to eligible participants with a current level of care and valid prior authorization subsequent to the screening and assessment by the Intake and Evaluation Team. Reimbursement is made only for services contained in the Individual Service Plan and authorized by the Regional DBHDD Office (See Appendix A). Failure to adhere to any provision of the NOW Program will require that the provider repay all funds collected for services, including funds collected for services for which required documentation was not prepared. In addition, if a provider is judged to have provided inadequate justification for services rendered, the Department will review all relevant documentation before authorizing payments.

Rev. 07 2011
1002. Reimbursement Methodology

The rates for NOW services are prospective rates based on historical costs where available, and based on State Plan costs for comparable services for new services where historical cost information is not available.

In extraordinary circumstances related to transition of an individual from an institution or imminent risk of institutionalization of an individual, providers may request:

(1) the payment of a rate that exceeds the established maximum rate for the following NOW services:

. Community Living Support Services

. Respite Overnight Services

. Community Access Group Services

(2) the approval of units that exceed the maximum allowable units for the following NOW services:

. Specialized Medical Supplies

. Specialized Medical Equipment

Exceptional rate approval or approval to exceed the maximum allowable units is tied to the assessment of individual needs of the participant as documented in the Intake and Evaluation approved Individual Service Plan (ISP). The Interdisciplinary Team must approve the need for an exceptional rate or exceeding the maximum allowable units, as documented in the ISP (see Appendix H for required documentation for consideration of an exceptional rate and the protocol for review of exceptional rate requests).
Rev. 07 2010
Exceptional rate requests and request to exceed the maximum allowable units are subject to the DBHDD approval with notification of approval to the Department. Exceptional rates are approved according to established tier rates, but in no instance, will an exceptional rate be approved that exceeds the actual provider costs to provide services. The DBHDD review of exceptional rate requests include consideration of the configuration of the residential setting that is most cost effective for the State.

Providers must be authorized by the DBHDD Regional Office and the Division of Developmental Disabilities to receive exceptional rates beyond the Medicaid maximum rates for waiver services or for additional units beyond the Medicaid allowable maximum units. Any approval of an exceptional rate or additional units beyond the maximum allowable units is time limited to a maximum of one year. The provider must maintain a copy of the exceptional rate or additional units beyond the maximum approval letter in the participant’s record.

1003. General Claims Submission Policy for Ordering, Prescribing, or Referring (OPR) Provider
Rev 07 2013
Rev 04 2014

The Affordable Care Act (ACA) requires physicians and other eligible practitioners who order, prescribe and refer items or services for Medicaid beneficiaries to be enrolled in the Georgia Medicaid Program. As a result, CMS expanded the claim editing requirements in Section 1833(q) of the Social Security Act and the providers’ definitions in sections 1861-r and 1842(b)(18)C. Therefore, claims for services that are ordered, prescribed, or referred must indicate who the ordering, prescribing, or referring (OPR) practitioner is. The department will utilize an enrolled OPR provider identification number for this purpose. Any OPR physicians or other eligible practitioners who are NOT already enrolled in Medicaid as participating (i.e., billing) providers must enroll separately as OPR Providers. The National Provider Identifier (NPI) of the OPR Provider must be included on the claim submitted by the participating, i.e., rendering, provider. If the NPI of the OPR Provider noted on the Georgia Medicaid claim is associated with a provider who is not enrolled in the Georgia Medicaid program, the claim cannot be paid.

Effective 4/1/2014, DCH will begin editing claims submitted through the web, EDI and on CMS-1500 forms for the presence of an ordering, referring or prescribing provider as required by program policy. The edit will be informational until 6/1/2014. Effective 6/1/2014, the ordering, prescribing and referring information will become a mandatory field and claims that do not contain the information as required by policy will begin to deny.

For the NEW CMS-1500 claim form:

Enter qualifiers to indicate if the claim has an ordering, referring, or prescribing provider to the left of the dotted line in box 17 (Ordering = DK; Referring = DN or Supervising = DQ).
For claims entered via the web:

Claims headers were updated to accept ordering or referring Provider ID and name for Dental and Institutional claims and the referring provider’s name for Professional claims. The claim detail was updated to accept an ordering or referring provider ID and name. Utilize the “ordering” provider field for claims that require a prescribing physician.

For claims transmitted via EDI:

The 837 D, I, and P companion guides were updated to specifically point out the provider loops that capture the rendering, ordering, prescribing, referring and service facility provider information that is now used to transmit OPR information.

The following resources are available for more information:

. Access the department’s DCH-i newsletter and FAQs at http://dch.georgia.gov/publications

. Search to see if a provider is enrolled at
https://www.mmis.georgia.gov/portal/default.aspx

Click on Provider Enrollment/Provider Contract Status. Enter Provider ID or NPI and provider’s last name.

1004. Limitations on Billing of Case Management

Case Management Services means services which will assist Medicaid eligible individuals to gain access to needed medical, social, educational and other services. Such services include but are not limited to, the following:
. Assessment of eligible individual to determine service needs, including activities that focus on needs identification, to determine the need for any medical educational, social or other services.

. Development of a specific care plan based on the information collected through assessment; that specifies the goals and actions to address the medical, social, educational and other services needed by eligible individuals.

. Referral and related activities to help and individual obtain needed services.

. Monitoring and follow-up activities, including activities and contacts that are necessary to ensure the care plan is effectively implemented and adequately addressing the needs of the individual.

Duplication of Case Management Services

Federal policy and the Department of Community Health (DCH) prohibit the
reimbursement for case management services to more than one agency or Medicaid provider that renders case management services to an individual. This policy is set forth according the federal Requirements and Limits Applicable to Specific Services defined in the State Medicaid Manual, section 4302.

It is the responsibility of the case manager to ensure that the participant is not receiving case management services from any other agency. The case manager must obtain from the participant information regarding any and all other services that he/she may be receiving prior to enrolling the participant in a case management program. If the case manager should learn that the participant is enrolled in another case management program, the case manager is advised not to render any case management services until it is verified that his/her case management services are primary. This may require termination of the participant from another case management provider before case management from the new provider can be billed. It is the case manager’s responsibility to advise the participant of the various case management choices available to the participant and to allow the participant to make an affirmative choice among them.

Basis for Reimbursement

DCH will reimburse only one provider agency for case management services. The Department has established the case management hierarchy below to define which case management is primary and will be reimbursed. The Department’s billing system has been modified to include edits to ensure the hierarchy is followed in the case of billing from more than one case management provider. The case management provider highest on the hierarchy will be reimbursed if 2 case managers should submit claims for the same month of service.

1) COS 830 – (Case Management Organization – CMO)
2) COS 851 – (SOURCE Case Management)
COS 930 – (SOURCE Case Management)
3) COS 660 – (Independent Care Waiver)
COS 680/681 (New Options Waiver/Comprehensive Supports Waiver) 4) COS 442 – (C-Bay)
5) COS 764 – (Child Protective Services Targeted Case Management) 6) COS 800 – (Early Intervention Case Management) 7) COS 765 – (Adult Protective Services Targeted Case Management) 8) COS 763 – (At Risk of Incarceration Targeted Case Management)
9) COS 762 – (Adults with AIDS Targeted Case Management)
10) COS 790 – (Rehab Services/DSPS)
11) COS 960 – (Children Intervention School Services)

NOTES: Persons enrolled in hospice have case managers who manage all of their care and may not receive case management from any other program while enrolled in hospice. The Department’s hospice lock-in system will automatically cause any
other claims for case management to be denied.

1005. CMS 1500 Claims Form

Effective April 1, 2014, providers who submit paper claims will be required to use the revised CMS 1500 claim form (version 02/12) for claims received on and after April 1, 2014. The revised CMS 1500 form contains a number of changes. These changes include but not limited to references to ICD-10 codes, identification of Ordering, Prescribing, and Referring providers, and the expansion of the number of possible diagnosis codes on a claim.
PART II – CHAPTER 1100

DOCUMENTATION AND RECORDS

1101. General

This chapter specifies the general requirements for documentation and records for NOW providers. The Part III, Policies and Procedures Manual for the New Options Waiver specifies documentation and record requirements specific to individual waiver services. Chapter 700 of this manual includes any documentation and record requirements for screening, as well as initial and reevaluations regarding level of care.

1102. Individualized Service Planning and Implementation
Rev. 10 2010

The intent of the development of the Individual Service Plan (ISP) is a process that focuses on the individual’s hopes, dreams and vision of a “life well-lived”. Information included within this individualized plan should be presented as a single plan describing the individual’s service/support needs within a daily life versus a daily service. Support networks should work closely together to identify issues of risk and needed supports to address those risks while never losing sight that the individual is at the center of the planning process and included in all discussions. Individualized service planning produces an organized statement of the proposed services to guide the provider(s) and participant throughout the duration of service. Chapter 700 of this manual covers the process of development of the initial Individual Service Plan. This section describes the process for updating subsequent Individual Service Plans.

A. Annual Individual Service Plan Document: After the initial Individual Service Plan (ISP), the participant’s support coordinator is responsible for the development of the annual ISP document. It is the responsibility of the support coordinator to discuss service options with the participant, his/her family and others as appropriate over the course of the year. Annual ISP meetings will use the participant’s date of birth as a guide to annual review.

B. Choice of Service Options and Providers: The ongoing discussion on the range of service options is repeated at time of the annual review. At this time, it is the Support Coordinator’s responsibility to discuss service options based on the participant’s assessed support needs, with the participant, his/her family and others as appropriate in order to identify social, education, and other needs. These needs may indicate Medicaid and non-Medicaid covered services. The support coordinator works with the participant and/or family/representative to determine their choices among the service options for the participant and available providers prior to the formal Individual Service Plan meeting with the chosen provider(s).
Rev. 01 2011
Rev. 01 2013

C. ISP Meeting Participants and Documentation: The participant’s support coordinator facilitates the ISP development. The support coordinator works with the participant (and his/her representative) to determine whom he or she wants to include in the ISP development meetings and the formal ISP meeting and invites those identified. Individuals participating in these meetings should include people who best know the participant outside the service system and from other agencies and resources as deemed appropriate, with the participant or legal representative’s consent. The support coordinator informs the participant that he or she can have a representative to help with the ISP development process. The support coordinator documents the occurrence of all ISP development meetings with the participant, his/her family and others as appropriate.

D. ISP Document: The planning process produces an organized statement of proposed services to guide the service provider(s) and the participant throughout the duration of service. The organized statement, or Individual Service Plan (ISP), is based on what is important to/for the participant and includes the following:
Rev. 01 2013

1. Desired outcomes of services (goals);
2. The services to be provided, including the frequency and amount;
3. Known medical conditions, allergies and medication summaries;
4. Diagnoses to ensure treatment of medical conditions such as obesity and diabetes.
5. Behavioral Health conditions and connections to community mental health services as appropriate.
6. Needed connections to primary care physicians and specialty medical providers.
7. The provider responsible for each service or the name of the service element and type of professional staff that is responsible for service (e.g., Registered Nurse);
8. Consideration of the following:
a. The participant’s support systems; and

b. The community resources available to be used

9. Wellness of individuals is facilitated through:

a. Advocacy;
Rev. 10 2013
b. Individual care practices;

c. Education;

d. Sensitivity to issues affecting wellness including, but not limited to:

i. Gender;

ii. Culture; and

iii. Age.

e. Incorporation of wellness goals within the individual plan.

f. The intent of the development of the ISP is a process that focuses on the individual’s hopes, dreams and visions of a “life well-lived.” Information included within this individualized plan should be presented as a single plan that addresses residential and all other paid supports that the individual receives. The Support networks should work closely together to identify issues of risk and needed supports to address those risks while never losing sight that the individual is at the center of the planning process and included in all discussions. If the individual receives residential services, the residential provider has the primary responsibility in conjunction with the support coordinator or state services coordinator to assure a holistic (i.e., integrated) support plan for all services identified as a need for the individual.

Rev. 01 2013
E. ISP Listing of Services: The ISP must list the services to be provided, the frequency of the services, and the name of provider to deliver the services. No service will be reimbursed which is not listed on the Individual Service Plan approved by the Regional DBHDD Intake and Evaluation Team. Assurance is made that goods and services provided by the waiver are not covered under the Medicaid State Plan when applicable.

F. Participant’s Involvement and Acceptance in Developing ISP Document: The participant’s involvement and acceptance, if applicable, in developing the ISP must be documented.

1. The participant’s signature on the ISP signifies this acceptance.

2. If a participant declines or is unable to sign the ISP, it is documented in the participant’s record.

G. Family Involvement: Unless clinically or programmatically contraindicated, participants are asked to consent to the family’s involvement in the service planning and service delivery processes. Contraindications, if present, and the participant’s refusal, if permission is not given, are documented in the record or ISP.

H. ISP Annual Review and Amendments: Each ISP must be reviewed and modified annually, or more often as needed to reflect all life changes progress or lack of progress, to identify changes in outcome, review changes in
medical, psychological or social services, and to identify new problems or goals. Circumstances warranting more frequent reviews would include, but are not limited to, significant changes in participant functioning, increases or decreases in services, change of provider(s), changes in medical, social or behavioral statuses, family crisis, and reduction in funding.

Individualized plans or portions of the plan must be reassessed as indicated by the following:
a. Changing needs, circumstances and responses of the individual, including but not limited to:

i Any life change;
ii Change in provider;
iii Change of address;
iv Change in frequency of service.
b. As requested by the individual;

c. As required for re-authorization;

d. At least annually;

e. When goals are not being met.
Rev. 10 201
I. The Organization Maintains a System of Information Management that Protects Individual Information and that is Secure, Organized and Confidential

1. The organization has clear policies, procedures, and practices that support secure, organized and confidential management of information, to include electronic individual records if applicable.

2. Maintenance and transfer of both written and spoken information is addressed:

a. Personal individual information;

b. Billing information; and

c. All service related information.
3. The organization has a Confidentiality and HIPAA Privacy Policy that clearly addresses state and federal confidentiality laws and regulations, including but not limited to federal regulations on “Confidentiality of Alcohol and Drug Abuse Patient Records” at 42 C.F.R. Part 2 (as applicable) and state laws at O.C.G.A. §§ 37-3-166 (MH), 37-4-125 (DD) and 37-7-166 (AD) as applicable. The organization has a Notice of Privacy Practices that gives the individual adequate notice of the organization’s policies and practices regarding use and disclosure of their Protected Health Information (PHI). The notice should contain mandatory elements required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II). In addition, the organization should address:

a. HIPAA Privacy and Security Rules, as outlined at 45 CFR Parts 160 and 164 are specifically reviewed with staff and individuals;
Rev 10 2013
b. Appointment of the Privacy Officer;

c. Training to be provided to all staff;

d. Posting of the Notice of Privacy Practices in a prominent place; and

e. Maintenance of the individual’s signed acknowledgement of receipt of Privacy Notice in their record;

f. Provision of the rights of individuals regarding their PHI as defined in federal and state laws and in HIPAA, including but not limited to:

i. Right to access to one’s own record.

ii. Right to request an amendment.

iii. Right to request communications by alternative means.

iv. Right to request restriction of access by others.

a. Identification of its Business Associates, and obtaining Business Associate agreements with Business Associates, in compliance with HIPAA requirements.

b. Identification of violations of confidentiality or HIPAA and follow up to include compliance with all requirements of HIPAA at 45 C.F.R. sections 164.400 through 164.414:

i. Reporting of violations to the Privacy Officer.

ii. Risk assessment of the violation as required by HIPAA provisions.

iii. Determination of whether the violation constitutes a “breach” as defined by HIPAA.

iv. Notifications of breaches to the individual(s) affected, to the Secretary of Health and Human Services, and if necessary to the media, in compliance with HIPAA requirements.

h. Corrective Actions for sanctions of employee(s) as necessary, mitigation of harm to any individual and preventing risks to PHI

4. A record of all disclosures of Protected Health Information (PHI) should be kept in the medical record, so that the organization can provide an accounting of disclosures to the individual for 6 years from the current date. The record must include:
a. Date of disclosure;

b. Name of entity or person who received the Protected Health Information;

c. A brief description of the Protected Health Information disclosed;

d. A copy of any written request for disclosure; and

e. Written authorization from the individual or legal guardian to disclose PHI, where applicable.

5. Authorization for release of information is obtained when Protected Health Information of an individual is to be released or shared between organizations or with others outside the

Rev 10 2013
Rev 10 2013
organization. All applicable DBHDD policies and procedures and HIPAA Privacy Rules (45 CFR parts 160 and 164) related to disclosure and authorization of Protected Health Information are followed. Information contained in each release of information must include:

a. Specific information to be released or obtained;

b. The purpose for the authorization for release of information;

c. To whom the information may be released or given;

d. The time period that the release authorization remains in effect (reasonable based on the topic of information, generally not to exceed a year); and,

e. A statement that authorization may be revoked at any time by the individual, to the extent that the organization has not already acted upon the authorization.
6. Exceptions to use of an authorization for release of information are clear in policy:

a. Disclosures may be made if required or permitted by law;

b. Disclosure is authorized as a valid exception to the law;

c. A valid court order or subpoena are required for mental health or developmental disabilities records;

d. A valid court order and subpoena are required for alcohol or drug abuse records;

e. When required to share individual information with the DBHDD or any provider of treatment or services for the individual under contract or LOA with the DBHDD; or

f. In the case of an emergency treatment situation as determined by the individual’s physician, the chief clinical officer can release Protected Health Information (PHI) to the treating physician or psychologist.
7. The organization has written operational procedures, consistent with legal requirements governing the retention, maintenance and purging of records.

a. Records are safely secured, maintained, and retained for a minimum of six (6) years from the date of their creation or the date when last in effect (whichever is later).

b. Protocol for all records to be returned to or disposed of as directed by the contracting regions after specified retention period or termination of contract/agreement; and

c. Compliance with HIPAA Security Rule provisions to the degree mandated by or appropriate under the Security Rule to protect the security, integrity and availability of records.
8. The organization has written policy, protocols and documented practice of how information in the record is transferred when an individual is relocated or discharged from service to include but not be limited to:

Rev 10 2013
Rev 10 2013
a. A complete certified copy of the record to DBHDD or the provider who will assume service provision, that includes individual’s Protected Health Information, billing information, service related information such as current medical orders, medications, behavior plans as deemed necessary for the purposes of the individual’s continuity of care and treatment;

b. Unused Special Medical Supplies (SMS), funds, personal belongings, burial accounts; and

c. The time frames by which transfer of documents and personal belongings will be completed.

9. Assessments, ISPs, and documentation required by Medicaid are to be retained in the individual’s records for six years.
Rev 10 2013
J. Medication Oversight and Monitoring

1. A copy of the physician(s) order or current prescription dated and signed within the past year is placed in the individual’s record for every medication administered or self-administered with supervision. These include:

c. Regular, on-going medications;

d. Controlled substances;

e. PRN (as needed) Over-the-counter (OTC) medications;

f. PRN medications (does not include standing orders for psychotropic medications for symptom management of behavior); or

g. Discontinuance order.

2. Anti-psychotic medications must be prescribed by a psychiatrist or psychiatric nurse practitioner unless the medication is prescribed for epilepsy or dementia and there is documentation that includes:

a. Informed consent for the medication is obtained and a signed copy is maintained in the clinical record. It is the responsibility of the physician/designee to complete the informed consent;

b. The treating psychiatrist or psychiatric nurse personally examines the individual to determine whether this person has the capacity to understand to consent for herself or himself;

c. If the individual does not have the capacity to consent for herself or himself, an appropriate substitute decision maker is identified based on the Order of Priority outlined in Georgia Medical Consent Law;

d. The risks/benefits is explained in language the individual can understand;

e. Medication education provided by the organization’s staff should be documented in the clinical record; and

f. Education regarding the risks and benefits of the medication is documented.

3. The organization has written policies, procedures, and practices for all aspects of medication management including, but not limited to:

a. Prescribing:
i. The physician’s order or current prescription is defined as a prescription signed by one authorized to prescribe in Georgia; and

ii. Electronic prescriptions (E-scripts and Sure scripts), if practiced

b. Authenticating orders: Describes the required time frame for obtaining the actual or faxed physician’s signature for telephone or verbal orders accepted by a licensed nurse.

c. Ordering and Procuring medication and refills: Procuring initial prescription medication and over-the-counter drugs within twenty-four hours of prescription receipt, and refills before twenty-four hours of the exhaustion of current drug supply.

d. Medication Labeling: Describes that all medications must have a label affixed by a licensed professional with the authority to do so. This includes sample medications.

e. Storing: Includes prescribed medications, floor stock drugs, refrigerated drugs, and controlled substances.

f. Security: Requires safe storage of medication as required by law including single and double locks, shift counting of the medications, individual dose sign-out recording, documented planned destruction, and refrigeration and daily temperature logs. All controlled substances are double locked and there is documented accountability of controlled substances at all stages of possession.

g. Dispensing: Describes the process allowed for pharmacists and/or physicians only. Includes the verification of the individual’s medications from other agencies and provides a documentation log with the pharmacist’s or physician’s signature and date when the drug was verified. Only physicians or pharmacists may re-package or dispense medications:

i. This includes the re-packaging of medications into containers such as “day minders” and medications that are sent with the individual when the individual is away from his residence.

ii. Note that an individual capable of independent self-administration of medication may be coached in setting up their personal “day minder”.

h. Supervision of individual self-administration: Includes all steps in the process from verifying the physician’s medication order to documentation and observation of the individual for the medication’s effects each time supervision of individual self-administration occurs. Makes clear that staff members may not administer medications unless licensed to do so, and the methods staff members may use to supervise or assist, such as via hand-over-hand technique, when an individual self-administers his/her medications. Where medications are self-administered, protocols are defined for training to support individual self-administration of medication.

i. Administration of medications: Administration of medications may be done only by those who are licensed in this state to do so.
j. Recording: Includes the guidelines for documentation of all aspects of medication management. This includes adding and discontinuing medication, charting scheduled and as needed medications, observations regarding the effects of drugs, refused and missing doses, making corrections, and a legend for recording. The legend includes initials, signature and title of staff member.

k. Disposal of discontinued or out-of-date medication: Includes via an environmentally friendly method of disposal by pharmacy.

l. Education to the individual and family (as approved by the individual) regarding all medications prescribed and documentation of the education provided in the clinical record.

m. All PRN or “as needed” medications will be accessible for each individual as per his/her prescriber(s) order(s) and as defined in the individual’s ISP. Additionally, the organization must have written protocols and documented practice that ensures safe and timely accessibility that includes, at a minimum, how medication will be stored, secured or refrigerated when transported to different programs and home visits.

4. Organizational policy, procedures and documented practices stipulate that:

a. The use of Proxy Caregivers for Health Maintenance Activities must be in accordance with requirements as specified in Chapter 900, Section 909 of this manual.

b. There are safeguards utilized for medications known to have substantial risk or undesirable effects, to include:

i. Obtaining and maintaining copies of appropriate lab testing and assessment tools that accompany the use of the medications prescribed from the individual’s physician for the individual’s clinical record, or at a minimum, documenting in the clinical record the requests for the copies of these tests and assessments, and follow-up appointments with the individual’s physician for any further actions needed;

ii. For individual in residential services, there is documentation of a review of polypharmacy usage in order to ensure that intra-class and inter-class polypharmacy use for psychiatric reasons are justifiable, if applicable, using the following monitoring criteria:

a) Intra-class Polypharmacy monitoring reports includes individuals who are on more than one psychotropic medication in the same single class of medications (2 or more antipsychotics, antidepressants, mood stabilizers), e.g., the use of 2 anti-depressants to treat depression.

b) Inter-class Polypharmacy monitoring reports include individuals who are on 3 or more different classes of medications (antipsychotics, antidepressants, mood stabilizers), e.g., the use of an antipsychotic, an antidepressant and mood stabilizer to treat someone with Schizoaffective Disorder.
c. There are protocols for the handling of licit and illicit drugs brought into the service setting. This includes confiscating, reporting, documenting, educating, and appropriate discarding of the substances.

d. The organization defines requirements for timely notification to the prescribing professional regarding:

i. Medication errors;

ii. Medication problems;

iii. Drug reactions; and

iv. Refusal of medication by the individual.

e. There are practices for regular and ongoing physician review of prescribed medication including, but not limited to:

i. Appropriateness of the medication;

ii. Documented need for continued use of the medication;

iii. Monitoring the presence of side effects. (Individuals on medications likely to cause tardive dyskinesia are monitored at prescribed intervals using an Abnormal Involuntary Movement Scale (AIMS) testing.);

iv. Monitoring of therapeutic blood levels, if required by the medication such as Blood Glucose testing, Dilantin blood levels and Depakote blood levels.

v. Ordering specific monitoring and treatment protocols for Diabetic, hypertensive, seizure disorder, and cardiac individuals, especially related to medications prescribed and required vital sign parameters for administration;

vi. Maintain medication protocols for specific individuals in:

a) Epinephrine for anaphylactic reaction;

b) Insulin required for diabetes;

c) Suppositories for ameliorating serious seizure activity; and

d) Medications through a nebulizer.

vii. Monitoring of other associated laboratory studies.

f. For organizations that secure their medications from retail pharmacies, there is a biennial assessment of agency practice of management of medications at all sites housing medications. An independent licensed pharmacist or licensed registered nurse conducts the assessment. The report shall include, but may not be limited to:

i. A written report of findings, including corrections required;

ii. A photocopy of the pharmacist’s license or a photocopy of the license of the Registered Nurse; and

iii. A statement of attestation from the independent licensed pharmacist or licensed Registered Nurse that all issues have been corrected.

5. The “Eight Rights” for medication administration are defined with detailed guidelines for staff to implement within the organization to verify that right:

a. Right person: Check the name on the order and the individual and include the use of at least two identifiers.
b. Right medication: Check the medication label against the order.

c. Right time: Check the frequency and time to be given of the ordered medication and double check that the ordered dose is given at the correct time. Confirm when last dose was given.

d. Right dose: includes verification of the physician’s medication order of dosage amount of the medication; with the label on the prescription drug container and the Medication Administration Record document to ensure all are the same.

e. Right route: Check the order and appropriateness of route ordered and confirm that the individual can take or receive the medication by the ordered route.

f. Right position: The correct anatomical position for the medication method or route to ensure its proper effect, instillation and retention. If needed, individual should be assisted to assume the correct position.

g. Right Documentation: Document the administration/supervision after the ordered medication is given on the MAR; and

h. Right to Refuse Medication: includes staff responsibilities to encourage compliance, document the refusal, and report the refusal to the administration, nurse administrator, and physician.

6. A Medication Administration Record is in place for each calendar month that an individual takes or receives medication(s):

a. Documentation of routine, ongoing medications occur in one discreet portion of the MAR and include but may not be limited to:

i. Documentation by calendar month that is sequential according to the days of the month;

ii. A listing of all medications taken or administered during that month including a full replication of information in the physician’s order for each medication:

a) Name of the medication;

b) Dose as ordered;

c) Route as ordered;

d) Time of day as ordered; and

e) Special instructions accompanying the order, if any, such as but not limited to:
1. Must be taken with meals;
2. Must be taken with fruit juice;
3. May not be taken with milk or milk products.
iii. If the individual is to take or receive the medication more than one time during one calendar day:

a) Each time of day must have a corresponding line that permits as many entries as there are days in the month;

iv. All lines representing days and times preceding the beginning or ending of an order for medications shall be marked through with a single line;

v. When a physician discontinues (D/C) a medication order, that discontinuation is reflected by the entry of “D/C” at the date and
time representing discontinuation; followed by a mark through of all lines representing days and times that were discontinued.

b. Documentation of medications that are taken or received on a periodic basis, including over the counter medications, occur in a separate discreet portion of the MAR and include but may not be limited to:

i. Documentation by calendar month that is sequential according to the days of the month;

ii. A listing of each medication taken or received on a periodic basis during that month including a full replication of information in the physician’s order for each medication:

a) Name of medication;

b) Dose as ordered;

c) Route as ordered;

d) Purpose of the medication; and

e) Frequency that the medication may be taken.

iii. The date and time the medication is taken or received is documented for each use.

iv. When ‘PRN’ or ‘as needed’ medication is used, the PRN medications shall be documented on the same MAR after the routine medications and clearly marked as “PRN” and the effectiveness is documented.

c. Each MAR shall include the legend that clarifies:

i. The identity of the authorized staff’s initials using full signature and title;

ii. The reasons that a medication may not be given, is held or otherwise note received by the individual, such as but not limited to:
“H” = Hospital
“R” = Refused
“NPO”= Nothing by mouth
“HM”= Home Visit
“DS” = Day Service

Rev 10 2013
K. Service Environment

Respectful Service Environment (To include Host Homes and Day Services Sites)

1. Services, supports, care or treatment approaches support the individual in:

a. Living in the most integrated community setting appropriate to the individual’s requirement, preferences and level of independence;

b. Exercising meaningful choices about living environments, providers of services received, the types of supports, and the manner by which services are provided;

c. Obtaining quality services in a manner as consistent as possible with community living preferences and priorities; and
d. Inclusion and active community integration is supported and evident in documentation.

2. Services are provided in an appropriate environment that is respectful of individuals supported or served. (For Host Homes and Community Access Services Sites refer to Operational Standards for Host Homes/Life Sharing and Physical Environment NOW/COMP Part III, Chapter 1700 for Community Access Services). The environment is:

a. Clean;

b. Age appropriate;

c. Accessible (individuals who need assistance with ambulation shall be provided bedrooms that have access to a ground level exit to the outside or have access to exits with easily negotiable ramps or accessible lifts. The home shall provide at least two (2) exits, remote from each other that are accessible to the individuals served);

d. Individual’s rooms are personalized;

e. Adequately lighted, ventilated, and temperature controlled;

f. There is sufficient space, equipment and privacy to accommodate;

g. An area/room for visitation; and

h. Telephone use for incoming and outgoing calls that is accessible and maintained in working order for persons served or supported.

3. The environment is safe:

a. All local and state ordinances are addressed:

i. Copies of inspection reports are available;

ii. Licenses or certificates are current and available as required by the site or the service;

iii. An automatic extinguishing system (sprinkler) shall be installed per city/county requirements for residential settings excluding host homes not governed by other federal, state and county rules and regulations, if applicable; and

iv. Approved smoke alarm shall be installed in all sleeping rooms, hallways and in all normally occupied areas on all levels of the residences per safety code. Smoke alarms especially in the bedrooms shall be tested monthly and practice documented. The facility shall be inspected annually to meet fire safety code and copies of inspection maintained.

b. Installation of Fire alarm system and inspection of equipment meets safety code.

c. Fire drills are conducted for individuals and staff:

i. Once a month at alternative times; including

ii. Twice a year during sleeping hours if residential services;

iii. All fire drills shall be documented with staffing involved;

iv. DBHDD maintains the right to require an immediate demonstration of a fire drill during any on-site visit.

4. When food service is utilized, required certifications related to health, safety and sanitation are available. A three day supply of non-perishable emergency
food and water is available for all individuals supported in residences. A residence shall arrange for and serve special diets as prescribed.

5. Policies, plans and procedures are in place that addresses Emergency Evacuation, Relocation, Preparedness and Disaster Response. Supplies needed for emergency evacuation are maintained in a readily accessible manner, including individuals’ information, family contact information and current copies of physician’s orders for all individual’s medications.

a. Plans include detailed information regarding evacuating, transporting and relocating individuals that coordinate with the local Emergency Management Agency and at a minimum address:

i. Medical emergencies;

ii. Missing persons;

a) Georgia’s Mattie’s Call Act provides for an alert system when an individual with developmental disabilities, dementia, or other cognitive impairment is missing. Law requires residences licensed as Personal Care Homes to notify law enforcement within 30 minutes of discovering a missing individual.

iii. Natural and man-made disasters;

iv. Power failures;

v. Continuity of medical care as required;

vi. Notifications to families or designees; and

vii. Continuity of Operation Planning (COOP) to include identifying locations and providing a signed agreement where individuals will be relocated temporarily in case of damage to the site where services are provided. COOP must also include plans for sheltering in place (for more information go to:
http://www.georgiadisaster.info/PersonsWithDisabilities/disasterpreparedness.html ; and
http://www.fema.gov/about/org/ncp/coop/templates.shtm).
b. Emergency preparedness notice and plans are:

i. Reviewed annually;

ii. Tested at least quarterly for emergencies that occur locally on a less frequent basis such as, but not limited to flood, tornado or hurricane; and

iii. Drilled with more frequency if there is a greater potential for the emergency.

6. Residential living support service options:

a. Are integrated and established within residential neighborhoods;

b. Are single family dwellings;

c. Have space for informal gatherings;

d. Have personal space and privacy for persons supported; and

e. Are understood to be the “home” of the person supported or served.

7. Video cameras may not be used in the following instances:

a. In an individual’s personal residence;

b. In lieu of staff presence; or
c. In the bedroom of individuals, as it is an invasion of privacy and is strictly prohibited.

8. There are policies, procedures, and practices for transportation of persons supported or served in residential services and in programs that require movement of persons served from place to place:

a. Policies and procedures apply to all vehicles used, including:

i. Those owned or leased by the organization;

ii. Those owned or lease by subcontractors; and

iii. Use of personal vehicles of staff.

b. Policies and procedures include, but are not limited to:

i. Authenticating licenses of drivers;

ii. Proof of insurance;

iii. Routine maintenance;

iv. Requirements for evidence of driver training;

v. Safe transport of persons served;

vi. Requirements for maintaining an attendance log of persons while in vehicles;

vii. “Safe use of lift;

viii. Availability of first aid kits;

ix. Fire suppression equipment; and

x. Emergency preparedness.

Rev 10 2013
L. Infection Control Practices are Evident in Service Settings:

1. The organization, at a minimum, has a basic Infection Control Plan which is reviewed bi-annually for effectiveness and revision, if needed. The Plan addresses:

a. Standard Precautions;

b. Hand Washing Guidelines;

c. Proper storage of Personal Hygiene items; and

d. Specific common illnesses/infectious diseases likely to be emergent in the particular service setting.

2. The organization has policies, procedures and practices for controlling and preventing infections in the service setting. There is evidence of:

a. Guidelines for environmental cleaning and sanitizing;

b. Guidelines for safe food handling and storage;

c. Guidelines for laundry; and

d. Guidelines for food preparation.

3. Procedures for the prevention of infestation by insects, rodents or pests shall be maintained and conducted continually to protect the health of individuals served.

4. No vicious/dangerous animals shall be kept. Any pets living in the service setting must be healthy and not pose a health risk to the individual supported. All pets must meet the local, state, and federal requirements to include the following:

a. All animals that require rabies vaccinations annually must have current documentation of the rabies inoculation;

b. Exotic animals must be obtained from federally approved sources; and
c. Parrots and Psittacine family birds must be USDA inspected and banded.

Rev 10 2013
M. Oversight of Contracted/Subcontracted Providers/Professionals by the Organization

1. The organization is responsible for the Contracted/Subcontracted Provider/Professional compliance with:

a. Contract/Agreement requirements, documented and maintained for review;

b. Standards of practice and specified requirements in the Provider manual for the Department of BHDD, including Community Standards for All Providers;

c. Licensure requirements;

d. Accreditation or Community Service Standards Quality Review requirements; and

e. Quality improvement and risk reduction activities.

2. There is documented evidence of active oversight of the Contracted/Subcontracted Provider/Professional capacity and compliance to provide quality care to include monitoring of:

a. Financial oversight and management of individual funds;

b. Staff competency and training;

c. Mechanisms that assure care is provided according to the plan of care for each individual served; and

d. The requirement for a Host Home Study when contracting with a Host Home provider.

3. A report shall be made quarterly to the agency’s Board of Directors regarding:

a. Services provided by Contracted/Subcontracted Provider/Professional ; and

b. Quality of performance of the Contracted/Subcontracted Provider/Professional.

4. A report shall be made to the DBHDD Regional Office prior to the end of the first quarter and third quarter of the fiscal year that includes:

a. Name and contact information of all contracted providers;

b. The specific services provided by each contracted provider;

c. The number and location of individual supported by each contracted provider; and

d. Annualized amount paid to each contracted provider.

1103. Provider Intake

Service providers, except for providers of participant-directed services, conduct an intake for participants at the beginning of waiver services. This section specifies requirements related to that intake. Requirements for providers of participant-directed services are covered in Chapter 1200 of this manual.

A. The service provider intake consists of basic identifying information, including information that the Division of DBHDD requests for the statewide participant data reporting system, appropriate consents to service, and other standardized agency forms. A release of information form will be obtained as needed and will be time, agency, and event specific.

B. The participant is to be informed of projected duration of service, hours of service, rules of conduct, involvement of family participants and participant rights.

Rev. 10 2010
1104. Individual Service Plan (ISP) Goal Progress Documentation

Providers are required to document progress towards moving the participant towards independence by meeting the participant’s 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. This section covers ISP progress documentation for providers, except for providers of participant-directed services. The Part III, Policies and Procedure Manual for the New Options Waiver specifies documentation and record requirements specific to individual waiver services. Chapter 1200 of this policy manual specifies documentation requirements for providers of participant-directed services.

A. Activity Notes/Learning Logs are formulated to document progress or lack of progress towards moving the participant towards independence by meeting the participant’s 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.

B. Activity Notes/Learning Logs document the actual implementation of the planned services, strategies or interventions and reflect the course of service received by the participant and participant’s response to the service provided.

1. Activity Notes/Learning Logs (which may include charts, tracking sheets, narratives, etc.) are a chronological record that reflects the direct contact, other direct and indirect services rendered to attain the expected participant outcomes. Justification for ISP modifications and reviews must be documented in the activity notes.

a. Activity Notes/Learning Logs must be dated and signed by the provider staff making the entries on the date of the occurrence/service.

b. Activity Notes must document provision of services, as indicated on the current ISP and correspond to progress towards moving the participant towards independence by meeting the participant’s 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.

c. Notations of communications from family, significant others and other community agencies that address the condition or needs of participants must be entered in the record.

d. Appointments missed or canceled by the participant or staff are to be documented along with appropriate follow-up attempts to reschedule.

e. Services for which Medicaid is billed must be accurately reflected in the services documented in the participant’s record.

f. Activity Notes/Learning Logs must be kept readily available for review by the Department for purposes of audit or monitoring.

2. Other than as noted above for providers of participant-directed services, there are no exceptions to activity note documentations in detailing service delivery to the NOW participant. Failure to adequately record service documentation to justify reimbursement claims may result in a request for refund by the Department when Utilization Reviews or other focused audits are conducted.

Provider staff must document the service provided to a participant each time service is delivered (See Appendix S of this manual for examples of documentation). If any form is used that includes staff initials, a key for the initials must be in the participant’s record. Any daily service must be documented each day the service is delivered. The daily documentation must include the required elements listed below. Except for providers of participant-directed services, all providers must document the following in the record of each participant each time a waiver service is delivered:
Rev 04 2013
. Specific activity, training, or assistance provided;

. Date and the beginning and ending time when the service was provided;

. 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;

. Progress towards moving the participant in the direction of independence by completing the participant’s 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.

1105. Maintenance of Records

Providers, with the exception of providers of participant-directed services, 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. Maintenance of records requirements for providers of participant-directed services are covered in Chapter 1200 of this manual.

The organization has written operational procedures, consistent with legal requirements governing the retention, maintenance and purging of records. Records are safely secured, maintained, and retained for a minimum of six (6) years from the date of its creation or the date when last in effect (whichever is later).

1105.1 Documentation
Rev. 10 2013

1. The individual record is a legal document, information in the record should be:

a. Organized;

b. Complete;

c. Current;

d. Meaningful;

e. Succinct; and

f. Essential to:

i. Provide adequate and accurate services, supports, care and treatment;

ii. Tell an accurate story of services, supports, care and treatment rendered and the individual’s response;

iii. Protect the individual; their rights; and

iv. Comply with legal regulation.

g. Dated, timed, and authenticated with the authors identified by name, credential and by title:

i. Notes entered retroactively into the record after an event or a shift must be identified as a “late entry”;

ii. Documentation is to be done each shift or service contact by staff providing the service;

iii. If notes are voice recorded and typed or a computer is used to write notes that are printed, each entry must be dated and the physical documentation must be signed and dated by the staff writing the note. Notes should then be placed in the individual’s record; and
iv. If handwritten notes are transcribed electronically at a later date, the former should be kept to demonstrate that documentation occurred on the day billed.

h. Written in black or blue ink;

i. Red ink may be used to denote allergies or special precautions;

j. Corrected as legally prescribed by:

i. Drawing a single line through the error;

ii. Labeling the change with the word “error”;

iii. Inserting the corrected information; and

iv. Initialing and dating the correction.

2. At a minimum, the individual’s information shall include:

a. The name of the individual, precautions, allergies (or no known allergies – NKA) and “volume #x of #y” on the front of the record;

i. Note that the individual’s name, allergies and precautions must be flagged on the medication administration record.

b. Individual’s identification and emergency contract information;

c. Financial information;

d. Rights, consent and legal information including but not limited to:

i. Consent for service;

ii. Release of information documentation;

iii. Any psychiatric or other advanced directive;

iv. Legal documentation establishing guardianship;

v. Evidence that individual rights are reviewed at least one time a year; and

vi. Evidence that individual responsibilities are reviewed at least one time a year.

e. Pertinent medical information;

f. Screening information and assessments, including but not limited to:

i. Functional, psychological and diagnostic assessments.

g. Individual service plan, including:

i. Identified outcomes or goals (in measurable terms);

ii. Interventions or activities occurring to achieve the goals;

iii. The individual’s response to the interventions or activities (progress notes, tracking sheets, learning logs or data);

iv. A projected plan to modify or decrease the intensity of services, supports, care and treatment as goals are achieved; and

v. Discharge planning is begun at the time of admission that includes specific objectives to be met prior to decreasing the intensity of service or discharge.

h. Discharge summary information provided to the individual and new service provider, if applicable, at the time of discharge includes:
i. Strengths, needs, preferences and abilities of the individual;

ii. Services, supports, care and treatment provided;

iii. Achievements;

iv. Necessary plans for referral; and

v. A dictated or hand-written summary of the course of services, supports, care
and treatment incorporating the discharge summary information provided to the individual and new service provider, if applicable, must be placed in the record within 30 days of discharge.
i. The organization must have policy, procedures and practices for Discharge/Transfer/ immediate transfer due to medical or behavioral needs of individuals in all cases. Agency employees, subcontractors and their employees and volunteers who abandon an individual are subject to administrative review by the contracting Regional Office(s) representing DBHDD to evaluate for recommendations to the Department of Community Health concerning increasing new admission capacity further or continuing the relationship with the provider agency.

j. All relocation/discharge of individuals within or outside the agency must have prior approval from the DBHDD Regional Office. A copy of the approval must be maintained in the individual record.

k. Progress notes or Learning Logs (for DD individuals) describing progress toward goals, including:

i. Implementation of interventions specified in the plan;

ii. The individual’s response to the intervention or activity based on data; and

iii. Date and the beginning and ending time when the service was provided.

l. Event notes documenting:

i. Issues, situations or events occurring in the life of the individual;

ii. The individual’s response to the issues, situations or events;

iii. Relationships and interactions with family and friends, if applicable;

iv. Missed appointments including:

a) Findings of follow-up; and

b) Strategies to avoid future missed appointments.

m. Records or reports from previous or other current providers; and

n. Correspondence.

3. The individual’s response to the services, supports, care and treatment is a consistent theme in documentation.

a. Frequency and style of documentation are appropriate to the frequency and intensity of services, supports, care and treatment; and
b. Documentation includes record of contacts with persons involved in other aspects of the individual’s care, including but not limited to internal or external referrals.

4. There is a process for ongoing communication between staff members working with the same individuals in different programs, activities, schedules or shifts.

Rev. 10 2010
1106. Management and Protection of Participant Funds

The personal funds of an individual are managed by the individual and are protected.

1. Policies and clear accountability practices regarding individual valuables and finances comply with all applicable DBHDD policies and Social Security Guide for Organizational and /or Representative Payees regarding management of personal need spending accounts for individuals served.

2. Providers are encouraged to utilize persons outside the organization to serve as “representative payee” such as, but not limited to:

a. Family

b. Other person of significance to the individual

c. Other persons in the community not associated with the agency
3. The agency is able to demonstrate documented effort to secure a qualified, independent party to manage the individual’s valuables and finances when the person served is unable to manage funds and there is no other person in the life of the individual who is able to assist in the management of individual valuables or funds.
Individual funds cannot be co-mingled with the agency’s funds or other individuals’ funds.

1107. Monitoring
All ISPs for recipients of services under the NOW will be reviewed and monitored by the State through the Regional DBHDD Office, the DCH Program Integrity Unit’s Utilization Review Team, and through desk reviews of the services provided. When DCH utilization reviews result in deficiencies, the provider must submit a Corrective Action (CAP) to the Department of Community Health within fifteen (15) calendar days of the date of utilization review reports. Failure to comply with the request for a corrective action plan may result in adverse action, including suspension of referrals or termination from the program.

Each Community Living Support (CLS) provider agency under NOW must provide a current Private Home Care Provider License from the Georgia Department of Behavioral Health and Departmental Disabilities, Healthcare Facilities Regulation Division (HFR), to the Regional DBHDD Office if providing covered PHC services as defined by HFR.

It will be the responsibility of the Regional DBHDD Office to assure that all CLS provider agencies providing PHC covered services as defined by HFR have and maintain a current PHC license for all ISPs for recipients of these CLS services under NOW. In the event that HFR should take action to change the provider license/permit from a permanent licensure or permit to a provisional status, the NOW CLS provider agency is at risk of being discharged as a Medicaid provider. Failure to adhere to maintaining a current PHC license will require that the agency repay all funds collected for CLS services rendered by a non-licensed CLS provider agency providing PHC covered services as defined by HFR.

1108. Multi-Purpose Information Consumer Profile

The Division of DBHDD is implementing a new comprehensive data collection and utilization management system titled the Multi-Purpose Information Consumer Profile (MICP). The MICP will be used to capture data regarding basic consumer demographics and service detail on all consumers served by the Division. This new form is being implemented in order to streamline and consolidate multiple data collection processes for registration, authorization, and reporting of publicly funded services.

The Division sponsors consumer satisfaction surveys for all adult populations. These surveys generally require no direct action from service providers. However, providers are expected to make their facilities and consumers available to teams who gather the survey responses.

NOTE: This is meant to cover access to consumers and facilities for the NCI Consumer Surveys (currently completed by the Support Coordination Agencies).

Providers of developmental disability services who serve ten or more waiver or state funded adults in residential, day or employment services (including subcontractors) are expected to complete – on an annual basis — the National Core Indicators Provider Staff Turnover and Board Participantship Survey. The survey instrument and instructions for completion will be sent directly to providers.

PART II – CHAPTER 1200

PARTICIPANT-DIRECTION

1201. General

The New Options Waiver (NOW) 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 participant.

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.
Rev 01 2013

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.
Rev 01 2013

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The policies, procedures and the conditions related to participation in Georgia’s New Options Waiver (NOW) 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 NOW provides for services to eligible individuals with I/DD who reside in or are at risk of an institutional placement, and opt to self-direct their NOW Services.

1202. Participant Eligibility

The NOW provides every Participant/Representative, the opportunity to elect to direct up to sixteen (16) waiver services. Should the Participant/Representative choose to direct allowable waiver services, the election to participant direct must be specified in the approved Individual Service Plan (ISP).
Rev 01 2012

The participant enrolled in Participant-Directed NOW Services may receive other NOW waiver services through Traditional Agency Providers except for the exclusions specified in the Part III, Policies and Procedures Manual for the NOW Program. Traditional Agency Provider services must be specified in the
Rev 01 2013
Individual Service Plan (ISP), and in accordance with provider requirements and qualifications specified for each respective service in the Part III, Policies and Procedures for the NOW Program.

1203. Participant-Direction by a Representative

Waiver services may be directed by:
. A legal representative of the participant, or

. 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 assists 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 Services 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 Georgia Department of Behavioral Health and Departmental Disabilities (DBHDD) uses the criteria below to determine whether a participant is appropriate for NOW 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 NOW Part III, Policies and Procedures, Chapter 1900 for personal assistance retainer details), and who:

A. 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 NOW Services and are capable of demonstrating that he/she is able to direct his or her NOW 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 NOW 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 NOW 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 all required timesheets/invoices and manage the individual budget for NOW 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 NOW services shall be confirmed.
An individual participant’s/representative’s ability to participant-direct NOW 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 NOW 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 NOW Services.

1206. Notification of Participant Approval/Disapproval

NOW applicants will be notified in writing of approval or disapproval for NOW services by the Regional DBHDD Office.

1207. Denial of Eligibility

Reasons for denial of eligibility for services under the New Options Waiver include those specified in Chapter 700. In addition, participants/representatives may be deemed ineligible to self-direct NOW 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 a denial of NOW funded services are specified in Chapter 700. A participant denied eligibility for Participant-Directed NOW 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 NOW 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 NOW applicants for services, Level of Care determinations and denials are detailed in Chapter 700 of this manual.

1209. Requirements for Enrollment in Participant-Direction

Once a participant or representative meets the eligibility for the Participant-Direction of NOW services, and voluntarily chooses to self-direct eligible NOW Services, the Support Coordinator must provide the following to initiate enrollment of the participant:

A. Documentation of willingness and ability of participant or representative to direct NOW services;

B. Documentation of a viable individual emergency back-up plan;

C. Completed Participant-Direction Memorandum of Understanding, with signatures of Participant and/or Representative;

D. Provision of a minimum of thirty (30) days written notice by the Support Coordinator to the NOW (traditional) provider;

E. 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 of thirty (30) day written notice to the FSS provider prior to a change request.
Rev 01 2013

For new enrollees, Participant-Directed NOW Services may only initiate on the first (1st) of the month.

1210. Eligible Waiver Services

NOW 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, NOW 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 and non-covered services, and reimbursement units and rates, can be found in Part III, NOW 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, NOW 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, NOW 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.

Details on service specifications, provider requirements and licensure, covered and non-covered services, and reimbursement units and rates, can be found in Part III, NOW Policies and Procedures, Chapter 1700.

NOTE: With the exception of Co-Employer Services, participant-directed Community Access Group Services, provided by an individual employee for one or more participants can not exceed a ratio of one (1) employee to three (3) participants.
Rev. 07 2011

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, NOW Policies and Procedures, Chapter 1800.

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, NOW 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, NOW Policies and Procedures, Chapter 2000.

Rev 01 2013
9. Individual Directed Goods and Services
Individual Directed Goods and Services are not otherwise provided through the NOW 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, NOW Policies and Procedures, Chapter 2200.

10. Natural Support Training Services
Natural Support Training Services provide training and education to individuals who provide unpaid support, training, companionship or supervision to 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, NOW Policies and Procedures, Chapter 2300.

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 a participant requiring a short period of structured support (typically due to behavioral support needs) or due to a family emergency.
Rev. 01 2012

Details on service specifications, provider requirements and licensure, covered and non-covered services, and reimbursement units and rates, can be found in Part III, NOW Policies and Procedures, Chapter 2500.

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, NOW Policies and Procedures, Chapter 2600.

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, NOW Policies and Procedures, Chapter 2700.

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, NOW Policies and Procedures, Chapter 2900.

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

Details on service specifications, provider requirements and licensure, covered and non-covered services, and reimbursement units and rates, can be found in Part III, NOW Policies and Procedures, Chapter 3000.

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.

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, NOW Policies and Procedures, Chapter 3100.

1211. Participant-Direction Opportunities

All waiver services eligible for participant-direction provide the following decision-making authorities for participants/representatives:

Rev 01 2013
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.

1. Participant/Common Law Employer Model
Rev 01 2013
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:

a. Recruit staff in accordance with specific service requirements as specified in the Part III, Policies and Procedures Manual for the NOW 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 NOW 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) Respite

5) Supported Employment

6) Transportation

Rev. 07 2009

The Participant/Representative and the Agency share these Co-Employer Responsibilities:
a. Recruit staff.

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:
a. Refer staff to agency for hiring

b. Verify time worked by staff and approve time sheets.

c. 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 services 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.

1212. Supports for Participant-Direction

The NOW 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:

1. Financial Management Services

2. Support Coordination (Case Management) Services, and

3. Community Guide Services

1212.1 Financial Management Services
A. 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 NOW Part III, Policies and Procedures Manual, Chapter 2100. 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 ensures 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 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;

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;

4) Any vendors must complete the vendor enrollment process prior to receiving any payment;

5) All invoices for vendor payments must be completed correctly;

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 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 established payment schedule;

11) The pay rate for employees is established during the development of the Individual Service Plan;

12) Information on unemployment benefits, workers’ compensation coverage, and tax withholding is available from the FSS provider.

13) Participants/Representatives 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 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 specified as Support Coordination Services in NOW Part III, Policies and Procedures Manual, Chapter 2800.

Responsibilities of Support Coordinators

a. Informing the participant or representative of the benefits, risks and responsibilities of Participant-Direction.

b. 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.

c. Informing the participant that a representative may assist him or her with Participant-Direction.

d. Informing the participant or representative about freedom of choice of providers, individual rights, and the grievance process.

e. Assisting the participant or representative with the development of the individual emergency back-up plan.

f. Assisting the participant or representative with the development of risk management agreements.

g. 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.

h. Providing the participant or representative with the process for changing the Individual Service Plan and the individual budget and the reassessment and review schedules.

i. Informing the participant or representative of state policies and procedures for Participant-Direction.

j. Assisting the participant or representative with recognizing and reporting critical events and with identifying and managing known and potential risk.

k. Linking the participant or representative to the training and technical assistance provided by the Financial Support Services provider.

l. 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 NOW 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:

1) Assist these participants with defining and directing their own services and supports and 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:

a. Direct assistance to participants in exploring and brokering available community resources.

b. Direct assistance to participants in meeting their participant-direction responsibilities.

c. Information and assistance that helps the participant in problem solving and decision-making.

d. Information and assistance that helps the participant in developing supportive community relationships and other resources that promote implementation of the Individual Service Plan.

e. Assistance with developing and managing the individual budget.

f. Assistance with recruiting, hiring, training, managing, evaluating, and changing employees.

g. Assistance with scheduling and outlining the duties of employees.

h. Training the participant to be an effective employer of support workers.

i. 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.

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:

1. 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.

2. 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.

3. 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.

4. 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:

1. Complex care such as administration of intravenous medications, central line maintenance, and complex wound care.

2. 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.

3. 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.

4. Provided without a written plan of care as defined above.

5. 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, Respite, Supported Employment, or Transportation Services are the common law employer or co-employer of employees who provide these services. These employees must meet the following in addition to the specific provider requirements specified for these services in the Part III, Policies and Procedures Manual for the NOW Program:

1. Are at least 18 years of age or older.

2. Are U.S citizens or legally authorized to work in the United States.

3. Have a valid Social Security Number.

4. 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.

5. Are prohibited from working overtime and shall not work in excess of 40 hours per week.

6. Agree to a criminal records check, prior to employment, to ensure that the employee has no history of a felony conviction.

7. Are willing to attend training (e.g., safety training) at the participant’s or representative’s request.

8. Sign affidavits regarding: incident reporting, abuse/neglect/exploitation; confidentiality; person-centered planning; and respect and rights.

9. 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 NOW Participant-Direction Option by legally responsible relatives, such as spouses, parents to minor children, or court-appointed legal guardians, is prohibited. Other family participants or relatives of the participant may be compensated for providing participant-directed NOW services if there are documented extenuating circumstances. Under these circumstances, family participants may be considered to provide the following participant-directed NOW services: Community Access, Community Living Support, Respite, Supported Employment, or Transportation Services. A family participant or relative who is serving as the participant’s representative may not be approved to provide NOW services for the participant.

In situations with extenuating circumstances, prior approval is obtained through the Georgia Department of Behavioral Health and Departmental Disabilities, according to the protocol outlined below. Extenuating circumstances include:

1. A lack of qualified providers in remote areas;

2. 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

3. 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

1. The individual or representative must work with the Support Coordinator on any letter requesting extenuating circumstances.

2. Requests for consideration of extenuating circumstances are to be made in writing and submitted to the designated regional Intake and Evaluation Team participant.

3. The designated regional Intake and Evaluation Team participant 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
Rev 01 2013

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 DBHDD, Division of 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 for NOW Participant-Directed services.

B. The utilization of other family participants/relatives of the participant as providers of NOW Participant-Directed services must be approved by the Georgia Department of Behavioral Health and Departmental 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 NOW 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 NOW 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 NOW 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 NOW 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.

4. Personal assistance retainer documentation.

1216.1 Participant-Direction through a FSS Provider

The participant/representative who opts for participant-direction through a FSS Provider must:

A. Maintain copies of timesheets and vendor payments for documentation of date and time of service delivery.

B. Maintain copies of CLS Personal Assistance Retainer Timesheet for any claims of this retainer for Community Living Support Services.

Note: see Part III, NOW Policies and Procedures, Chapter 1900 and Appendix C for additional information on the personal assistance retainer.

C. 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:

A. Maintain copies of timesheets and vendor payments for documentation of date and time of service delivery.

B. Document the following in the record of each participant for whom a personal assistance retainer is a component of Community Living Support Services;

a. Beginning and end date of absence.

b. Reason for absence.

c. Scheduled days and units per day for Community Living Support Services as specified in the ISP.

d. Scheduled staff was not deployed to work at any other provider location.
Note: see Part III, NOW Policies and Procedures, Chapter 1900 and Appendix C for additional information on the personal assistance retainer.

C. 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.

D. 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

1. 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.

2. Payment directly or indirectly for NOW 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 participants or relatives of the participant may be compensated for some NOW services as indicated in Section 1214 of this manual.

3. Services provided by relatives or friends, except as noted above, may be covered only if:

a. The family participant or friend must meet the provider qualifications and training standards specified in the waiver for that service (see NOW Part III, Policies and Procedures for these requirements);
b. The family participant or friend must meet the training qualifications prior to rendering services to a NOW participant;
c. An agreement must be in place between the participant and employee before services are rendered;
d. 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;
e. The service must not be an activity that the family would ordinarily perform or is responsible to perform;
f. An individual employee may not provider more than 40 hours of paid NOW services in a seven-day period;
g. The employee must maintain and submit timesheets and other required documentation for hours paid.
4. Provider agencies enrolled to provide NOW services cannot be vendors for self-directed services.

1219. Termination of Participant-Direction

1. A participant or representative may voluntarily decide to terminate Participant-Direction and return to provider-managed services.

2. 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.

3. 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.

4. A period of twelve (12) months must elapse prior to consideration for re-enrollment in the participant-directed option
APPENDIX A

REGIONAL OFFICE OF DBHDD CONTACT LIST

DBHDD Region 1
DBHDD Region 2
DBHDD Region 3

Charles Fetner
Audrey Sumner
Lynn Copeland

Regional Coordinator
Regional Coordinator
Regional Coordinator

cafetner@dbhdd.ga.gov
acsumner@dbhdd.ga.gov
lcopelan@dbhdd.ga.gov

Ronald Wakefield
Karla Brown
Carole Crowley

Regional Services Administrator – DD
Regional Services Administrator – DD
Regional Services Administrator – DD

rfwakefield@dbhdd.ga.gov
KBBrown8@dbhdd.ga.gov
cacrowley@dbhdd.ga.gov

705 North Division Street
3405 Mike Padgett Highway
100 Crescent Centre Parkway

Building 104
Building 3
Suite 900

Rome, Georgia 30165
Augusta, Georgia 30906
Tucker, Georgia 30084-7055

Phone 706-802-5272
Phone 706-792-7733
Phone 770-414-3052

Fax 706-802-5280
FAX 706-792-7740
FAX 770-414-3048

Toll Free 1-800-646-7721
Toll Free 1-866-380-4835

DBHDD Region 4
DBHDD Region 5
DBHDD Region 6

Michael Link
Charles Ringling
Michael Link

Acting Regional Coordinator
Regional Coordinator
Acting Regional Coordinator

Michael.Link@dbhdd.ga.gov
cpringling@dbhdd.ga.gov
Michael.Link@dbhdd.ga.gov

Michael Bee
Stephanie Stewart
Valona Baldwin

Regional Services Administrator – DD
Regional Services Administrator – DD
Regional Services Administrator –DD

MBee@dbhdd.ga.gov
sgstewart@dbhdd.ga.gov
vjbaldwin@dbhdd.ga.gov

P.O. Box 1378
1915 Eisenhower Dr., Building 2
3000 Shatulga Rd., Bldg. 4

Thomasville, Georgia 31799-1378
Savannah, GA 31406
P.O. Box 12435

Phone 229-225-5099
Phone: 912-303-1670
Columbus, Georgia 31907-2435

FAX 229-227-2918
FAX: 912 303-1681
Phone (706)565-7835

Toll Free 1-877-683-8557
Toll Free 1-800-348-3503
FAX (706)565-3565

APPENDIX B

Application for services 7-06__Page_1

Application for services 7-06__Page_2
Untitled
APPENDIX C

Section A – Identifying Information

1. Applicant’s Name/Address:

County
2. Medicaid Number:
3. Social Security Number

————

4. Sex
Age
4A. Birthdate

7. Patient’s Name (Last, First, Middle Initial)

5. Type of Facility (Check One)
1. . Nursing Facility
2. . ICF/MR
6. Type of Recommendation
1. . Nursing Facility
2. . ICF/MR
3. . Continued Placement
8. Date of Nursing Facility Admission

/ /

9. Patient Transferring From (Check One):
. Hospital . Home . Another Nursing home
. Private Pay . Medicare

Recipient’s Home Address:
Recipient’s Telephone Number:
Date of Medicaid Application
9A. State Authority (MH & MR Screening)

/ /

Level I/II

This is to certify that the facility of attending physician is hereby authorized to provider the Department of Community Health, Division of Medical Assistance and the Division of Family and Children Services, Department of Human Resources with necessary information including Medical Data.
10. Signature _______________________ 11. Date
(Patient, Spouse, Parent or other Relative or Legal Representative)
Restricted Auth Code Date

9B. This is not a re-admission for OBRA purposes

Restricted Auth Code Date

Section B – Physician’s Report and Recommendation
1. ICD-9
2. ICD-9
3. ICD-9

12. Diagnosis on admission to the facility (hospital transfer report may be attached)
1. Primary 2. Secondary 3. Other

12A. Diagnosis on admission to the facility (hospital transfer report may be attached)
1. Primary 2. Secondary 3. Other

1. ICD-10
2. ICD-10
3. ICD-10

13. Treatment Plan (Attach copy of order sheet if more convenient) Hospital Dates: to

Hospital Diagnosis 1. Primary 2. Secondary 3. Other

Medications
16. Diagnostic and Treatment Procedures

Name
Dosage
Route
Frequency
Type Frequency

14. Recommendation Regarding Level of Care Considered Necessary
1. . Skilled 2. . Intermediate 3. . Intermediate Care for
the Mentally Retarded
15. Length of Time Care Needed Months
1. . Permanent 2. . Temporary ___________ estimated
16. Is Patient free of communicable diseases?
1. . Yes 2. . No

17. This patient’s condition . could . could not be managed by provisions
of . community care or . home health services.
18. I certify that the patient requires the level of care provide by a nursing facility or an Intermediate care facility for the mentally retarded.

_______________________________________________________________
Physician’s Signature
19. Physician’s Name (Print)

Physician’s Address (Print)

20. Date Signed by Physician
/ /
21. Physician’s License Number
Physician’s Phone Number
( )

Section C– Evaluation of Nursing Care Needed (check appropriate box only)

22. Diet
23. Bowel
24. Overall Condition
25. Restorative Potential
26. Mental & Behavioral Status

. Regular
. Diabetic
. Formula
. Low Sodium
. Tube feeding
. Other

. Continent
. Occas. Incontinent
. Incontinent
. Colostomy
. Improving
. Stable
. Fluctuating
. Deteriorating
. Critical
. Terminal
. Good
. Fair
. Poor
. Questionable
. None
. Agitated . Noisy . Dependent
. Confused . Nonresponsive . Independent
. Cooperative . Vacillating . Anxious
. Depressed . Violent . Well Adjusted
. Forgetful . Wanders . Disoriented
. Alert . Withdrawn . Inappropriate Reaction

27. Decubitus
28. Bladder
30. Indicate Frequency Per Week

. Yes . Surgery
. No Date:
. Infected
. On Admission

. Continent
. Occas. Incontinent
. Incontinent
. Catheter

Physical Therapy
Occupational Therapy
Remotive Therapy
Reality Orientation
Speech Therapy
Bowel and Bladder Retrain
Activities Program

Received

29. Hours Out of Bed . Catheter Care
Per Day ________ . Colostomy Care
. Intake . IV . Sterile Dressing
. Output . Bedrest . Suctioning
Needed

31. Record Appropriate Legend

IMPAIRMENTS
ACTIVITIES OF DAILY LIVING

1. Severe

2. Moderate

3. Mild

4. None
Sight Hear Speech Ltd. Motion Paralysis
. . . . .
1. Dependent

2. Needs Asst.

3. Independent

4. Not App
Eats Wheelchair Transfer Bath Ambulation Dressing
. . . . . .

32. Remarks

33. Pre-Admission Certification Number
34. Signed
35. Date Signed
/ /

DO NOT WRITE BELOW THIS LINE

Continued Stay Review Date: Payment Date Approved for _Days

36. Level of Care Recommended by GMCF
LOS
37. Signature (GMCF)
Date:
/ /
38. Attachments (GMCF)
1. . Yes 2. . No

PHYSICIAN’S RECOMMENDATION CONCERNING NURSING FACILITY CARE OR
INTERMEDIATE CARE FOR THE MENTALLY RETARDED

Form DMA-6 Instructions
This section provides detailed instructions for completion of the Form DMA-6. Before payment can be made, a Form DMA-6 must be completed and signed by the admitting physician.
Section A – Identifying Information
Item 1: Applicant’s Name and Address
Enter the complete name and address of the applicant including the city and zip code.
Item 2: Medicaid Number
Enter the Medicaid number exactly as it appears on the Medical Assistance Eligibility Certification (this number may change so it is imperative that you review the Certification during each month of service.). A valid Medicaid number will be formatted in one of three ways:
a. If the member or applicant is in the Medicaid System, the ID number will be the 12-digit number, e.g., 111222333444;
b. If the member or applicant was previously determined eligible by DFCS staff or making application for services, the number will be the 9-digit SUCCESS number plus a “P”, e.g., 123456789P; or
c. If the individual is eligible for Medicaid due to the receipt of Supplemental Security Income (SSI), the number will be the 9-digit Social Security number plus an “S”, e.g., 123456789S.
The entire number must be placed on the form correctly. In exceptional instances, it may be necessary to contact the caseworker in the DFCS office for the Medicaid number.
Item 3: Social Security Number
Enter the applicant’s nine-digit Social Security number.
Item 4: Sex &Age
Enter the applicant’s sex, whether male or female and age.
Item 4A: Date of birth
Enter applicant date of birth.
Item 5: Type of Facility
Enter a check in the box corresponding to the type of facility.
Item 6: Type of Recommendation
Enter a check in the box corresponding to the type of recommendation being made. If the recommendation is for a recipient’s initial admission or readmission to the facility, the box corresponding to initial should be checked. If the recommendation is for continued placement, the box corresponding to continued placement should be checked on the subsequent recommendation form.
Item 7: Patient’s Name (Last, First, Middle Initial)
Enter the patient’s full name, first name, and middle initial in that order
Item 8: Date of Nursing Facility Admission
Enter the date of the recipient’s admission to the nursing facility.
Item 9: Patient Transferred From:
Enter a check in the box corresponding to either hospital, private pay, home, another nursing facility, or Medicare, according to the recipient’s status immediately preceding admission to the facility.
Enter the recipient’s home address, mother’s maiden name, and the date of Medicaid application.
Item 9A: State Authority (MH & MR Screening)
Please enter the restricted authorization code and date assigned by the Contractor. This field is for new admissions only.
Item 9B: State Authority (MH & MR Screening)
Please enter the restricted authorization code and date assigned by the Contractor originally (new
admission PA). This field should be used for a readmission or transfer to another nursing facility.
Item 10 & 11: Signature
Authorization for Facility or Attending Physician to provide the Department of Community Health, Division of Medical Assistance and the Division of Family and chi1dren Services, Department of Human Resources with necessary information including Medical Data.
Have the patient, his/her spouse, parents or other relative or legal representative sign and date (Item 11) the authorization.
Section B – Physician’s Examination Report and Recommendation
Item 12: ICD-9 Diagnosis (Add attachment(s) for additional diagnoses)
Describe the primary, secondary, and any third ICD-9 diagnoses relevant to the
applicant’s condition on the appropriate lines. Leave the blocks labeled ICD blank. The
Contractor’s staff will complete these boxes.
Item 12A: ICD-10 Diagnosis Code (Add attachment(s) for additional diagnoses)
Describe the primary, secondary, and any third ICD-10 diagnoses relevant to the
applicant’s condition on the appropriate lines. Leave the blocks labeled ICD blank. The
Contractor’s staff will complete these boxes.
Item 13: Treatment Plan (Attach a Copy of the Order Sheet if More Convenient), Hospital Dates, Hospital Diagnosis
The admitting diagnoses (primary, secondary and other) and dates of admission and discharge must be recorded. The treatment plan also should include all medications the recipient is to receive. Names of drugs with dosages, routes, and frequencies of administration are to be included. Any diagnostic or treatment procedures and frequencies should be indicated.
Item 14: Recommendation Regarding Level of Care Considered Necessary
Enter a check in the correct box for Skilled or Intermediate Care for Mentally Retarded. The Skilled box is appropriated as the nursing facility level of care.
Item 15: Length of time is Needed
Enter the length of time as permanent
Item 16: Is Patient free of communicable disease?
Enter a check in the appropriate box (Yes or No)
Item 17: Alternatives to Nursing Home Placement
The admitting or attending physician must indicate whether the patient’s condition could be managed by provision of Community Care or Home Health Services. Enter a check in the box corresponding to “could” and either/both the box(es) corresponding to Community Care and/or Home Health Services if either/or both is appropriate. Enter a check in the box corresponding to “could not “ if neither is appropriate.
Item 18: Certification Statement of the Physician and Signature
The admitting or attending physician must certify that the applicant requires the level of care provided by a nursing facility, hospital, or an intermediate care facility for the mentally retarded. Signature stamps are not acceptable. If the physician does not agree that institutional care is appropriate, enter N/A and sign.
Item 19: Physician’s Name and Address (Print)
Print the admitting or attending physician’s name and address in the spaces provided.
Item 20: Date signed by the physician
Enter the date the physician signs the form.
Item 21: Physician’s Licensure Number and Physician’s Telephone Number
Enter the Georgia license number for the attending or admitting physician.
Enter the attending or admitting physician’s telephone number including area code.

——————————————————————————————————

Section C – Evaluation of Nursing Care Needed (Check Appropriate box only)

All items in Section C of this form must be completed by Licensed personnel involved in the care of the applicant.
Item 22: Diet
Enter the appropriate diet for the recipient. If “other” is checked, please specify type of diet.
Item 23: Bowel
Check the appropriate box to indicate the bowel and bladder habits of the recipient.
Item 24: Overall Condition
Check the appropriate box to indicate the recipient’s overall condition.
Item 25: Restorative
Check the appropriate box to indicate the recipient’s restorative potential.
Item 26: Mental & Behavioral Status
Check all appropriate boxes to indicate the recipient’s mental and behavioral status.
Item 27: Decubiti
Check the appropriate box to indicate if the recipient has decubiti. If “yes” is checked and “surgery” is also checked, the date of surgery should be included in the space provided.
Item 28: Bladder
Check the appropriate box to indicate bladder habits of the recipient.
Item 29: Hours Out of Bed Per Day
Indicate the number of hours the recipient is to be out of bed per day in the space provided. Check other treatment procedures the recipient requires.
Item 30: Indicate Frequency Per Week
If applicable, indicate the number of treatment or therapy sessions per week the recipient receives or needs.
Item 31: Record Appropriate Legend
Enter appropriate number indicating the level of impairment or level of assistance needed in the boxes provided.
Item 32: Remarks
Indicate the patient’s vital signs, height, weight, and other pertinent information not otherwise indicated on this form.
Item 33: Pre-admission Certification Number
Indicate the pre-admission certification number (if applicable).
Item 34: Signed
The person completing Section C should sign in this space.
Item 35: Date Signed
Enter the date this section of the form is completed.

Item 43: Print Name of MD or RN
The individual completing Section C should print their name and sign the DMA-6 (A).

Do Not Write Below This Line
Items 44 through 52
criteria1
criteria3

criteria4
.
criteria5

Protocol for Physicians Signature

A physician’s signature is required on the ISP if-

. When the completed HRST indicates a level 3 or above, a physician review is required. When the CMC screening tool indicates a level 3 or above, a physician review is required. If the CMC screening tool indicates a level 2, then the nurse will use their judgment to determine the need for physician review of the ISP.

The nurse will-

. The comprehensive assessment will be uploaded into Miscellaneous Docs section. * Note- if a comprehensive assessment is uploaded, a note will be placed in the blank built-in nursing assessment to see comprehensive assessment in misc. docs and the nurse will electronically sign the built in assessment.

. The nurse will then check the physician review box in Section 1 of the ISP.

Personal Information

Consumer Name:
First Name:
MI:
Last Name:

Preferred Name:

Allergies:
NKA
Physician’s Review Required
Physician will –

. Complete and sign the Physician Review form in the electronic ISP and check the physician’s review button.

. If the I&E physician identifies any issues that need any special prompt attention the RN will be contacted by phone/email in addition to the physician writing the recommendations in the physician’s review section

. The R.N will be responsible for contacting the Support Coordinator and provider to ensure follow up.

. A revision or addendum to the goals/ action plan and or risk protection page will be recommended accordingly

. OA’s will approve the ISP

.
Type of Program:
. Nursing Facility
. GAPP

. TEFRA/Katie Beckett
. MR/DD

PEDIATRIC DMA 6(A)
PHYSICIAN’S RECOMMENDATION FOR PEDIATRIC CARE
Section A – Identifying Information

1. Applicant’s Name/Address:

DFCS County_ Mailing Address
2. Medicaid Number:
3. Social Security Number

—————————————-

4. Sex
Age
4A. Birthdate

5. Primary Care Physician

6. Applicant’s Telephone #

7. In the caretaker’s opinion, would the child require institutionalization if
the child did not receive community services? . Yes . No
8. Does child attend school?
. Yes . No
9. Date of Medicaid Application
//

Name of Caregiver #1: Name of Caregiver #2:

I hereby authorize the physician, facility or other health care provider named herein to disclose protected health information and release the medical records of the applicant/beneficiary to
the Department of Community Health and the Department of Human Resources, as may be requested by those agencies, for the purpose of Medicaid eligibility determination. This authorization expires twelve (12) months from the date signed or when revoked by me, whichever comes first.

10. Signature: 11. Date: (Parent or other Legal Representative)

Section B – Physician’s Report and Recommendation

12. History: (attach additional sheet if needed)

1. ICD-9
2. ICD-9
3. ICD-9

13. ICD-9Diagnosis
1) 2) 3)
(Add attachment for additional diagnoses)

13A. ICD-10Diagnosis
1) 2) 3)
(Add attachment for additional diagnoses)
1. ICD-10
2. ICD-10
3. ICD-10

15. Medications
16. Diagnostic and Treatment Procedures

Name
Dosage
Route
Frequency
Type Frequency

17. Treatment Plan (Attach copy of order sheet if more convenient or other pertinent documents)
Previous Hospitalizations:_ Rehabilitative/Habilitative Services:_ Other Health Services: Hospital Diagnosis: 1)_ 2) Secondary 3) Other

18. Anticipated Dates of Hospitalization: _/
/
19. Level of Care Recommended: . Hospital . Nursing Facility . IC/MR Facility

20. Type of Recommendation:
. Initial
. Change Level of Care
. Continued Placement
21. Patient Transferred from (check one):
. Hospital . Another NF
. Private Pay . Lives at home
22. Length of Time Care Needed Months
1) . Permanent
2) . Temporary estimated
23. Is patient free of
communicable diseases?
. Yes . No

24. This patient’s condition . could . could not be managed by
provision of . Community Care or . Home Health Services
25. Physician’s Name (Print):

Physician’s Address (Print):

26. I certify that this patient requires the level of care provided
by a nursing facility, IC/MR facility, or hospital
Physician’s Signature
27. Date signed by Physician
28. Physician’s Licensure No.
28. Physician’s Telephone #:
( )

Section C– Evaluation of Nursing Care Needed (check appropriate box only)

29. Nutrition
30. Bowel
31. Cardiopulmonary Status
32. Mobility
33. Behavioral S tatus

. Regular
. Diabetic Shots
. Formula-Special
. Tube feeding
. N/G-tube/G-tube
. Slow Feeder
. FTT or Premature
. Hyperal
. IV Use
. Medications/GT Meds
. Age Dependent
Incontinence
. Incontinent – Age > 3
. Colostomy
. Continent
. Other
. Monitoring
. CPAP/Bi-PAP)
. CP Monitor
. Pulse Ox
. Vital signs > 2/day
. Therapy
. Oxygen
. Home Vent
. Trach
. Nebulizer Tx
. Suctioning
. Chest – Physical Tx
. Room Air
. Prosthesis
. Splints
. Unable to ambulate >
18 months old wheel chair
. Normal
. Agitated
. Cooperative
. Alert
. Developmental Delay
. Mental Retardation
. Behavioral Problems
(please describe, if checked)
. Suicidal
. Hostile

34. Integument System
35. Urogenital
36. Surgery
37. Therapy/Visits
38. Neurological Status

. Burn Care
. Sterile Dressings
. Decubiti
. Bedridden
. Eczema-severe
. Normal
. Dialysis in home
. Ostomy
. Incontinent – Age > 3
. Catheterization
. Continent
. Level 1 (5 or > surgeries)
. Level II (< 5 surgeries)
. None
Day care Services
. High Tech – 4 or more times per week
. Low Tech – 3 or less times per week or MD visits > 4
per month
. None
. Deaf
. Blind
. Seizures
. Neurological Deficits
. Paralysis
. Normal

39. Other Therapy Visits
. Five days per week . Less than 5 days per week
40. Remarks

41. Pre-Admission Certification Number
42. Date Signed
43. Print Name of MD or RN:

Signature of MD or RN:

DO NOT WRITE BELOW

44. Continued Stay Review Date: Admission Date Approved for _Days or Months

45. Are nursing services, rehabilitative/habilitative services or other health related services requested ordinarily provided in an institution? . Yes . No . NA
46A. State Authority MH & MR Screening)

Level I/II

Restricted Auth. Code Date

46B. This is not a re-admission for OBRA purposes

47. Hospitalization Precertification . Met . Not Met
Restricted Auth. Code Date

48. Level of Care Recommended by Contractor
. Hospital . Nursing Facility . IC/MR Facility

49. Approval Period
50. Signature (Contractor)
51. Date
/ /
52. Attachments (Contractor)
. Yes . No

. DMA-6A (12/2013)

PHYSICIAN’S RECOMMENDATION FOR PEDIATRIC CARE

INSTRUCTIONS FOR COMPLETING THE PEDIATRIC CARE FORM DMA-6(A)

This section provides detailed instructions for completion of the Form DMA-6 (A). Before payment can be made, a Form DMA-6 (A) must be completed by the Primary Care Physician (PCP) and the parent or legal representative and signed by the PCP. The Form DMA-6 (A) is considered valid only if it is signed by the Primary Care Physician and dated.

Section A – Identifying Information
It is the responsibility of the responsible party to see that Section A of the form is completed with the applicant’s name and address.

Item 1: Applicant’s Name and Address
Enter the complete name and address of the applicant including the city and zip code.

The caseworker in the Department of Family and Children Services (DFCS) will complete the mailing address and county of the originating application.

Item 2: Medicaid Number
Enter the Medicaid number exactly as it appears on the Medicaid card or Form 962. A valid Medicaid number will be formatted in one of three ways:

a. If the member or applicant is in the Medicaid System, the ID number will be the 12-digit number, e.g., 111222333444;

b. If the member or applicant was previously determined eligible by DFCS staff or making application for services, the number will be the 9-digit SUCCESS number plus a “P”, e.g., 123456789P; or

c. If the individual is eligible for Medicaid due to the receipt of Supplemental Security Income (SSI), the number will be the 9-digit Social Security number plus an “S”, e.g., 123456789S.

The entire number must be placed on the form correctly. In exceptional instances, it may be necessary to contact the caseworker in the DFCS office for the Medicaid number.

Item 3: Social Security Number
Enter the applicant’s nine-digit Social Security number.

Item 4 & 4A: Sex, Age and Date of birth
Enter the applicant’s sex, age, and date of birth.

Item 5: Primary Care Physician
Enter the entire name of the Primary Care Physician (PCP).

Item 6: Telephone Number
Enter the telephone number including area code of the applicant’s parent or the legal
representative.

Item 7: Does the child meet the Level of Care (LOC) criteria? (Refer to the DCH’s
website for the LOC definitions.) Statement being asked to caregiver to support
LOC. Please check the appropriate box.

Item 8: Does the child attend school?
Please check the appropriate box if the member attends school.

Item 9: Date of Medicaid Application
Enter the date the family made application for Medicaid services.

Fields below Item 9:
Please enter the name of the primary caregiver for the applicant. If a secondary caregiver is available to care for the applicant, please indicate the name of the caregiver.

Read the statement below the name(s) of the caregiver(s) and then;
Item 10: Signature
The parent or legal representative for the applicant should sign the DMA-6 (A).

Item 11: Date
Please include the date the DMA-6 (A) was signed by the parent or the legal representative.

Section B – Physician’s Examination Report and Recommendation

Item 12: History (attach additional sheet(s) if needed)
Describe the applicant’s medical history (Hospital records may be attached).

Item 13: Diagnosis (Add attachment(s) for additional diagnoses)
Describe the primary, secondary, and any third ICD-9 diagnoses relevant to the
applicant’s condition on the appropriate lines. Leave the blocks labeled ICD blank. The
Contractor’s staff will complete these boxes.

Item 13A: Diagnosis (Add attachment(s) for additional diagnoses)
Describe the primary, secondary, and any third ICD-10 diagnoses relevant to the
applicant’s condition on the appropriate lines. Leave the blocks labeled ICD blank. The
Contractor’s staff will complete these boxes.

Item 14: Medications (Add attachment(s) for additional medication(s)
The name of all medications the applicant is to receive should be listed. Name of drugs with dosages, routes, and frequencies of administration are to be included.

Item 15: Diagnostic and Treatment Procedures
Any diagnostic or treatment procedures and frequencies should be indicated.

Item 16: Treatment Plan (Attach copy of order sheet if more convenient or other
pertinent documentation)
List previous hospitalization dates, as well as rehabilitative/habilitative, and other health care services the applicant has received or currently receiving. The hospital admitting diagnoses (primary, secondary, and other diagnoses) and dates of admission and discharge must be recorded. The treatment plan may also include other pertinent documents to assist with the evaluation of the applicant.

Item 17: Anticipated Dates of Hospitalization
List any dates the applicant may be hospitalized in the near future for services. Enter N/A if not applicable.

Item 18: Level of Care Recommended
Recommendation regarding the level of care considered necessary. Enter a check in the correct box for hospital, nursing facility, or an intermediate care facility for the mentally retarded. Enter N/A if institutional care is not applicable.

Item 19: Type of Recommendation
Indicate if this is an initial recommendation for services, a change in the member’s level of care, or a continued placement review for the member.

Item: 20: Patient Transferred from (Check one)
Indicate if the applicant was transferred from a hospital, private pay, another nursing facility or lives at home.

Item 21: Length of Time Care Needed
Enter the length of time the applicant will require care and services from the Medicaid program. Check the appropriate box on the length of time care is needed either permanent or temporary. If temporary, please provide an estimate of the length of time care will be needed.

Item 22: Is Patient Free of Communicable Diseases?
Enter a check in the appropriate box.

Item 23: Alternatives to Nursing Facility Placement
The admitting or attending physician must indicate whether the applicant’s condition could or could not be managed by provision of the Community Care or Home Health Care Services Programs. Enter a check in the box corresponding to “could” and either/both the box(es) corresponding to Community Care and/or Home Health Services if either/or both is appropriate. Enter a check in the box corresponding to “could not” if neither is appropriate.

Item 24: Physician’s Name and Address
Print the admitting or attending physician’s name and address in the spaces provided.

Item 25: Certification Statement of the Physician and Signature
The admitting or attending physician must certify that the applicant requires the level of care provided by a nursing facility, hospital, or an intermediate care facility for the mentally retarded. Signature stamps are not acceptable. If the physician does not agree that institutional care is appropriate, enter N/A and sign.

Item 26: Date signed by the physician
Enter the date the physician signs the form.

Item 27: Physician’s Licensure Number
Enter the Georgia license number for the attending or admitting physician.

Item 28: Physician’s Telephone Number
Enter the attending or admitting physician’s telephone number including area code.

——————————————————————————————————

Section C – Evaluation of Nursing Care Needed (Check Appropriate box only)

Licensed personnel involved in the care of the applicant should complete Section C of
this form.

Item 29: Nutrition
Check the appropriate box(es) regarding the nutritional needs of the applicant.

Item 30: Bowel
Check the appropriate box(es) to indicate the bowel and bladder habits of the applicant.

Item 31: Cardiopulmonary Status
Check the appropriate box(es) to indicate the cardiopulmonary status of the applicant.
Enter N/A, if not applicable.

Item 32: Mobility
Check the appropriate box(es) to indicate the mobility of the applicant.

Item 33: Behavioral Status
Check all appropriate box(es) to indicate the applicant’s mental and behavioral status.

Item 34: Integument System
Check the appropriate box(es) to indicate the integument system of the applicant.

Item 35: Urogenital
Check the appropriate box(es) for the urogenital functioning of the applicant.

Item 36: Surgery
Check the appropriate box regarding the number of surgeries the applicant has had to your knowledge or obtain this information from the parent or other legal representative.

Item 37: Therapy/Visits
Check the appropriate box to indicate the amount of therapy visits the applicant receives.

Item 38: Neurological Status
Check the appropriate box (es) regarding the neurological status of the applicant.

Item 39: Other Therapy Visits
If applicable, indicate the number of treatment or therapy sessions per week the applicant receives or needs. Enter N/A, if not applicable.

Item 40: Remarks
Indicate the patient’s vital signs, height, weight, and other pertinent information not otherwise indicated on this form or any additional comments.

Item 41: Pre-admission Certification Number
Indicate the pre-admission certification number (if applicable).

Item 42: Date Signed
Enter the date this section of the form is completed.

Item 43: Print Name of MD or RN
The individual completing Section C should print their name and sign the DMA-6 (A).

Do Not Write Below This Line
Items 44 through 52

Level of Care Re-Evaluation Form for ICF/ID

NAME:

SS#
Region

Support Plan Effective Date:

Level of Care Eligibility: The individual meets one of the following criteria and is eligible to receive the services provided in an ICF/ID. Check the criteria that are met.

The individual’s disability is intellectual disability.

The individual is eligible under the category of Other Closely Related Condition.

Please check all that Apply:

.
Disability Conditions
.
Major Life Activities

Ambulation Deficits

Self Care

Sensory Deficits

Understanding and Use of Language

Chronic Health Problems

Learning

Behavior Problems

Mobility

Autism

Self Direction

Cerebral Palsy

Capacity for Independent Living

Epilepsy

Spina Bifida

Prader-Willi Syndrome

Other__________________________

Medicaid Eligibility:
Individual has a current Medicaid Number. Medicaid # is ____________________

Eligibility Determination: Check the correct statement:

Individual has met Level of Care Eligibility (1) has a Medicaid number (2) and is eligible for Waiver Services.

Individual has not met the Level of Care Eligibility and is not eligible for Waiver Services.

Individual is in an ICF-ID and was referred for Medicaid eligibility on ________________
Date
The result was: Eligible ____ Ineligible ____ Date of Determination_____________________

Home and Community Based Waiver Level of Care Re-Evaluation (if applicable)
. Support Coordinator signs the Level of Care Re-Evaluation

. LOC Nurse with the Regional Intake and Evaluation Team signs the Level of Care Re-Evaluation

Support Coordinator: Date:

Regional Level of Care RN Signature: Date:

Approval Period:

ICF-ID Facility Level of Care Re-Evaluation (if applicable)
. Facility RN and Regional LOC RN sign the Level of Care Re-Evaluation

Facility RN Signature: Date:

Regional Level of Care RN Signature: Date:

Approval Period:

Individual/Representative Signatures:
. This section is only completed for individuals residing in the community

It is the policy of the State of Georgia that services are delivered in the least restrictive manner that addresses the service needs of the individual while enhancing the promotion of social integration. Further, it is the policy of the State to recognize the recipient’s full citizenship and individual dignity; providing safeguards to protect rights, health and the welfare of recipients. I have been offered waiver services and choose to receive community based supports and services. I understand that I have a choice of enrolled providers.

Individual Signature:
Date:

Representative (if applicable):
Date:

DMA-7 Rev 4/13)
INSTRUCTIONS FOR COMPLETING THE LEVEL OF CARE
RE-EVALUATION FOR ICF-ID (DMA-7)

This document provides detailed instructions for completion of the Level of Care (LOC) Re-Evaluation Form. Before payment can be made, the LOC Re-Evaluation form must be completed by the individual’s Support Coordinator and approved by the DBHDD Regional Office.

Item 1: Participant’s Name
Enter the complete name beginning with the Last Name then the First Name of the participant

Item 2: Social Security Number
Enter the participant’s nine-digit Social Security number.

Item 3: Region
Enter the participant’s DBHDD Region

Item 4: Support Plan Effective Date
Enter the start date of the most current ISP

Item 5: Level of Care Eligibility: The individual meets one of the following criteria and is eligible to receive the services provided in an ICF/ID. Check the criteria that are met.

1. Check that the individual’s disability is an intellectual disability if the individual’s waiver eligibility determination indicated eligibility by diagnosis of an intellectual disability.

2. Check that the individual is eligible under the category of “Other Related Condition” if the individual’s waiver eligibility determination indicated eligibility by diagnosis of a condition found to be closely related to an intellectual disability and attributable to: (a) cerebral palsy or epilepsy; or (b) any other condition, other than mental illness, which results in impairment of general intellectual functioning or adaptive behavior similar to that of persons with an intellectual disability.

Item 6a: Please check all Disability Conditions that apply to the individual:
Disability Conditions

Ambulation Deficits

Sensory Deficits

Chronic Health Problems

Behavior Problems

Autism

Cerebral Palsy

Epilepsy

Spina Bifida

Prader-Willi Syndrome

Other: ______________________ (Specify any other disability conditions)

Item 6b: Please check all Major Life Activities that apply to the LOC Re-Evaluation:
Major Life Activities: Check all areas in which the individual has substantial deficits. Note: To meet ICF/ID Level of Care the individual must have substantial deficits in at least two areas if the individual’s disability is intellectual disability and in at least three areas if the individual is eligible under the category of Other Closely Related Condition.

Self Care – Basic Activities of Daily Living include:
. Bathing and showering (washing the body)

. Bowel and bladder management (recognizing the need to relieve oneself)

. Dressing

. Personal hygiene and grooming (including washing hair)

. Eating (including chewing and swallowing)

. Feeding (setting up food and bringing it to the mouth)

. Toilet hygiene (completing the act of relieving oneself)

Understanding and Use of Language – Impairments in receptive and/or expressive language. This major life activity includes ability to understand others and to fully express oneself in own language (including sign language) with adaptive communication devices if used by individual.

Learning – Limitations in practical and functional academics, such as reading, computation, and telling time. This major life activity includes the ability to apply reasoning and problem solving, learn new tasks, apply to new situations, or adapt to change

Mobility – limitation in one’s ability to move the body or one or more extremities independently. This major life activity includes physical movement of one’s body from place to place, with adaptive aids if used by individual, and consists of the ability to transfer, to walk, or to be reliant on a wheelchair or scooter for mobility. It does not include vehicle transportation.

Self Direction – limitation in making decisions and setting and carrying out goals independently. This major life activity includes the ability to make decisions that match one’s own values and desires.

Capacity for Independent Living – limitation in age appropriate behaviors for the individual to live independently. This major life activity includes ability to prepare food, manage money, clean house, do laundry, work independently or use the telephone with assistive devices if uses them.
Item 7: Medicaid Eligibility
Enter the Medicaid number exactly as it appears on the Medicaid card or Form 962. A valid Medicaid number will be formatted in one of three ways:
a. If the member or applicant is in the Medicaid System, the ID number will be the 12-digit number, e.g., 111222333444;

b. If the member or applicant was previously determined eligible by DFCS staff or making application for services, the number will be the 9-digit SUCCESS number plus a “P”, e.g., 123456789P; or

c. If the individual is eligible for Medicaid due to the receipt of Supplemental Security Income (SSI), the number will be the 9-digit Social Security number plus an “S”, e.g., 123456789S.

Item 8: Eligibility Determination: Check the correct statement:

Individual has met Level of Care Eligibility (1) has a Medicaid number and is (2) eligible for waiver services.

Individual has not met the Level of Care Eligibility and is not eligible for Waiver Services

Individual is in an ICF-ID and was referred for Medicaid Eligibility on (enter the date).
The result was ___Eligible ____Ineligible Date of Determination: ______

Item 8: Home and Community Based Waiver LOC Re-Evaluation (if applicable)
The individual’s Support Coordinator and the Regional Level of Care RN must sign and date this section. The Regional RN reviews the LOC Re-Evaluation form, the ISP, and any accompanying assessment updates to determine whether the person continues to meet the level of care requirement. The Regional RN will sign and date this document after that review. The signature of the Regional LOC RN must be within 30 days of the date the Support Coordinator signed this document

Item 9: Approval Period
This section is completed by the LOC RN and is the time period for which the LOC has been re-certified for Home and Community Based Waiver services. The initial date the completed LOC Re-evaluation form is received by the DBHDD Regional Office with all additional required documentation for recertification will constitute the earliest re-certification date once approved.

Item 10: ICF-ID Facility Level of Care Re-Evaluation (if applicable)
The facility RN completes the Level of Care Re-Evaluation Form, signs and forwards the completed form, the current individualized program plan, and any accompanying assessment updates to the Regional Level of Care RN for review. The Regional Level of Care RN signs and dates this section.

Approval Period: This section is completed by the LOC RN and is the time period for which the LOC has been re-certified for ICF-ID Facility based services. The initial date the completed LOC Re-evaluation form is received by the DBHDD Regional Office with all additional required documentation for recertification will constitute the earliest re-certification date once approved.

Item 11: Individual/Representative Signature
This section is only completed for individuals residing in the community. The participant should sign or make their mark in this section. The participant’s signature should be dated.
If the participant is a minor or has been adjudicated legally incompetent, this block should contain the signature of the legal guardian. That signature should be dated.

Appendix D
I&E Screening Tool for Chronic Medical Conditions

NOTE: All conditions Level 3 and above require forwarding ISP to I&E Physician for Review; Conditions at Level 2 require nurse judgment for forwarding for I & E Physician Review

Individual: Birthdate: Completed by: Date Completed:

CMC
L-1
L-2 *
L-3 *
L-4 *

Diabetes
If end stage organ damage present increase to next level (Ex: Kidney Disease, Heart Disease, Eye Involvement)

Diagnosis; no medications
Fasting Blood sugar 100-120
A1C (If available) –Under 6%

1-2 oral meds
Fasting Blood sugar 120-140
A1C Over 6%

2 or more oral meds
Fasting Blood Sugar 140-180
A1C Over 7%
To L 4 if end organ damage

Insulin Dependent
and /or
Fasting Blood sugar level over 180
A1C Over 7%

Hypertension
If end stage organ damage present increase to next level (Ex: Kidney Disease, Heart Disease, Eye Involvement)
BP 120/80 – 139/89
No prescribed medications
BP 140/90-159/99
Less than 2 meds

BP 160/100 or higher
2 or more meds and/or
Organ damage

Hyperlipidemia
Total Cholesterol – over 200
Triglycerides – over 200
HDL under 50 LDL over 130
Diet only – No prescribed medications and history of Coronary Artery Disease
Cholesterol Triglycerides, HDL, LDL, same as Level 1 Plus
Takes prescribed medications
No history of CAD

Level 2 with a history of CAD,CVD, or PAD

Respiratory Conditions Symptoms may include wheeze, chest tightness, shortness of breath, and/or cough
Symptoms less than 2 x month

Symptoms more than 2 x week ;
Night-time-symptoms more than 2 x month
Daily use of albuterol or other bronchodilator (rescue inhaler)
Continuous symptoms with severe exacerbations
Frequent night time symptoms
History or current (inhaled or oral) corticosteroids

COPD
Diagnosis of COPD (Emphysema, Chronic Bronchitis)
Chronic cough with presence of sputum
Same as level 1
Plus
Dyspnea on exertion
Mild-Moderate airflow obstruction per spirometry
May use PRN Oxygen Therapy

Continuous Oxygen Therapy
Dyspnea with little exertion
Severe airflow obstruction per Spirometry With or without history of Respiratory Failure/Right Heart Failure

Cardiac Conditions

Asymptomatic, but has a history of MI, Angina, Valvular Heart Disease, Heart Failure
No activity limitations

Symptomatic (Ex: Angina, Dyspnea, Edema, etc)
Heart Failure
Limited functional status

ESRD
End Stage Renal Disease
or Chronic Kidney Disease

Stable with prescribed medications

Undergoing Dialysis on routine basis and/or awaiting kidney transplant

Obesity
If unable to obtain weight, note reason. Mention any reported weight changes
BMI 25-30lbs (Overweight)
BMI over 30 (Obese)
BMI Over 40
(Morbid or Severe Obesity)

Cancer
History of cancer in remission and no treatment

Current diagnosis malignancy.
Current or recent history of Immune-Suppressive therapy.

Osteoporosis
Risk Factors:
Non-ambulatory, Anticonvulsant,, Small frame, Caucasian, Natural or artificial menopause, Smoking, Family History

Under 65years of age with
no history of fractures.
And
Any known risk factors:

Any age with a history of fracture and/or the following:
Any known risk factors:
May or may not have proven Osteopenia or Osteoporosis

Substance Abuse
History of alcohol, drugs, or nicotine abuse.
Current abuse of alcohol, drugs or nicotine.

Chronic Pain

As determined by levels L2 on the “smiley face” scoring sheet

Dementia

Dementia of any etiology and a Developmental Disability

Electrolyte Imbalance
Risk Factors:
Medication, Kidney disease, History Diabetes Insipidus, Pychogenicpolydypsia

Any risk factor that could cause an imbalance

Treatment requiring interventions in the past or current treatment.

Mental Health

No medication
History of mental illness
Current Diagnosis with medications

Medical Condition
Description
Detailed on “Risks” sheet? yes/no

Diabetes, Type 2
aka adult-onset diabetes

( Takes two oral meds )
Carbohydrate metabolism d/o that results in inadequate secretion or utilization of the hormone insulin; symptoms include polyuria (excessive urination), polydipsia (excessive thirst), polyphagia (excessive hunger), weight loss and high sugar levels in the blood and urine
Type 2: develops most often in adults and persons who are overweight; characterized by high blood sugar that results from the body’s impaired ability to use and secrete insulin

Hyperlipidemia
(takes no prescribed meds)

Increased triglycerides/cholesterol (excess fat or lipids) in blood stream: Triglycerides > 200 HDL < 50 ;
LDL > 130; Total Cholesterol > 200

I&E Screening Tool for Chronic Medical Conditions

*NOTE: All conditions Level 3 and above require ISP signature by I&E Physician Review; Conditions at Level 2 require nurse judgment for forwarding for I & E Physician Review

Individual: Birthdate: Completed by: Date Completed:

Chronic Medical Condition
L-1
L-2
L-3
L-4
Comments

Diabetes

Hypertension

Hyperlipidemia

. expands .

Respiratory Conditions

COPD

Cardiac Conditions

ESRD

Obesity

Cancer

Osteoporosis

Substance Abuse

Chronic Pain

Dementia

Electrolyte Imbalance

Mental Health

RN Signature: __________________ Date: __________________________

Rev. 07 2011

APPENDIX E
New Options Waiver Program
FREEDOM OF CHOICE
(Statement of Informed Consent)

It is the policy of the State of Georgia that services are delivered in the least restrictive manner that addresses the service needs of the individual while enhancing the promotion of social integration. Further, it is the policy of the State to recognize the recipient’s full citizenship and individual dignity; providing safeguards to protect rights, health and the welfare of recipients.

Based on these beliefs the State of Georgia assures that potential recipients and their authorized representative(s) will be afforded an opportunity to make an informed choice concerning services and providers.

Once a recipient is determined to be likely to require the level of care provided in an SNF, ICF or ICF/ID the recipient and his/her authorized representative will be informed of any feasible alternative available under the waiver and given the choice of either institutional or home and community-based services. This choice of care is documented.

Recipients may request through the regional office that a different support coordinator be assigned. Recipients have the choice of qualified providers in all areas of care and may request a change in providers through the region.

The substance of the information provided will make one reasonably familiar with service options, provider options, their alternatives, and possible benefits and hazards, and the disclosure of said information is designed to be fully understood and appears to be fully understood.

Verification

I have verified that the recipient and his/her authorized representative have been informed about their choices in the manner outlined above. The recipient has received a copy of this signed form.

________________________________________ ___________________
Planning List Administrator/Support Coordinator Date
or Authorized Designee

Acceptance

I and/or my authorized representative have been informed of my choices and have chosen to accept the program and providers described in the attached Individualized Service Plan.

________________________________ _____________________
Recipient Date

________________________________ _____________________
Authorized Representative Date

________________________________ _____________________
Witness Date

Refusal

I and/or my authorized representative have been informed of my choices and have chosen to refuse waiver services.

________________________________ _____________________
Recipient Date

________________________________ _____________________
Authorized Representative Date

________________________________ _____________________
Witness Date
New Options Waiver Program

FREEDOM OF CHOICE FORM INSTRUCTIONS

Purpose

The intent of this form is to assure that the participants and their representatives will be:

(1) Informed of any alternatives available under the waiver and

(2) Given the choice of either institutional or home and community-based services.

This process assures that recipients and their representatives can make an informed choice concerning service options(s). The presumption of the law is that a person may consent for him/herself. This presumption should be abandoned only when it is evident that the individual is not capable of doing so. The very nature of a diagnosed condition of an intellectual/developmental disability confirms that the individual who is diagnosed with an intellectual/developmental disability lacks capacity. The recognized reality and trend in the law is that individuals with intellectual/developmental disabilities are often neither wholly competent nor wholly incompetent. The New Options Waiver Program has chosen to involve and recognize the rights of all recipients while at the same time protecting the rights of recipients through the request of concurrent consent by recipients’ authorized representatives.

Whoever is selected as authorized representative must meet the three tests for effect consent: that is, he/she must be competent, adequately informed about the factors involved in the decision and be knowledgeable about the person for whom consent is sought, and voluntary (free from coercion or conflict of interest). The authorized representative must act on the basis of the best interest of the person for whom his or her consent is sought. A suggested list of potential candidates for authorized representatives includes, but is not limited to the following: guardian or conservator, parent, participant’s spouse, adult child, adult next-of-kin, any responsible relative, and attorney(s). In the absence of an available, suitable candidate an advocate appointed by the Georgia Advocacy Office may serve as the designated representative.

Process

Step (1) Provide an overview of service options, noting pro’s and con’s related to
each option; this includes inherent and potential risks, benefits, and stigmas.

A) The content of the overview should make one reasonably familiar with service options.

B) The presentation of information should be designed to match the recipient’s and/or his/her representative’s level of comprehension.

C) Evidence of participant/representative’s understanding of information should be evidenced in the discussion of the same.

Step (2) Once information has been provided and appears to be understood, the
Planning List Administrator/Support Coordinator (or designee) should verify that this information has been provided appropriately and is understood. Once verified, the form should be signed at the designated sign-off under verification statement.

Step (3) Informed participant/representative chooses a service option. The
Informed participant/representative should sign under the appropriate statement that reflects their choice. In cases where the individual participant is a minor, and/or unable due to physical and/or mental causes to sign his/her name, and/or unable to legibly write his/her name, the participant’s
name should be printed, above his/her signature or mark, if any, and be initialed by the participant’s authorized representative.

A witness should sign verifying both the participant’s and authorized representative’s signature. The witness may be the Planning List Administrator/Support Coordinator or his/her authorized designee.

Step (4) Once the form is completed (with signatures under appropriate statements), it should be placed in the participant’s record.

APPENDIX F
MR/DD WAIVER PROGRAM COMMUNICATOR
MAO DETERMINATION

Participant Name

Address

City State Zip Code

County

Soc. Sec. #

Date of Birth

MHID #

Medicaid #

(Area Code) Phone #
Provider Phone #

SECTION I COMPLETED BY PLANNING LIST ADMIN/SUPPORT COORDINATOR
_________ Date participant was determined eligible for New Options Waiver (NOW)/Comprehensive Supports Waiver (COMP)

Signature: Date

SECTION II COMPLETED BY PLANNING LIST ADMIN/SUPPORT COORDINATOR (check those which apply)

Participant currently resides in an ICF-MR which receives Medicaid reimbursement for his/her services. Please compute cost share. Discharge Date: ________________
NOW/COMP Enrollment Date: _________________

Participant currently resides in the community and does not receive Medicaid. Please determine eligibility and cost share. Date services begin:

Participant is currently receiving MAO. Please compute cost share.

Participant needs annual re-determination of MAO status and cost share.

Participant requires a home visit for application. (Reason in Remarks)

Signature: Phone No. Date

SECTION III COMPLETED BY DFACS CASEWORKER

Date participant applied for MAO ELIGIBILITY DATE:

$ Participant’s cost share Effective Date:

$ Participant’s cost share due to liability change Effective Date:

Date participant was determined INELIGIBLE. (Reason in Remarks)

Signature: Phone No. Date

SECTION IV COMPLETED BY NOW/COMP PLANNING LIST ADMIN/SUPPORT COORDINATOR

This member has been released from the NOW/COMP effective , for the following reason.

Signature: Phone No. Date

SECTION V COMPLETED BY NOW/COMP SUPPORT COORDINATOR OR DFACS CASEWORKER

REMARKS:
APPENDIX G Prior Authorization Form

App

APPENDIX H
Rev. 04 2014

Exceptional Rate Request or
Request to Exceed Maximum Allowable Units for Traditional Provider Agency

NOTE: Appendix H Revision effective January 1, 2014 will be implemented according to the annual renewal process.

In extraordinary circumstances related to transition of an individual from an institution or imminent risk of institutionalization of an individual, providers may request the payment of a rate that exceeds the established maximum rate for a New Options Waiver (NOW) service. Exceptional rate requests are subject to the Department of Behavioral Health and Developmental Disabilities approval with notification of approval to the Department of Community Health. Providers must be authorized by the DBHDD Regional Office and the Division of Developmental Disabilities to receive exceptional rates beyond the Medicaid maximum rates for waiver services. Any approval of an exceptional rate is time limited up to a maximum of one year.

Services Eligible for Exceptional Rates:
Exceptional rate requests may be submitted for the following NOW waiver services:

a. Community Living Support Services
b. Community Access Group Services
c. Respite Overnight Services
d. Specialized Medical Supplies to exceed allowable units
e. Specialized Medical Equipment to exceed allowable units

Eligibility Criteria for Exceptional Rates:

To be considered for an exceptional rate or to exceed maximum allowable units, extraordinary circumstances must be demonstrated by the following:

1. Extraordinary Placement Circumstances: Extraordinary circumstances related to the placement or continued stay of the participant in the community must be documented by:

The individual is currently in an institution and unable to move to the least restrictive alternative in the community due to needed services requiring rate(s) above the established maximum rate(s), OR

The extent of an individual participant’s needs presents imminent risk of institutionalization (i.e., the only options are institutionalization or enhanced waiver service delivery beyond that provided by the established Medicaid maximum rate);

AND

2. Assessed Exceptional Needs of the Participant: Exceptional needs of the participant must be documented by at least one of the following assessment findings from the Health Risk Screening Tool or the Supports Intensity Scale.

a. Health Risk Screening Tool (HRST)

a. A rating of 4 on Eating or Toileting in the HRST Category I – Functional Status, with Georgia licensed Registered Nurse review and signature, OR
b. A rating of 4 on Self Abuse or Aggression Toward Others and Property in the HRST Category II – Behaviors, with Georgia licensed Registered Nurse review, signature, and documented consultation of RN with Qualified Mental Retardation Professional (QMRP) level psychology professional, OR
c. Any rating of 4 on Treatments in the HRST Category III – Physiological, with Georgia licensed Registered Nurse review and signature, OR
d. Four or more ratings of 4 overall on the HSRT, with Georgia licensed Registered Nurse review and signature,
OR

b. Supports Intensity Scale (SIS)

a. A rating of 2 (Extensive Support Needed) on Lifting and/or Transferring, Turning or Positioning, or Seizure Management in the Supports Intensity Scale (SIS) Section 3A: Exceptional Medical Supports Needed, with Georgia licensed Registered Nurse review and signature, OR
b. A rating of 2 (Extensive Support Needed) on Prevention of Assaults/Injuries to Others, Prevention of Property Destruction, or Prevention of Tantrums/Outbursts in the SIS Section 3B: Exceptional Behavioral Supports Needed with Georgia licensed Registered Nurse review, signature, and documented consultation of RN with Qualified Intellectual Disability Professional (QIDP) level psychology professional, OR
c. A Total Rating of at least 6 that includes a minimum of one rating of 2 in the SIS Section 3A: Exceptional Medical Supports Needed or the SIS Section 3B: Exceptional Behavioral Supports Needed, with Georgia licensed Registered Nurse review and signature, and documented consultation of RN with Qualified Intellectual Disability Professional (QIDP) level psychology professional if exceptional rate request relates to exceptional behavior support needs;

AND

3. Enhanced Service Delivery Requirements: Service delivery requirements for the participant must be demonstrated to:
Exceed that provided by the established Medicaid maximum rate for the service for which the exceptional rate is being requested; AND

Link to the assessed exceptional needs of the participant;

AND

4. Individual Service Plan: The assessed exceptional needs of the participant that support the exceptional rate request;

AND

5. Interdisciplinary Team Approval: The Interdisciplinary Team must approve the need for an exceptional rate, as documented in the ISP for hospital transitions, the Clinical Triage Team serves as the Interdisciplinary Team and identifies the exceptional medical and/or behavioral supports needed by the individual.

Enhanced Medical and Behavior Support
A clinical based review and specification of the enhanced medical and/or behavior supports required by an individual will be conducted by the Intake & Evaluation Team for individuals currently on the waivers or entering the waivers from the community. A Transition Triage Team will conduct the clinically based review and specification of the enhanced medical and/or behavioral supports required by individuals transitioning to the community.

For individuals entering the waivers with approved exceptional rates, a clinical review of the initial, enhanced medical and/or behavioral supports will occur for the first birthday renewal. If the clinical review supports that there are no changes in the enhanced medical and/or behavioral supports needed by the individual, then the exceptional rate as initially approved will be maintained until the following annual birthday renewal.

Individual Support Plan
Enhanced Service Delivery Requirements must be written in the Individual Support Plan that describes the direct service delivery related to the care of the participant. The exceptional rate must derive from the enhanced service delivery specific to the exceptional needs of the participant, which include one or more of the following:

. Extraordinary Staffing Requirements: Additional paraprofessional, direct care or staffing requirements and duties for support, which include enhanced paraprofessional, direct care staffing ratios, and/or additional hours of direct Medical or Behavioral service provision. DDP staffing for exceptional rates are DDPs in the nursing and behavioral categories only.
Rev 10 2014

Developmental Disability Professional: DDP service provision for medical must be provided by an individual who meets DDP requirements such as Registered Nurse (Associate Degree or Diploma) or Registered Nurse (Bachelor Degree) and exceptional behavioral support needs must be provided by an individual who meets the DDP requirements for a Behavior Specialist or Board Certified Behavior Analyst. DDP staffing for exceptional rates are DDPs in the nursing and behavioral categories only. See NOW/COMP policies Appendix I for additional information on DDP.

. Specialized Medical Supplies Requirements: Additional frequency of use of medical supplies, which results in an exceptional quantity of medical supplies, or requirements for multiple types of medical supplies on a frequent basis.

. Specialized Medical Equipment Requirements: Extraordinary medical equipment requirements, which result in need for a one-time purchase at the lifetime maximum.

Documentation for Exceptional Rate Request or Request to Exceed Maximum Allowable Units
. Provider completes Exceptional Rate Request template and Exceptional Rate Budget template for exceptional rate Regional Office (templates available in the Providers Toolkit at www.dbhdd.georgia.gov). Hourly wage for direct care and DDP staff included in the Exceptional Rate Budget template are as indicated in DBHDD policy on the Exceptional Rate Submission and Review Procedures (available at https://gadbhdd.policystat.com).

. The most recent annual Health Risk Screening Tool (HRST) and Supports Intensity Scale (SIS) full assessment findings; either of these assessments supporting the request for renewal of an exceptional rate must be updated within 120 days to 90 days prior to the expiration of an existing exceptional rate.
Rev 10 2014

. Individual Service Plan (ISP) documentation of the enhanced supports due to the exceptional medical and/or behavioral supports needs of the individual recommended by the Regional Intake & Evaluation & Transition Triage Team.

. Crisis Plan submission is required for all Exceptional Rate Requests. Crisis Plan for any crisis is defined as an occurrence that poses a health and safety risk to the participant and/or others as a result of the exceptional behavioral or medical support needs of the participant; the Crisis Plan, as applicable to the exceptional rate request, includes, but is not limited to, the following:

. Back up plans when critical staff are absent for all exceptional rate requests;

. Crisis interventions when behaviors occur that pose health and safety risks to the participant and/or others both in the home, the community, or in transit for Behavioral Support Exceptional Rate Requests; and/or
. Support protocol for any participant at risk of elopement in the event of an elopement for Behavioral Support Exceptional Rate Requests.

Requests for Exceptional Rates based on the Exceptional Behavioral Support needs of the Participant must include the following:

. An agency developed and approved behavior support plan applicable to service provision by the provider agency requesting the exceptional rate for all renewals and within 90 days for initials.

. Documentation that provider agency employees, or individuals under contract, supporting the participant with exceptional behavioral support needs are trained in the use of emergency safety interventions. These employees or individuals must maintain certification in a DBHDD approved emergency safety intervention curriculum. The circumstances under which the emergency intervention shall be implemented should be detailed in the participant’s behavior support plan and crisis plan.

. If available, a graph, or graphs, of behavioral data are preferred submissions. Quantitative data in the form of frequency, rate, or duration should be provided for each target behavior identified in the behavior support plan. This data must include the most recent three (3) month period of continuous data collection for each behavior targeted by the behavior support plan. Data should be in an objective, numerical, and graphical form.

Exceptional Rate or Exceeding Maximum Allowable Units Request Review:
DBHDD, Division of Developmental Disabilities conducts a clinical/programmatic review of the basis for the exceptional rate or exceeding maximum allowable units request and a review of the enhanced service delivery requirements associated with the requested exceptional rate as follows:

. Clinical/Programmatic Review: The Division of DD will deny any exceptional rate or exceeding maximum allowable units request that:

a. Does not meet or adequately document the meeting of Extraordinary Circumstances Requirements for an Exceptional Rate; OR

b. Does not adequately link the Enhanced Service Delivery Requirements to the exceptional needs of the individual participant.
. Enhanced Service Delivery Requirements Review: The Division of DD does not approve any exceptional rate request that has inadequate documentation of the Enhanced Service Delivery Requirements for the participant.

Administrative Cost for Exceptional Rates
Administrative costs are based on 15 percent of the standard maximum rate for the service: however, the administrative cost determination will differ for Specialized Medical Supplies (SMS). The administrative costs for SMS Exceptional Rates include ordering, billing, handling, delivery, processing, and documenting. The administrative costs are based on the unique items ordered. For example, formula is one unique item, and 12 cases of formula are regarded as one
unique item.

NOTE: Any supplies in the category of over-the-counter medications are counted as one unique item for all supplies in this category. Also, any supplies in the category of herbal supplements, nutritional oils, other non-nutritional supplements, and vitamins are counted as one unique item for all supplies in this category.

Administrative costs for SMS Exceptional Rates are based on unique items as defined above. The administrative costs are as follows:

Number of Unique Items
Annual Administrative Costs

1 to 4
$250

5 to 8
$335

9 to 12
$449

13 to 16
$602

Above 16
$807
For additional information on the processing of exceptional rates, please review the link for DBHDD home page: http://gadbhdd.policystat.com

Accountability and Program Integrity
Delivery of services must be documented based upon the enhanced service delivery requirements for the participant due to his or her exceptional needs and in accordance with Medicaid guidelines. Failure by the provider to deliver services as approved will result in recoupment. All exceptional rates are subject to DCH Program Integrity audits and quality and compliance reviews by DBHDD State and Regional Offices. DBHDD State and Regional Offices make referrals to DCH Program Integrity if reviews indicate failure of the provider to deliver services as approved.

ANY EXCEPTIONAL RATE OR ADDITIONAL UNITS ABOVE THE ANNUAL MAXIMUM THAT EXPIRES WITHOUT A REQUEST FOR CONTINUATION AND APPROVAL FOR CONTINUATION BY THE DIVISION OF DD WILL BE TERMINATED ON THE DATE OF THE EXPIRATION.

APPENDIX I
Glossary of Terms

Accreditation
A review process conducted by a nationally recognized and approved accrediting body of a person or agency that is a direct service provider for people with mental illness, developmental disabilities or addictive diseases, focusing on prescribed standards as they relate to services and supports for those individuals.

Approved Accrediting Bodies
National accrediting organizations approved and recognized by the Division of Georgia Department of Behavioral Health and Developmental Disabilities are the following:
1. CARF – the Rehabilitation Accreditation Commission
2. JCAHO – The Joint Commission on Accreditation of Healthcare Organizations
3. The Council – The Council on Quality and Leadership
Rev. 10 2009
4. COA – Council on Accreditation of Services for Families and Children
5. ACHC – the Accreditation Council for Health Care for Community Residential Alternative (CRA) and Community Living Support (CLS) Nursing Services only.
Certification
A review process conducted by the Certification Unit of the Division of Georgia Department of Behavioral Health and Developmental Disabilities of a person or agency that is a direct service provider for people with mental illness, developmental disabilities or addictive diseases, focusing on standards found in the “Core Requirements for All Providers.”

Comprehensive Supports Waiver Program (COMP)
A home and community based services waiver developed to serve individuals with mental retardation/developmental disabilities that have been transferred to the community from an institution or are living in the community and require comprehensive and intensive services.

Core Requirements for All Providers
Core standards or requirements of the Division of DBHDD that are applicable to all individual and organizational providers who receive funds authorized by the division through contract, sub-contract or letter of agreement, regardless of the accreditation or certification status of the provider.

Rev. 07 2011

Developmental Disability Professional (DDP)
All intellectual/developmental disabilities services are provided by or under the direct supervision of a Developmental Disability Professional. The following are considered to be Developmental Disability Professionals:

a. Advanced Practice Nurse – A registered professional nurse who meets those educational, practice, certification requirements, OR any combination of such requirements, as specified by the Georgia Board of Nursing AND includes certified nurse midwives, nurse practitioners, certified registered nurse anesthetists, clinical nurse specialists in psychiatric/mental health,
AND others recognized by the board AND who have one year experience in treating individuals with intellectual/developmental disabilities in a medical setting or a community-based setting for delivery of nursing services.

Rev 10 2011
b. Behavior Specialist – A behavior specialist who has completed of a Master’s degree in psychology, school psychology, counseling, vocational rehabilitation or a related field which included one course in psychometric testing and two courses in any combination of the following: behavior analysis or modification, therapeutic intervention, counseling, or psychosocial assessment, AND one year of individualized treatment programming, monitoring and observing behavior; collecting and recording behavioral observations in a treatment setting and developing and implementing behavior management plans for individuals with intellectual disabilities OR developmental disabilities OR completion of a Bachelor’s degree in psychology, counseling, OR a related field which included one course in psychometric testing and two courses in any combination of the following: behavior analysis or modification, counseling, learning theory or psychology of adjustment AND two years of individualized treatment programming, monitoring and observing behavior; collecting and recording behavioral observations in a treatment setting and developing and implementing behavior management plans for individuals with intellectual/developmental disabilities.

c. Board Certified Behavior Analyst (BCBA) – A BCBA who has completed a Master’s degree, with 225 hours of approved graduate coursework, AND 1500 hours of experience in the field with 5% of those hours being supervised by a BCBA, AND has received a passing score on the Behavior Analyst Certification Board Exam, AND maintains a prescribed number of continuing educations units annually, AND has specialized training in developmental disabilities as evidenced by college coursework or practicum/internship experience OR one year of experience in providing services to individuals with intellectual/developmental disabilities.

d. Educator – An educator with a degree in education from an accredited program that includes a concentration in Special Education in college coursework OR teaching certificate in Special Education, AND one year of classroom experience in teaching individuals with intellectual/developmental disabilities.

e. Human Service Professional – A human services professional with a bachelor’s degree in social work OR a bachelor’s degree in human services field other than social work (including the study of human behavior, human development or basic human care needs) AND with specialized training OR one year of experience in providing human services to individuals with intellectual/developmental disabilities.

f. Master’s or Doctoral Degree Holders – A person with a Masters or Doctoral degree in one of the behavioral OR social sciences AND with specialized training in developmental disabilities as evidenced by college coursework OR practicum/internship experience OR one year of experience in providing services to individuals with intellectual/developmental disabilities.

g. Physical or Occupational Therapist – A licensed physical or occupational therapist who has specialized training in developmental disabilities as evidenced by college coursework OR practicum/internship experience OR one year of experience in treating individuals with intellectual/developmental disabilities.

h. Physician – A physician licensed under State law to practice medicine or osteopathy AND with specialized training in developmental disabilities OR one year of experience in treating individuals with intellectual/developmental disabilities in a medical setting.

i. Physician’s Assistant – A skilled person qualified by academic and practical training to provide patients´ services not necessarily within the physical presence but under the personal direction or supervision of a physician, AND who has one year experience in treating individuals with intellectual/developmental disabilities in a medical setting.

j. Psychologist – A holder of a doctoral degree from an accredited university or college, AND who is licensed in the State of Georgia AND who has specialized training in developmental disabilities OR one year of experience in evaluating or providing psychological services to individuals with intellectual/developmental disabilities.

k. Registered Nurse (Associate Degree or Diploma) – A registered nurse who is authorized by a license to practice nursing as a registered professional nurse, who holds an associate or diploma degree in nursing AND who has three years of experience, two of which are in treating individuals with intellectual/developmental disabilities in a medical setting, or a community-based setting for delivery of nursing services.
Rev 10 2011

l. Registered Nurse (Bachelor Degree) – A registered nurse who is authorized by a license to practice nursing as a registered professional nurse AND who holds a bachelor’s degree in nursing with one year experience in treating individuals with intellectual/developmental disabilities in a medical setting or a community-based setting for delivery of nursing services.
Rev 10 2011

m. Speech Pathologist or Audiologist – A licensed speech pathologist or audiologist who has specialized training in developmental disabilities as evidenced by college coursework or practicum/internship experience OR one year of experience in treating individuals with intellectual/developmental disabilities.

n. Therapeutic Recreation Specialist – A therapeutic recreation specialist who graduated from an accredited program AND who had specialized training in developmental disabilities as evidenced by college coursework OR practicum/internship experience OR one year experience in providing therapeutic recreational services to individuals with intellectual/developmental disabilities.

DBHDD – Department of Behavioral Health and Developmental Disabilities
The Department of Behavioral Health and Developmental Disabilities is responsible for the administration of the DD waiver programs. This is done through DBHDD’s Division of Developmental Disabilities.

DMA – Division of Medicaid
The Division of Medicaid is responsible for the final approval of all services and claims reimbursed to providers. DMA contracts with the Department of Behavioral Health and Developmental Disabilities for the overall coordination and daily administration of the waiver programs.

Family
Family is defined as a person who is related by blood within the third degree of consanguinity or by marriage. Third degree of consanguinity means mother, father, grandmother, grandfather, sister, brother, daughter, son, granddaughter, grandson, aunt, uncle, great aunt, great uncle, niece, nephew, grand niece, grand nephew, 1st cousins, 1st cousins once removed and 2nd cousins.

Funding through Authorization
Cumulative monies received by providers including any combination of funds through contract(s) or letter(s) of agreement with the department through the division:
1. State Dollars
2. Medicaid Waiver Funds

Facility
Rev.
07
2009
A provider owned or operated building or place.

Georgia Health Partnership (GHP)
DMA contracts with GHP to process all Provider Enrollment Applications, assign provider
enrollment numbers, and process provider claims.

Individual Service Plan (ISP)
An ISP is a written comprehensive plan that identifies in measurable terms the expected outcomes of all services to be provided to the participant. The ISP is directed toward achieving self-sufficiency and community integration.

Intake and Evaluation
The Intake and Evaluation Regional Office staff who evaluate applicant’s eligibility for waiver-
funded services. The team includes a physician, nurse, social worker, and a psychologist or
behavioral specialist. Other disciplines that provide services to the applicant must also be a part
of the team (Occupational Therapist, Speech Therapist, Physical Therapist and others which may
provide services).

Interdisciplinary Team
The interdisciplinary team is a group of individuals representing various disciplines that work
together to develop the Individual Service Plan for a participant. The interdisciplinary team must
include a social worker, nurse, and behavior specialist or psychologist. Additionally, if a
participant receives services from an occupational therapist, physical therapist, and/or speech
therapist, that professional(s) also must be part of the interdisciplinary team. Similarly, the
physician also must be part of the interdisciplinary team if a participant receives services from a
physician (beyond the annual physical and acute care).

License or Certificate
Proof of legal authority to operate. Examples of agencies that are required to be licensed or certified to provide direct care to consumers are (but are not limited to) the following:
1. Personal Care Homes
2. Private Home Care Providers
3. Nursing Homes
4. Community Living Arrangements

Mental Health Developmental Diseases &Addictive Diseases (DBHDD)
DBHDD, is responsible for the coordination and administration of the MR
waiver programs. DBHDD Regional Offices are part of this division.

New Options Waiver Program (NOW)
A home and community based services waiver developed to serve individuals with mental retardation/developmental disabilities who live in their own or family home.

Regional DBHDD Offices
The Regional DBHDD Office coordinates and monitors the waiver as well as funding for other
services and resources for Georgia’s MR/DD population. The state is currently divided into 5
regions. Individuals seeking MR/DD services should apply through the Regional Office that
serves their county.

Waiver of Accreditation
A letter stating that a person or agency may have an extension of a period of time during which to complete their accreditation process.

Waiver of Certification
A letter stating that a person or agency may have an extension of a period of time during which to complete their certification process.
APPENDIX J
Georgia Health Partnership (GHP)

Provider Correspondence Provider Enrollment
GHP GHP
P.O. Box 105200 P.O. Box 150201
Tucker, GA 30085-5200 Atlanta, GA 30085-5201

Provider Paper Claims Submission
GHP
P.O. Box 105202
Tucker, GA 300850-5202

Prior Authorization & Electronic Data Interchange (EDI)
Pre-Certification
GMCF 877-261-8785
P.O. Box 105329
Atlanta, GA 30348
. Asynchronous

. Web portal

. Physical media

. Network Data Mover (NDM)

. Systems Network Architecture (SNA)

. Transmission Control Protocol/
Internet Protocol (TCP/IP)

Provider Inquiry Number:

800 766-4456 (Toll free)

The web contact address is www.mmis.georgia.gov.
APPENDIX K

ID_Card_Front

ID_Card_Back

APPENDIX L
Medicaid Provider Application Process for DBHDD Services

App

April, 2014 Appendix M
Georgia Families

Georgia Families (GF) is a statewide program designed to deliver health care services to members of Medicaid and PeachCare for Kids®. The program is a partnership between the Department of Community Health (DCH) and private Care Management Organizations (CMOs). By providing a choice of health plans, Georgia Families allows members to select a health care plan that fits their needs.
It is important to note that GF is a full-risk program; this means that the three CMOs licensed in Georgia to participate in GF are responsible and accept full financial risk for providing and authorizing covered services. This also means a greater focus on case and disease management with an emphasis on preventative care to improve individual health outcomes. In addition, each CMO may contract with a behavioral health or therapy service organization in order to coordinate physical and mental health services to improve member care, coordination, and efficiency.

Medicaid and PeachCare for Kids® members will continue to be eligible for the same services they receive through traditional Medicaid as well as new services. Members will not have to pay more than they paid for Medicaid co-payments or PeachCare for Kids® premiums. With a focus on health and wellness, the CMOs will provide members with health education and prevention programs as well as expanded access to plans and providers, giving them the tools needed to live healthier lives. Providers participating in Georgia Families will have the added assistance of the CMOs to educate members about accessing care, referrals to specialists, member benefits, and health and wellness education.

The Department of Community Health has contracted with three CMOs to provide these services: Amerigroup Community Care, Peach State Health Plan and WellCare of Georgia.

Members can contact Georgia Families at www.georgia-families.com or call 1-888-GA-ENROLL (1-888-423-6765) for assistance to determine which program best fits their family’s needs. If members do not select a plan, Georgia Families will select a health plan for them.
CMOs
Amerigroup Community Care
800-600-4441
www.myamerigroup.com
Peach State Health Plan
800-704-1484 www.pshpgeorgia.com
WellCare of Georgia
866-231-1821
www.wellcare.com
Children, pregnant women and women with breast or cervical cancer on Medicaid, as well as children enrolled in PeachCare for Kids® are eligible to participate in Georgia Families.

Georgia Families Regions
Region
Counties
Health Plans

Atlanta
Barrow, Bartow, Butts, Carroll, Cherokee, Clayton, Cobb, Coweta, DeKalb, Douglas, Fayette, Forsyth, Fulton, Gwinnett, Haralson, Henry, Jasper, Newton, Paulding, Pickens, Rockdale, Spalding, Walton
Amerigroup Community Care
Peach State Health Plan
WellCare of Georgia

Central
Baldwin, Bibb, Bleckley, Chattahoochee, Crawford, Crisp, Dodge, Dooly, Harris, Heard, Houston, Johnson, Jones, Lamar, Laurens, Macon, Marion, Meriwether, Monroe, Muscogee, Peach, Pike, Pulaski, Talbot, Taylor, Telfair, Treutlen, Troup, Twiggs, Upson, Wheeler, Wilcox, Wilkinson
Amerigroup Community Care
Peach State Health Plan
WellCare of Georgia

East
Burke, Columbia, Emanuel, Glascock, Greene, Hancock, Jefferson, Jenkins, Lincoln, McDuffie, Putnam, Richmond, Taliaferro, Warren, Washington, Wilkes
Amerigroup Community Care
Peach State Health Plan
WellCare of Georgia

North
Banks, Catoosa, Chattooga, Clarke, Dade, Dawson, Elbert, Fannin, Floyd, Franklin, Gilmer, Gordon, Habersham, Hall, Hart, Jackson, Lumpkin, Madison, Morgan, Murray, Oconee, Oglethorpe, Polk, Rabun, Stephens, Towns, Union, Walker, White, Whitfield
Amerigroup Community Care
Peach State Health Plan
WellCare of Georgia

Southeast
Appling, Bacon, Brantley, Bryan, Bulloch, Camden, Candler, Charlton, Chatham, Effingham, Evans, Glynn, Jeff Davis, Liberty, Long, McIntosh, Montgomery, Pierce, Screven, Tattnall, Toombs, Ware, Wayne
Amerigroup Community Care
Peach State Health Plan
WellCare of Georgia

Southwest
Atkinson, Baker, Ben Hill, Berrien, Brooks, Calhoun, Clay, Clinch, Coffee, Colquitt, Cook, Decatur, Dougherty, Early, Echols, Grady, Irwin, Lanier, Lee, Lowndes, Miller, Mitchell, Quitman, Randolph, Schley, Seminole, Stewart, Sumter, Terrell, Thomas, Tift, Turner, Webster, Worth
Amerigroup Community Care
Peach State Health Plan
WellCare of Georgia

Georgia Families Eligibility Categories
Included Populations
Excluded Populations

PeachCare for Kids®
Nursing home

Low-Income Medicaid (LIM)
Federally Recognized Indian Tribe

Right from the Start Medicaid (RSM)
Georgia Pediatric Program (GAPP)

Women’s Health Medicaid (WHM)
Community Based Alternative for Youths (CBAY)

Transitional Medicaid
Children’s Medical Services program

Refugees
Medicare Eligible

Planning for Healthy Babies
Supplemental Security Income (SSI) Medicaid
Medically Needy

Resource Mother’s Outreach
Long-term care

Children (Newborn)

Breast and Cervical Cancer

Included Categories of Eligibility:

COE
DESCRIPTION

104
LIM – Adult

105
LIM – Child

118
LIM – 1st Yr Trans Med Ast Adult

119
LIM – 1st Yr Trans Med Ast Child

120
LIM – 2nd Yr Trans Med Ast Adult

121
LIM – 2nd Yr Trans Med Ast Child

122
CS Adult 4 Month Extended

123
CS Child 4 Month Extended

126
Stepchild

135
Newborn Child

170
RSM Pregnant Women

171
RSM Child

194
RSM Expansion Pregnant Women

195
RSM Expansion Child < 1 Yr

196
RSM Expn Child w/DOB < = 10/1/83

197
RSM Preg Women Income < 185 FPL

245
BCC Waiver

471
RSM Child

506
Refugee (DMP) – Adult

507
Refugee (DMP) – Child

508
Post Ref Extended Med – Adult

509
Post Ref Extended Med – Child

510
Refugee MAO – Adult

511
Refugee MAO – Child

571
Refugee RSM – Child

595
Refugee RSM Exp. Child < 1

596
Refugee RSM Exp Child DOB </= 10/01/83

790
Peachcare < 150% FPL

791
Peachcare 150 – 200% FPL

792
Peachcare 201 – 235% FPL

793
Peachcare > 235% FPL

800
Presumptive BCC

804
Lim REI Adult

805
Lim REI Child

818
TMA REI Adult

819
TMA REI Child

835
Newborn

836
Newborn (DFACS)

871
RSM (DHACS)

872
RSM 150% Expansion (DHACS)

876
RSM Pregnant Women (DHACS)

894
RSM Exp Pregnant Women (DHACS)

895
RSM Exp Child < 1 (DHACS)

896
RSM Exp Child </= 10/01/83 (DHACS)

897
RSM Pregnant Women Income > 185% FPL (DHACS)

898
RSM Child < 1 Moth Aid = 897 (DHACS)

918
LIM Adult

919
LIM Child

920
Refugee Adult

921
Refugee Child
Excluded Categories of Eligibility:

COE
DESCRIPTION

124
Standard Filing Unit – Adult

125
Standard Filing Unit – Child

131
Child Welfare Foster Care

132
State Funded Adoption Assistance

147
Family Medically Needy Spend down

148
Pregnant Women Medical Needy Spend down

172
RSM 150% Expansion

177
Family Planning Waiver

180
Interconceptional Waiver

210
Nursing Home – Aged

211
Nursing Home – Blind

212
Nursing Home – Disabled

215
30 Day Hospital – Aged

216
30 Day Hospital – Blind

217
30 Day Hospital – Disabled

218
Protected Med/1972 Cola – Aged

219
Protected Med/1972 Cola – Blind

220
Protected Med/1972 Cola – Disabled

221
Disabled Widower 1984 Cola – Aged

222
Disabled Widower 1984 Cola – Blind

223
Disabled Widower 1984 Cola – Disabled

224
Pickle – Aged

225
Pickle – Blind

226
Pickle – Disabled

227
Disabled Adult Child – Aged

228
Disabled Adult Child – Blind

229
Disabled Adult Child – Disabled

230
Disabled Widower Age 50-59 – Aged

231
Disabled Widower Age 50-59 – Blind

232
Disabled Widower Age 50-59 – Disabled

233
Widower Age 60-64 – Aged

234
Widower Age 60-64 – Blind

235
Widower Age 60-64 – Disabled

236
3 Mo. Prior Medicaid – Aged

237
3 Mo. Prior Medicaid – Blind

238
3 Mo. Prior Medicaid – Disabled

239
Abd Med. Needy Defacto – Aged

240
Abd Med. Needy Defacto – Blind

241
Abd Med. Needy Defacto – Disabled

242
Abd Med Spend down – Aged

243
Abd Med Spend down – Blind

244
Abd Med Spend down – Disabled

246
Ticket to Work

247
Disabled Child – 1996

250
Deeming Waiver

251
Independent Waiver

252
Mental Retardation Waiver

253
Laurens Co. Waiver

254
HIV Waiver

255
Cystic Fibrosis Waiver

259
Community Care Waiver

280
Hospice – Aged

281
Hospice – Blind

282
Hospice – Disabled

283
LTC Med. Needy Defacto – Aged

284
LTC Med. Needy Defacto –Blind

285
LTC Med. Needy Defacto – Disabled

286
LTC Med. Needy Spend down – Aged

287
LTC Med. Needy Spend down – Blind

288
LTC Med. Needy Spend down – Disabled

289
Institutional Hospice – Aged

290
Institutional Hospice – Blind

291
Institutional Hospice – Disabled

301
SSI – Aged

302
SSI – Blind

303
SSI – Disabled

304
SSI Appeal – Aged

305
SSI Appeal – Blind

306
SSI Appeal – Disabled

307
SSI Work Continuance – Aged

308
SSI Work Continuance – Blind

309
SSI Work Continuance – Disabled

315
SSI Zebley Child

321
SSI E02 Month – Aged

322
SSI E02 Month – Blind

323
SSI E02 Month – Disabled

387
SSI Trans. Medicaid – Aged

388
SSI Trans. Medicaid – Blind

389
SSI Trans. Medicaid – Disabled

410
Nursing Home – Aged

411
Nursing Home – Blind

412
Nursing Home – Disabled

424
Pickle – Aged

425
Pickle – Blind

426
Pickle – Disabled

427
Disabled Adult Child – Aged

428
Disabled Adult Child – Blind

429
Disabled Adult Child – Disabled

445
N07 Child

446
Widower – Aged

447
Widower – Blind

448
Widower – Disabled

460
Qualified Medicare Beneficiary

466
Spec. Low Inc. Medicare Beneficiary

575
Refugee Med. Needy Spend down

660
Qualified Medicare Beneficiary

661
Spec. Low Income Medicare Beneficiary

662
Q11 Beneficiary

663
Q12 Beneficiary

664
Qua. Working Disabled Individual

815
Aged Inmate

817
Disabled Inmate

870
Emergency Alien – Adult

873
Emergency Alien – Child

874
Pregnant Adult Inmate

915
Aged MAO

916
Blind MAO

917
Disabled MAO

983
Aged Medically Needy

984
Blind Medically Needy

985
Disabled Medically Needy
HEALTH CARE PROVIDERS

For information regarding the participating health plans (enrollment, rates, and procedures), please call the numbers listed below.

Prior to providing services, you should contact the member’s health plan to verify eligibility, PCP assignment and covered benefits. You should also contact the health plan to check prior authorizations and submit claims.

Amerigroup Community Care

800-454-3730 (general information)
888-821-1108 (provider recruitment)
www.amerigroupcorp.com

Peach State Health Plan

866-874-0633 (general information)
866-874-0633 (claims)
800-704-1483 (medical management)
www.pshpgeorgia.com
WellCare of Georgia

866-231-1821
www.wellcare.com

Registering immunizations with GRITS:

If you are a Vaccine for Children (VFC) provider, please continue to use the GRITS (Georgia Immunization Registry) system for all children, including those in Medicaid and PeachCare for Kids®, fee-for-service, and managed care.

Important tips for the provider to know/do when a member comes in:

Understanding the process for verifying eligibility is now more important than ever. You will need to determine if the patient is eligible for Medicaid/PeachCare for Kids® benefits and if they are enrolled in a Georgia Families health plan. Each plan sets its own medical management and referral processes. Members will have a new identification card and primary care provider assignment.

You may also contact Hewlett Packard (HP) at 1-800-766-4456 (statewide) or www.mmis.georgia.gov for information on a member’s health plan.

Use of the Medicaid Management Information System (MMIS) web portal:
The call center and web portal will be able to provide you information about a member’s Medicaid eligibility and health plan enrollment. HP will not be able to assist you with benefits, claims processing or prior approvals for members assigned to a Georgia Families health plan. You will need to contact the member’s plan directly for this information.

Participating in a Georgia Families’ health plan:

A Medicaid provider makes a business decision whether to participate in one, two or all three health plans. To participate in a health plan, the provider must be enrolled in Medicaid and sign a contract and be credentialed by the health plan. Each health plan has its own contracting procedures and credentialing requirements. If a provider is interested in participating with a health plan, he/she should contact the plan’s provider enrollment department.

Assignment of separate provider numbers by all of the health plans:

Each health plan will assign provider numbers, which will be different from the provider’s Medicaid provider number and the numbers assigned by other health plans.

Billing the health plans for services provided:

For members who are in Georgia Families, you should file claims with the member’s health plan.

If a claim is submitted to HP in error:

HP will deny the claim with a specific denial code. Prior to receiving this denial, you may go ahead and submit the claim to the member’s health plan.

Receiving payment:

Claims should be submitted to the member’s health plan. Each health plan has its own claims processing and you should consult the health plan about their payment procedures.

Health plans payment of clean claims:

Each health plan (and subcontractors) has its own claims processing and payment cycles. The claims processing and payment timeframes are as follows:

Amerigroup Community Care

Amerigroup runs claims cycles twice each week (on Monday and Thursday) for clean claims that have been adjudicated.
Monday Claims run: Checks mailed on Tuesday. Providers enrolled in ERA/EFT receive the ACH on Thursday.
Thursday Claims run: Checks mailed on Wednesday. Providers enrolled in ERA/EFT receive the ACH on Tuesday.
Dental: Checks are mailed weekly on Thursday for clean claims.
Vision: Checks are mailed weekly on Wednesday for clean claims (beginning June 7th)
Pharmacy: Checks are mailed to pharmacies weekly on Friday (except when a holiday falls on Friday, then mailed the next business day).
Peach State Health Plan

Peach State has two weekly claims payment cycles per week that produces payments for clean claims to providers on Tuesday and Friday.
For further information, please refer to the Peach State website, or the Peach State provider manual.
WellCare of Georgia

WellCare runs claims payment cycles up to six (6) times each week for clean claims.
For further information, please refer to the WellCare website, the WellCare provider manual, or contact Customer Service at 866-231-1821.

How often can a patient change his/her PCP?

Amerigroup Community Care

Peach State Health Plan

WellCare of Georgia
Anytime

Within the first 90 days of a member’s enrollment, he/she can change PCP monthly. If the member has been with the plan for 90 days or longer, the member can change PCPs once every six months. There are a few exclusions that apply and would warrant an immediate PCP change.
Anytime

Once the patient requests a PCP change, how long it takes for the new PCP to be assigned:

Amerigroup Community Care

Next business day

Peach State Health Plan

PCP changes are updated in Peach State’s systems daily.
WellCare of Georgia

PCP changes made between the 1st and 10th of the month will go into effect right away. Changes made after the 10th of the month will take effect at the beginning of the next month.

PHARMACY

Georgia Families does provide pharmacy benefits to members. Check with the member’s health plan about the who to call to find out more about enrolling to provide pharmacy benefits, including information about their plans reimbursement rates, specific benefits that are available, including prior approval requirements.

To request information about contracting with the health plans, you can call the CMOs provider enrollment services.

Amerigroup Community Care
888-821-1108
www.amerigroupcorp.com
Peach State Health Plan
866-874-0633
www.pshpgeorgia.com
WellCare of Georgia
866-231-1821
https://georgia.wellcare.com/

All providers must be enrolled as a Medicaid provider to be eligible to contract with a health plan to provide services to Georgia Families members.

The CMO Pharmacy Benefit Managers (PBM) and the Bin Numbers, Processor Control Numbers and Group Numbers are:

Health Plan
PBM
BIN #
PCN

Amerigroup
Caremark
610415
PCS

Peach State Health Plan
US Script
008019
Not Required

WellCare
CatamaranRx
603286
01410000

If a patient does not have an identification card:
Providers can check the enrollment status of Medicaid and PeachCare for Kids® members through HP by calling 1-800-766-4456 or going to the web portal at www.mmis.georgia.gov. HP will let you know if the member is eligible for services and the health plan they are enrolled in. You can contact the member’s health plan to get the member’s identification number.

Use of the member’s Medicaid or PeachCare for Kids® identification number to file a pharmacy claim:

Amerigroup Community Care
No, you will need the member’s health plan ID number
Peach State Health Plan
Yes

WellCare of Georgia
Yes

Health plans preferred drug list, prior authorization criteria, benefit design, and reimbursement rates:

Each health plan sets their own procedures, including preferred drug list, prior authorization criteria, benefit design, and reimbursement rates.

Will Medicaid cover prescriptions for members that the health plans do not?

No, Medicaid will not provide a “wrap-around” benefit for medications not covered or approved by the health plan. Each health plan will set its own processes for determining medical necessity and appeals.

Who to call to request a PA:

Amerigroup Community Care
1 (800) 454-3730, option 3, option 3
Peach State Health Plan
1 (866) 874-0633
WellCare of Georgia
1 (866) 269-5251 (phone)
1 (866) 455-6558 (fax)

APPENDIX N
Rev 07 2012
Non-Emergency Transportation

People enrolled in the Medicaid program need to get to and from health care services, but many do not have any means of transportation. The Non-Emergency Transportation Program (NET) provides a way for Medicaid recipients to get that transportation so they can receive necessary medical services covered by Medicaid.

How do I get non-emergency transportation services?
If you are a Medicaid recipient and have no other way to get to medical care or services covered by Medicaid, you can contact a transportation broker to take you. In most cases, you must call three days in advance to schedule transportation. Urgent care situations and a few other exceptions can be arranged more quickly. Each broker has a toll-free telephone number to schedule transportation services, and is available weekdays (Monday-Friday) from 7 a.m. to 6 p.m. All counties in Georgia are grouped into five regions for NET services. A NET Broker covers each region. If you need NET services, you must contact the NET Broker serving the county you live in to ask for non-emergency transportation. See the chart below to determine which broker serves your county, and call the broker’s telephone number for that region.

What if I have problems with a NET broker?
The Division of Medical Assistance (DMA) monitors the quality of the services brokers provide, handling consumer complaints and requiring periodic reports from the brokers. The state Department of Audits also performs on-site evaluations of the services provided by each broker. If you have a question, comment or complaint about a broker, call the Member CIC at 866-211-0950.

Region
Broker / Phone number
Counties served

North

Southeastrans

Toll free
1-866-388-9844

Local
678-510-4555
Banks, Barrow, Bartow, Catoosa, Chattooga, Cherokee, Cobb, Dade, Dawson, Douglas, Fannin, Floyd, Forsyth, Franklin, Gilmer, Gordon, Habersham, Hall, Haralson, Jackson, Lumpkin, Morgan, Murray, Paulding, Pickens, Polk, Rabun, Stephens, Towns, Union, Walker, Walton, White and Whitfield

Atlanta
Southeastrans 404-209-4000
Fulton, DeKalb and Gwinnett

Central

LogistiCare

Toll free

1-888-224-7981
Baldwin, Bibb, Bleckley, Butts, Carroll, Clayton, Coweta, Dodge, Fayette, Heard, Henry, Jasper, Jones, Lamar, Laurens, Meriwether, Monroe, Newton, Pike, Putnam, Rockdale, Spalding, Telfair, Troup, Twiggs and Wilkinson

East

LogistiCare
Toll free
1-888-224-7988
Appling, Bacon, Brantley, Bryan, Bulloch, Burke, Camden, Candler, Charlton, Chatham, Clarke, Columbia, Effingham, Elbert, Emanuel, Evans, Glascock, Glynn, Greene, Hancock, Hart, Jeff Davis, Jefferson, Jenkins, Johnson, Liberty, Lincoln, Long, Madison, McDuffie, McIntosh, Montgomery, Oconee, Oglethorpe, Pierce, Richmond, Screven, Taliaferro, Tattnall, Toombs, Treutlen, Ware, Warren, Washington, Wayne, Wheeler and Wilkes

Southwest

LogistiCare
Toll free 1-888-224-7985
Atkinson, Baker, Ben Hill, Berrien, Brooks, Calhoun, Chattahoochee, Clay, Clinch, Coffee, Colquitt, Cook, Crawford, Crisp, Decatur, Dooly, Dougherty, Early, Echols, Grady, Harris, Houston, Irwin, Lanier, Lee, Lowndes, Macon, Marion, Miller, Mitchell, Muscogee, Peach, Pulaski, Quitman, Randolph, Schley, Seminole, Stewart, Sumter, Talbot, Taylor, Terrell, Thomas, Tift, Turner, Upson, Webster, Wilcox and Worth

APPENDIX O

Person Centered Planning

Person Centered Organizations: Creating Transformational Change
Basics of Person Centered Thinking (PCT):
(1) What is it?

. Set of tools that convey the core belief that all people are valued

. A common language, easily communicated, that activate the agency’s values

. A set of skills that result in teams keeping the focus on the person who needs support –not agency or turf issues

. A way to describe the desired lifestyle of the person who is supported, not the lifestyle desired by the agency

. Creates a blueprint for critical thinking skills for frontline staff, supervisors and managers that is consistent

(2) How does it benefit an Organization?
. Aligns the agency’s approach towards its employees with its approach towards people supported

. Creates a focus on the preferences of the customer, resulting in context necessary to address issues of health, safety and valued social roles.

. Replaces jargon with a common language

. Uses a set of tools, easily taught, that build critical thinking skills for employees

. Tools are interrelated –one supports the next

. Initial Two-Day Training builds knowledge, followed by structured practice to develop skill

. Same tools used to develop and support the people served are used to develop and support the abilities of all employees throughout the agency.

How does PCT do this?
. Person Centered Planning-> PC Plan (many people involved, one person’s plan)

. Person Centered Thinking(changes in our language)

. Person Centered Practices–(changes in our Tools and documents)

. Person Centered Organizations–(changes in our Processes-business and program)

. Person Centered Systems–(changes in our Relationships with external agencies)
The Evolution of the Efforts

. Training in Person Centered Planning 1990

. Training in Person Centered Thinking 2001

. Training + the Development and Support of Coaches 2002

. Training and Coaches + the Sustained Engagement of Organizational Leadership – 2005

. Training, Coaches, Organizational Leadership + Sustained Engagement of System Leadership – 2006

. Teaching person centered thinking skills

. Developing and supporting coaches to spread the skills

. Creating structured ways for leadership to listen to coaches

. Building local capacity/creating sustainability

. Person centered thinking trainers
. Teaching leadership/quality management skills

. Intentionally building better partnerships between all of the key stakeholders

The structure of the effort –
. Transactional Dynamics –the everyday interactions and exchanges that create the working climate; changes in these interactions can change the climate of the workplace; structure, roles, reporting, tasks, management practice, supervisory activities etc.

. Transformative Change –change within an organization that creates a shift in values or culture; generally requires “entirely new behavior sets on the part of organization members”

Transactional vs. Transformative*
*From W. Warner Burke, Diagnosis for Organizational Change
Culture Change permeates the full organization:

. Leadership

. Employees

. Service Delivery/Programs

. Business Departments –Finance, Information Technology, HR

. Mission/Vision/Values and Strategy

. Relationships with external organizations and partners

Transformative Change
. Customer Focus clearly defines expectations, and ties to the M/V/V and strategy of the organization

. Leaders demonstrate through their own language, and clear messages that labels are not acceptable

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

. I am listened to

. What is important to me is recognized and present every day

.
. Focus on becoming a learning organization –continuous quality improvement

. Dedicated to learning from all engagements, alleviating blame culture, and building strong partnerships internally and externally

. Full organization is focused on how to move beyond simply meeting standards –

. Recognizing compliance as the floor, not the ceiling, of high quality service/performance.

. What should be shared?

. With others in the organization
. With others outside of the organization
. What should be celebrated?

. What should be changed?

. Is this story typical practice or is it exceptional practice?
. What organizational issues of structure, practice, rules or communication are getting in the way of implementing person centered practice? (Level 2)
. What system-wide issues (as above) exist? (Level 3)
. What did you hear in the story?
. What methods/strategies will you use? Is it repeatable?

. What is the sequence of activity?
. Which departments will be included? Which areas, offices or locations? Which service sector?
. Who will need to know, and how will they be informed?
. How will you make sure it is uniform?
. How will you determine that your approach is effective?
. How will you know it is working? What is your strategy for learning from your approach?
. What measures will you use?
. Where does the change need to occur?

Answers to the QUESTION: What do you think you are doing differently because of your efforts at creating Person Centered Organizations?
From long term services organizations–July 2009
. “This project made me look at people in a different way”

. “I have gained the ability to listen to people better and more carefully and ask better questions as I try to get to know them” (regulator)

. “This program has (helped) us to become team players.”

. “Whenever situations arise, we come together as a team.”

Answers to the QUESTION: What do you think you are doing differently because of your work?
From Developmental Disability Services:

. “Opens up communication”

. “The tools are versatile; you can use them with everyone”

. “This effort has brought common sense into supporting people”

. “Results in better lives and a better workplace”

. “Keeps our organization focused” (from CEO)

. “Makes our job easier”

. “Helps us focus on the people and not just the regulations”

. “I have been in the field for 19 years and this is so much better, not just collecting data, but learning about a better life”

. “It brings people together and unifies them for the right purpose”

Appendix P

LETTER OF INTENT TO PROVIDE SERVICES FORM
GEORGIA DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL DISABILITIES
Division of Developmental Disabilities

SERVICE SITE
(Legal name and address must be registered with the Georgia Secretary of State’s office)
Legal Name:

Tax ID #:

Corporate Street Address:

City: County: State: Zip Code:

Service Site Name:

Service Site Address:

City: County: State: Zip Code:

Mailing Address (if different):

City: County: State: Zip Code:

Owner:

Telephone: Fax:

Email Address: Website:

Director:

Telephone: Fax:

Email Address: Website:

Nurse:

Telephone: Fax:

Email Address: Website:

Developmental Disabilities Professional:

Telephone: Fax:

Email Address: Website:
EMAIL ADDRESSES MUST BE CURRENT AND CORRECT AS ALL FUTURE CORRESPONDENCE FROM DBHDD WILL BE CONDUCTED VIA EMAIL. IT IS THE RESPONSIBILITY OF THE POTENTIAL PROVIDER TO ENSURE THAT EMAILS FROM DBHDD ARE ACCEPTED BY YOUR EMAIL SYSTEM AND DO NOT GO TO THE “SPAM” MAILBOX.
List below the Waiver Services that you are applying to provide and the number of individuals to be served in each Service.
Waiver Service
Such as CRA, CLS, SE etc.
Number of Individuals to be Served In Each Service
County of Service
Provision
Region of Service Provision
Licensed
Service
Y/N?

In accordance with Department of Community Health (DCH) Healthcare Facility Regulation Division (HFR) [which was formerly known as Office of Regulatory Services or ORS], please indicate all applicable license(s) that you possess:

. Child Placing Agency (CPA) license . Community Living Arrangement (CLA) license
. Home Health Agency (HHA) license . Personal Care Home (PCH) license
. Private Home Care (PHC) license

Please list any services that the organization has delivered to citizens with developmental disabilities within the past five years.
Name of Service
Location of Service
Length Of Service

Please list any previous Contracts, Letters of Agreement (LOA) or Provider Agreements (PA) issued to the organization within the last five years by any of the following:
. Division of Mental Health, Developmental Disabilities & Addictive Diseases (DMHDDAD) – currently known as the Department of Behavioral Health and Developmental Disabilities (DBHDD)

. Division of Aging – currently known as the Department of Human Services (DHS), Division of Aging

. Department of Community Health (DCH)
List Agency Name Used On Contract or LOA
List all Key Personnel Names
Such as CEO/President Key Management Staff, Relative or Board of Directors
Contact Phone Number And E-Mail Address of each Key Personnel Name Listed
Department Issuing Contract
Service Provided Such as Aging, ICWP, Source etc.

With this Letter of Intent to Provide Services Form, your organization must also submit all pre-qualifiers listed within the Recruitment and Application to Become a Provider of Developmental Disabilities Services Policy. Any incomplete Letter of Intent to Provide Services Form, and/or incomplete or deficient pre-qualifier will result in no invitation to move forward to the application process.

Under applicable state and federal laws, I do hereby affirm that I am the authorized agent to complete this document and that the information contained herein this document is complete, true, and correct.

Name of Organization (please print) Owner / Title (please print)
Signature of Owner/ Title Date
APPENDIX Q
MR/DD NEW SITE INSPECTION CHECKLIST

Contracted Provider Making Request:
Date Request Emailed to the Region:

Contracted Provider’s CRA #:
Region of Responsibility for the Individual:

Person Responsible for Ensuring Placement Meets Requirements:

Phone:
Email:

Ext:
Targeted Move-In Date for the Individual:

Reason for Move:
Support Coordination Agency:

Support Coordinator:

_____ New Allocation _____ Internal Move w/in Agency _____ New Admission to Agency _____ Other (Explain):

Complete the following section(s) for EACH individual identified for placement in the home:

#1: Name
Axis I Axis II
Axis III Requires Assistance: Ambulation ___ Transfer____ Uses Medical Equipment: (describe) _________________________________________ Medical Issues: (describe) _________________________________________Behavior Issues: (describe) _________________________________________
#2: Name
Axis I Axis II
Axis III Requires Assistance: Ambulation ___ Transfer___ Uses Medical Equipment: (describe) _________________________________________ Medical Issues: (describe) _________________________________________ Behavior Issues: (describe) _________________________________________

#3: Name
Axis I Axis II
Axis III Requires Assistance: Ambulation ___ Transfer____ Uses Medical Equipment: (describe) _________________________________________ Medical Issues: (describe) _________________________________________Behavior Issues: (describe) _________________________________________
#4: Name
Axis I Axis II
Axis III Requires Assistance: Ambulation ___ Transfer___ Uses Medical Equipment: (describe) _________________________________________ Medical Issues: (describe) _________________________________________ Behavior Issues: (describe) _________________________________________

Appendix R

Antipsychotic Medications

Generic Trade

Aripiprazole Abilify
Chlorpromazine Thorazine
Chlorprothixene Taractan
Clozapine Clozaril
Fluphenazine Permitil, Prolixin*
Haloperidol Haldol*
Loxapine Loxitane
Mesoridazine Serentil
Molindone Lidone, Moban
Olanzapine Zyprexa
Palinperidone Invega*
Perphenazine Trilafon
Pimozide (for Tourette’s) Orap
Quetiapine Seroquel
Risperidone Risperdal*
Thioridazine Mellaril
Thiothixene Navane
Trifluoperazine Stelazine
Trifluopromazine Vesprin
Ziprasidone Geodon

*Also has a sustained release injectable form

Mood Stabilizer Medications

Generic Trade

Lithium Carbonate Eskalith
Lithium Carbonate Lithonate
Divalproex Sodium Depakote
Tiagabine Gabatril
Levetiracetam Keppra
Lamotrigine Lamitcal
Gabapentin Neurontin
Carbamazepine Tegretol
Oxcarbazepine Trileptal
Topiramate Topamax
Zonisamide Zonegran
Verapamil Calan
Clonidine Catapres
Propranolol Inderal
Mexiletine Mexitil
Guanfacine Tenex

Appendix S
Rev 04 2013
Documentation Progress Note and Summary Examples
(For all services except CRA, CLS and Respite)
Individual Progress Note Log

Person’s Name:
Provider Name:
MHN ID Number:
Service:
Support Plan Date: Addendum date: Procedure Code:

Month/Year:

Peer Quality Assurance Review: Date:

Codes:
Disclaimer: The use of this form does not guarantee compliance with all policies/standards for documentation.

ISP Goal A:
Service:
Date:
Time: In

Total hours/Units:

Time: Out

Objectives listed on ISP Action Plan
Frequency/completion date
Code

1.

2

3.

4.

Progress Note (Optional – Documentation can be written here if the person is not working on a specific goal for the day):

Direct Support Staff printed name/title:
Signature of Direct Support Staff: Date:
Weekly Additional Person Centered Progress
Achievements
Identified Barriers

What did he/she enjoy?

What did he/she not enjoy?

What worked and needs to be continued?

What did not work and needs to be changed?

You can place any other information about the goal into this section. OPTIONAL

Direct Support Staff printed name/title:
Signature of Direct Support Staff:
Date:
Weekly Additional Routine Person Centered Supports (Supports are pre-filled by the provider agency and additional supports can be added if necessary):

Additional Comments/Significant Events(s)(If no comments/significant events, indicate N/A):

Direct Support Staff printed name/title:
Signature of Direct Support Staff:
Date:
Legend Individual Progress Note Log
Section I Individual Identifiable Information (This section is pre-filled by the provider agency)
a. Person’s Name:
g. Provider Name:
b. MHN ID Number:
h. Service:
c. Support Plan Date: f. Addendum date: i. Procedure Code:

d. Month/Year:

e. Peer Quality Assurance Review: j. Date:

a. Person’s Name: Name of the individual served

b. MHN ID Number: Individual’s MHN ID number

c. Support Plan Date: Identify the ISP timeframe

d. Month/Year: Identify month and year of when services are being documented

e. Peer Quality Assurance Review: Professional reviewer’s name and signature

f. Addendum date: Identify any addendum date if applicable

g. Provider Name: This is where you place your provider name

h. Service: Specific service documenting

i. Procedure Code: Code for the service providing.

j. Date: Date reviewed by the Peer Quality Assurance reviewer (not pre-filled by the provider agency)

Section II Codes
Codes:
Codes: In this section you identify the codes used to identify the level of intervention/support the person required at the time of the training. For example: I=Independent, GP=Gestural prompt, VP=Verbal prompt, H-H=Hand-over-Hand assistance, M=Modeling, PPA=Partial physical assistance, FPA=Full physical assistance, N/A=Not applicable at this stage of progress, R= Refused (The cues should be individualized and may depend on the objective. Codes can be added in this section)

Section III ISP Goal A:
a. Service:
b. Date:
c. Time: IN

e. Total hours/Units:

d. Time: Out

f. Objectives listed on ISP Action Plan
g. Frequency/completion date
h. Codes

1.

2

3.

4.

i. Progress Note (Optional – Documentation can be written here if the person is not working on a specific goal for the day):

J. Direct Support Staff printed name/title:
j. K. Signature of Direct Support Staff: l. Date:

Section III
ISP Goal A: This is the Goal for the service listed in the individual’s ISP.
a. Service: Service rendered

b. Date: Date service provided

c. Time In: Start time

d. Time Out: End Time

e. Total hours/Units: Identify the total number of hours and units to be billed for the day

f. Objectives: List objectives identified on the person’s ISP

g. Frequency/completion date: For the objective (1) include the frequency on the ISP or if the objective was met, identify the completion date

h. Code: In this section you identify the codes used to identify the level of intervention or supports the person required at the time of the training.

i. Progress Notes: Optional – Documentation can be written here if the person is not working on a specific goal for the day): Staff can document on what the person did related to the services provided outside the scope of the goal/objectives. Include how the person responded, any significant event, new experiences, and/or what is next. Any requests the person makes for the service/supports provided. Elaborating on any progress needing to be documented or completion of objective/goal.

j. Direct Support Staff printed name/title: Name of direct support professional working with the individual on the goal

k. Signature of Direct Support Staff: Can be hand written or a secure electronic signature

l. Date: Date note written and service rendered
Section IV Weekly Additional Person Centered Progress
Achievements
Identified Barriers

a. What did he/she enjoy?

b. What did he/she not enjoy?

c. What worked and needs to be continued?

d. What did not work and needs to be changed?

e. You can place any other information about the goal into this section. OPTIONAL

f. Direct Support Staff printed name/title:
g. Signature of Direct Support Staff:

h. Date:
a. What did he/she enjoy? For the week services were rendered identify what the person enjoyed doing, working on and/or experiencing.

b. What did he/she not enjoy? For the week services were rendered identify what the person did not enjoy doing, working on and/or experiencing.

c. What worked and needs to be continued? For the week services were rendered identify what strategies, methods, techniques and supports worked for the person and needs to become a regular part of how supports and services are provided.
d. What did not work and needs to be changed? For the week services were rendered identify what strategies, methods, techniques and supports did not work for the person and needs to change.

e. You can place any other information about the goal into this section. (Example: who, what, where, why, when and what’s next to progress) Can be a weekly summary of the person’s progress on goals/objectives and/or the supports and services provided and how the person responded.

f. Direct Support Staff printed name/title: Name of direct support professional working with the individual

g. Signature of Direct Support Staff: Can be hand written or a secure electronic signature

h. Date: Date note written and service rendered

Section V
a. Weekly Additional Routine Person Centered Supports (Supports are pre-filled by the provider agency and additional supports can be added if necessary):

b.

c. Additional Comments/Significant Events(s) (If no comments/significant events, indicate N/A):

d. Direct Support Staff printed name/title:
e. Signature of Direct Support Staff:
f. Date:
a. Weekly Additional Routine Person Centered Supports: This section is designed for routine supports/needs that the person may require on an on-going basis. This section should be individualized based upon the identified needs in the ISP.

b. Identified additional support: Identify any additional ongoing support/needs by each box. This section can be prefilled with the regular supports provided to the person and the staff will check off which specific supports occurred during the reporting period.

c. Additional Comments/Significant Events: The box below can be utilized to capture any significant events from the day or week that is in direct relationship to the person. The box below will expand when you write! (Examples: how the person reacted to a new experience, new faces-new places, significant event changes in the person life, choices made, and any information about rights, health, safety, community connections, etc.).

d. Direct Support Staff printed name/title: Name of direct support professional working with the individual.

e. Signature of Direct Support Staff: Can be hand written or a secure electronic signature.

f. Date: Date note written and service rendered.

Disclaimer: The use of this form does not guarantee compliance with all policies/standards for documentation.
Monthly Quality Assurance Summary of Services
(This summary will be done by case manager or whoever is designated by the provider to have professional clinical oversight of individual’s services. When the clinical oversight staff provide direct supports and complete progress notes, the provider must assure oversight of this direct service provision.)
Person’s Name: Provider Name:
Support Plan/ Addendum Date: Procedure Code:
MHN ID Number: Month/ Year:
Disclaimer: The use of this form does not guarantee compliance with all policies/standards for documentation.

Support Plan Goals and Objectives by Service
Goal from ISP:

Objectives:

Contact with Direct Support Professional

Name of Direct Support Staff: Date of Contact:

Monthly Summary by Service:

Follow-up from previous month:

Expectations: (Of these expectations, this summary must address B, H, I and J. Others are optional.)

A. Health/Medical/ Behavioral:

B. Person’s Perspective/Person Directed Planning:

C. Choice:

D. Rights:

E. Community Life:

F. Safety:

G. Collaboration:

H. Progress (what’s working/not working):

I. Significant Changes and Events:

J. Follow Up/Next Steps for future progression:

Printed Name of Clinical Oversight Staff: Credentials:
Signature of Clinical Oversight Staff: Date:
Legend Monthly Quality Assurance Summary of Services
(This summary will be done by case manager or whoever is designated by the provider to have professional clinical oversight of individual’s services. When the clinical oversight staff provide direct supports and complete progress notes, the provider must assure oversight of this direct service provision.)

Section I Individual Identifiable Information (Prefilled by the provider agency)

a. Person’s Name:
b. Provider Name:

c. Support Plan/Addendum Date:
d. Procedure Code:

e. MHN ID Number:
f. Month/Year

a. Person’s Name: Name of the individual served

b. Provider Name: This is where you place your provider name

c. Support Plan/Addendum Date: Identify the ISP timeframe or addendum date

d. Procedure Code: Code for the service providing

e. MHN ID Number: Individual’s MHN ID number

f. Month/Year: Identify month and year of when services are being documented
Section II Support Plan Goals and Objectives by Service

a. Goal from ISP:

b. Objectives:
a. Goal from ISP: List the goals directly from the ISP

b. Objectives: List objectives identified on the person’s ISP

Section III Contact with Direct Support Professional

a. Name of Direct Support Staff: Name of DSP contacted for this report

b. Date of Contact: Day met with DSP

c. Monthly Summary by Service: Identify the service the monthly summary reflects

d. Follow-up from previous month: Identify what activities or actions completed to follow-up from the previous month’s summary

Section IV Expectations (Of these expectations, this summary must address B, H, I and J. Others are optional)

Health/Medical/ Behavioral:
What education/ training took place on health related topics to support the individual to manage their own healthcare? Identify any health/medical/behavioral issues (picture a holistic approach) addressed or identified? Identify changes in health, medical and behavioral matters such as: doctor appointments, medications, critical incidents, behavioral incidents and tracking. Identify any follow-up done or needed, including but not limited to referrals for treatment (Physical Therapy, Occupational Therapy, Speech &
Language Pathologist, Registered Nurse, Physician, Registered Dietitian, and Mental Health Practitioner). Identify any adaptive equipment needs/repairs/modifications.

Person’s Perspective/Person Directed Planning:
How does the person feel he/she has progressed on his/her goals? What changes has the person requested to make to their supports, services and goals? Have they used their circle of supports to assist them in directing their goal this month? Reflect here what matters most to the person and any new preferences.
A. Choice:
What choice/ options have been explored by the person? What Education, Exposure and Experiences have been presented to the person in all areas of life? Identify any informed choices the person has made. Identify all options presented and/or rejected by the person.
B. Rights:
What training based upon the person’s learning style has the person received and/or learned concerning rights? Have they expresses what right matters most to them? Have they self-advocated for one of their rights to be upheld? Has any unresolved issue concerning rights been resolved this month? Has training taken place for the person’s legal representative concerning rights restrictions this month? Identify any complaints or grievances the person has expressed and the results/resolution. Identify any preferences related to exercising rights expressed by the person. What education, exposure and experiences were provided to the person to expand their knowledge of rights?
C. Community Life:
Has the person made any new acquaintances (other than paid staff/teachers/providers) or developed a social role within his/her community? What social and community inclusion (new places) have been explored to promote community integration this month based on the person’s preferences? How have already established social roles been supported?
D. Safety:
Identify any critical incidents filed on behalf of the individual and if necessary any interventions put into place to prevent further incidents. What education has taken place concerning abuse, neglect and exploitation? How has the person responded to training concerning prevention of abuse, neglect and exploitation and/or understanding for each of these? If the person has had a previous event from their past that needs to be addressed, what was done? Describe safety training in all areas of the person’s life, i.e. mobility, travel, community, home and personal safety. Document any skills the person has gained in self preservation. List any referrals for environmental safety modifications and results.
E. Collaboration:
Has any communication taken place with the person’s circle of support/team? What were the results of any brainstorming on behalf of the person? What self-advocacy has taken place by the person concerning his/her referrals or follow-ups? Has the process worked to the satisfaction of the person? Does further action need to be taken and who will take the lead?
F. Progress (what’s working/not working):
What has the person achieved on their Support plan/targeted goals/objectives? What are the results of the monthly tracking? What are the necessary steps left to take to assist the person to accomplish his/her targeted goal (s)? If the targeted goal is accomplished how did the person choose to celebrate? What mattered most to the person concerning his/her
goal progress, and what would the person change or need to change to accomplish his/her goal? Have there been any changes developed based upon the lack of progress made to the person’s action plan? Has the supports and services been altered based upon the person’s learning style, communication style or other impact?
G. Significant Changes and Events:
Describe any additional changes or events not captured above and the person’s response.
H. Follow Up/Next Steps for future progression:
List the next steps and follow up needed based upon the summaries above and which will be worked on for the following month.

Section IV Printed Name of Person who has Clinical oversight and credentials

a. Printed Name of Clinical Oversight Staff: Name of the clinical oversight staff

b. Credentials: Credentials or job title

c. Signature of Clinical Oversight Staff: Can be hand written or a secure electronic signature

d. Date: Date report written

Disclaimer: The use of this form does not guarantee compliance with all policies/standards for documentation.
Home Services Individual Training Log
(CRA, CLS & Respite services Only)
a. Person’s Name:
g. Provider Name:
b. MHN ID Number:
h. Service:
c. Support Plan Date: f. Addendum date: i. Procedure Code:

d. Month/Year:

e. Peer Quality Assurance Review: j. Date:

Disclaimer: The use of this form does not guarantee compliance with all policies/standards for documentation.

Code:

HOME SERVICES TRAINING LOG
Goal:

Objective
Frequency/Completion Date

1.

2.

3.

4.

Staff Instructions

Date:
1
2
3
4
5
6
7
8
9
10
11
12

25
26
27
28
29
30
31

Objective number (1-4) – which objective worked on

Objective met (+) or
(-) not met

Prompt Code Required – from list above

# of prompts
or cues

Staff Initials

Direct Support Staff printed name/title:
Signature of Direct Support Staff: (can be hand written or a secure electronic signature)
Weekly Additional Person Centered Progress
Achievements
Identified Barriers

What he/she enjoyed?
What he/she did not enjoy?

What worked and/or needs to continue?
What didn’t work and/or needs to change?

You can place any other information about the goal into this section. OPTIONAL

Direct Support Staff printed name/title:
Signature of Direct Support Staff:
Date:

Weekly Additional Routine Person Centered Supports:

Additional Comments/Significant Event(s) (If no comments/significant events, indicate N/A):

Direct Support Staff printed name/title:
Signature of Direct Support Staff:
Date:
Legend for Home Services Training Log
Section I Individual Identifiable Information (This section is pre-filled by the provider agency)
a. Person’s Name:
g. Provider Name:
b. MHN ID Number:
h. Service:
c. Support Plan Date: f. Addendum date: i. Procedure Code:

d. Month/Year:

e. Peer Quality Assurance Review: j. Date:

a. Person’s Name: Name of the individual served

b. MHN ID Number: Individual’s MHN ID number

c. Support Plan Date: Identify the ISP timeframe

d. Month/Year: Identify month and year of when services are being documented

e. Peer Quality Assurance Review: Professional reviewer’s name and signature

f. Addendum date: Identify any addendum date if applicable

g. Provider Name: This is where you place your provider name

h. Service: Specific service documenting

i. Procedure Code: Code for the service providing.

j. Date: Date reviewed by the Peer Quality Assurance reviewer (not pre-filled by the provider agency)
Section II Codes
Codes:
Codes: In this section you identify the codes used to identify the level of intervention/support the person required at the time of the training. For example: I=Independent, GP=Gestural prompt, VP=Verbal prompt, H-H=Hand-over-Hand assistance, M=Modeling, PPA=Partial physical assistance, FPA=Full physical assistance, N/A=Not applicable at this stage of progress, R= Refused (The cues should be individualized and may depend on the objective. Codes can be added in this section)

Section III Home Services Residential Training Log
a. Goal

b. Objectives:
c. Frequency/completion date

1.

2.

3.

4.

d. Staff Instructions:
a. Goal This is the Goal for the service listed in the individual’s
ISP
b. Objectives: List objectives identified on the person’s ISP , list each
objective by number
c. Frequency/completion date For the objective (1) include the frequency on the ISP or
if the objective was met, identify the completion date
d. Staff Instructions: Identify what strategies, methods, techniques and
supports needed for the person to meet their goal/objectives

Date:
1
2
3
4
5
6
7
8
9
10
11
12

25
26
27
28
29
30
31

e. Objective number (1-4) – which objective worked on

f.Objective met (+) or
(-) not met

g.Prompt Code Required – from list above

h.# of prompts
or cues

i. Staff Initials

Direct Support Staff printed name/title:
Signature of Direct Support Staff: (can be hand written or a secure electronic signature)
e. Objective Number List each objective by number that was worked on

f. Objective status List if the object was met or not met by using a plus or
negative symbol (+ / -)
g. Prompt code The codes used to implement the objective

h. Number of Prompts List how many times prompts or codes were used

i. Staff Initials Initials of staff training
Section IV Weekly Additional Person Centered Progress

Achievements
Identified Barriers

i. What did he/she enjoy?

j. What did he/she not enjoy?

k. What worked and needs to be continued?

l. What did not work and needs to be changed?

m. You can place any other information about the goal into this section. OPTIONAL

n. Direct Support Staff printed name/title:
o. Signature of Direct Support Staff:

p. Date:
i. What did he/she enjoy? For the week services were rendered identify what the person enjoyed doing, working on and/or experiencing.

j. What did he/she not enjoy? For the week services were rendered identify what the person did not enjoy doing, working on and/or experiencing
k. What worked and needs to be continued? For the week services were rendered identify what strategies, methods, techniques and supports worked for the person and needs to become a regular part of how supports and services are provided.

l. What did not work and needs to be changed? For the week services were rendered identify what strategies, methods, techniques and supports did not work for the person and needs to change. (Example: who, what, where, why, when and what’s next to progress) A weekly summary of the person’s progress on goals/objectives and/or the supports and services provided and how the person responded.

m. Direct Support Staff printed name/title: Name of direct support professional working with the individual

n. Signature of Direct Support Staff: Can be hand written or a secure electronic signature

o. Date: Date note written and service rendered

Section V a. Weekly Additional Routine Person Centered Support s (Supports are pre-filled by the provider agency and additional supports can be added if necessary):

b.

c. Additional Comments/Significant Event(s) (If no comments/significant events, indicate N/A):

d. Direct Support Staff printed name/title:
e. Signature of Direct Support Staff:
f. Date:
a. Weekly Additional Routine Person Centered Intervention: This section is designed for routine supports/needs that the person may require on an on-going basis. This section should be individualized based upon the identified needs in the ISP.

b. Identified additional support: Identify any additional ongoing support/needs by each box. This section can be prefilled with the regular supports provided to the person and the staff will check off which specific supports occurred during the reporting period.

c. Additional Comments/Significant Events: The box below can be utilized to capture any significant events from the day or week that is in direct relationship to the person. The box below will expand when you write! (Examples: how the person reacted to a new experience, new faces-new places, significant event changes in the person life, choices made, and any information about rights, health, safety, community connections, etc.).

d. Direct Support Staff printed name/title: Name of direct support professional working with the individual.

e. Signature of Direct Support Staff: Can be hand written or a secure electronic signature.

f. Date: Date note written and service rendered.

Disclaimer: The use of this form does not guarantee compliance with all policies/standards for documentation.
APPENDIX T

ICD-10 Overview

On October 1, 2015, the United States’ health care system will undergo a major transformation from the use of Ninth Edition of the International Classification of Diseases (ICD-9) set of diagnosis and inpatient procedure codes to the Tenth Edition (ICD-10). ICD-10-CM replaces the ICD-9-CM diagnosis codes (volumes 1-2) and ICD-10-PCS replaces the ICD-9-CM procedure codes (Volume 3). The current system of ICD-9 has several limitations that prevent complete and precise coding and billing of health conditions and treatments. ICD-9 codes are a 35-year-old code set that contains outdated terminology and is inconsistent with current medical practice. The code length and alphanumeric structure limit the number of new codes that can be created, and many ICD-9 categories are already full.

ICD-10 allows for greater specificity and detail in describing a patient’s diagnosis, condition, diagnostic needs, and in classifying inpatient procedures. ICD-10 provides more specific data than ICD-9 and better reflects current medical practice. The added detail embedded within ICD-10 codes informs health care providers and health plans of patient incidence and history, which allows for more effective case management and better coordination of care.

This ICD-10 transition (which is mandatory) will have a major impact on every HIPAA compliant entity that uses health care information containing a diagnosis and/or inpatient procedure code. All covered entities as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) are required to adopt ICD-10 codes for services provided on or after October 1, 2015, the mandated compliance date.
GA Medicaid like other payers must institute new policies as a result of the transformation to the new ICD-10 code sets. The following policies are areas in GA Medicaid that are impacted with implementation of ICD-10 on or after October 1, 2015:

1. The Tenth Edition of the International Classification of Diseases (ICD-10) set of diagnosis (CM) and inpatient procedure (PCS) codes must be used on or after October 1, 2015. The Ninth Edition of the International Classification of Diseases (ICD-9) set of diagnosis and inpatient procedure codes will only be allowed on claims or any adjustments for dates of services/treatments rendered prior to October 1, 2015.

2. ICD-10 diagnosis (CM) and procedure (PCS) codes are required on all inpatient stays (admission) with discharge dates on or after October 1, 2015. With the ICD-10 transition on or after October 1, 2015, inpatient (admission) claims will be adjudicated based on the patient’s discharge date using ICD-10 CM and PCS codes.

3. The Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes are not impacted by ICD-10 and are not changing.

4. To process ICD-10 claims or other transactions electronically, providers, payers, and vendors must first implement the “Version 5010” health care transaction standards mandated by HIPAA. The previous HIPAA “Version 4010/4010A1” transaction standards do not support the ICD-10 codes. This implementation was effective January 1, 2012.

5. Span dates on claims: GA Medicaid will not adjudicate claims submitted with dates that span the October 1, 2015 date except for inpatient stays or PRTF (psych residential) UB claims.

6. During the ICD-10 transition on and after October 1, 2015, both code sets (ICD-9 and ICD-10) will be supported in the GA Medicaid Management Information System (GAMMIS) for claim processing and adjustments. Any software vendors that provide business intelligence solutions should support both code sets, ICD-9 and ICD-10 codes, simultaneously during the transition.

7. An ICD-9 code submitted for a service on or after October 1, 2015 cannot be processed or paid under federal law.

8. Claims submitted for payment with both ICD-9 and ICD-10 (CM or PCS) codes will not be adjudicated in GAMMIS on or after October 1, 2015 and will be denied. Claims with span dates of services rendered prior to September 30, 2015 and on or after October 1, 2015, must be submitted on separate claims. The split (separate) claims must be billed with the appropriate ICD-9 or ICD-10 codes.

9. GA Medicaid has conducted mapping of thousands of ICD-9 diagnosis (CM) and procedure (PCS) codes to ICD-10 codes and the reverse. ICD-9 codes were mapped forward and backwards using General Equivalence Mappings (GEMs) to maximize all ICD-9 to ICD-10 code possibilities.

10. Unspecified or unlisted or non-specific diagnosis (CM) codes should be avoided on claims using ICD-10 codes. Unspecified codes may be acceptable on UB-04 (hospital) claims under ICD-10 but any other provider specialty types and/or Categories of Service must bill the lowest possible level ICD-10 diagnosis code. There may be services and/or procedures that do not have a specified code or procedure and warrants billing an unspecified code. However, providers must bill the most detailed ICD-10 code available for the service rendered. Claims billed with unlisted and/or unspecified codes will be denied if determined that a more appropriate code is available. The physician’s clinical documentation should support the specificity of the code(s) being billed.

11. Prior authorization (PA) requests already approved prior to the ICD-10 transition on October 1, 2015, will not need to be resubmitted. If the PA request is submitted for approval on or after October 1, 2015, the request form must have ICD-10 diagnosis (CM) codes for claim processing. Any PA renewals or requests submitted on or after October 1, 2015, will need to have ICD-10 diagnosis (CM) codes.

NOTE: The PA start date is the key to which code set (ICD-9 or ICD-10) to submit on a PA. The correct diagnosis code set must be used on the claim to be adjudicated in GAMMIS.

12. Some ICD-10 diagnosis codes are restricted such as those related to age, gender, and sex. The GAMMIS is configured to accept these restrictive types of ICD-10 diagnosis codes.

13. ICD-10 procedure (PCS) codes must be used on all inpatient (admit) facility or hospital claims. The GAMMIS is configured for ICD-10 transition to auto-deny any UB-claims that have missing or inappropriate ICD-10 procedure codes. The ICD-10-PCS codes are associated to the appropriate anatomic sites related to each Major Diagnostic Category (MDC).

DOCUMENTATION REQUIREMENTS UNDER ICD-10

Implementation of ICD-10 on October 1, 2015, will affect the clinical documentation of providers to payer organizations. ICD-10 coding provides the opportunity for greater accuracy in creating standardized data that describes the patient’s condition and supports the billing and payment based on the physician’s documentation. Increased code detail contained in ICD-10-CM (diagnosis codes) means that documentation requirements will change substantially. ICD-10-CM (diagnosis) includes a fuller definition of severity, comorbidities, complications, sequelae, manifestations, causes, and a variety of other important parameters that characterize the patient’s condition.

A large number of the ICD-10-CM (diagnosis) codes are the same except for indicating laterality of a patient’s body part: RIGHT, LEFT, BILATERAL, UNILATERAL, or UNSPECIFIED SIDE. Thousands of other codes differ only in the way they distinguish “initial encounter [first visit= A],” versus “subsequent encounter [second or follow-up visit= D],” versus “sequelae [secondary codes produced by an acute phase of illness or injury and cannot be billed without the initial code= S].”

RESOURCES AVAILABLE TO EASE THE ICD-10 TRANSITION

There are a number of industry resources available to assist all HIPAA entities in the ICD-10 transition. Below are several resources that provide a wealth of ICD-10 information:
. General Equivalence Mappings (GEMs) attempt to include all valid relationships between the codes in the ICD-9-CM diagnosis classification and the ICD-10-CM diagnosis classification. The tool allows coders and providers to look up an ICD-9 code and be provided with the most appropriate ICD-10 matches and vice versa. GEMs are not a “crosswalk”; they are merely meant to be a guide. Visit the CMS website at www.cms.gov/ICD10 for more information on GEMs.

. Centers for Medicare & Medicaid Services (CMS) website:. www.cms.gov/ICD10

. Georgia Department of Community Health ICD 10 Project website: http://dch.georgia.gov/icd-10

APPENDIX U
Georgia Families 3600 SM,

Information for Providers Serving Medicaid Members
in the Georgia Families 3600 SM Program

Georgia Families 3600 SM, the state’s new managed care program for children, youth, and young adults in Foster Care, children and youth receiving Adoption Assistance, as well as select youth in the juvenile justice system, launched Monday, March 3, 2014. Amerigroup Community Care is the single Care Management Organization (CMO) that will be managing this population.

DCH, Amerigroup, and partner agencies — the Department of Human Services (DHS) and DHS’ Division of Family and Children Services (DFCS), the Department of Juvenile Justice (DJJ) and the Department of Behavioral Health and Developmental Disabilities (DBHDD), as well as the Children’s and Families Task Force continue their collaborative efforts to successfully rollout this new program.

Amerigroup is responsible through its provider network for coordinating all DFCS, DJJ required assessments and medically necessary services for children, youth and young adults who are eligible to participate in the Georgia Families 3600SM Program. Amerigroup will coordinate all medical/dental/trauma assessments for youth upon entry into foster care or juvenile justice (and as required periodically).

Georgia Families 3600 SM members will also have a medical and dental home to promote consistency and continuity of care. Providers, foster parents, adoptive parents and other caregivers will be involved in the ongoing health care plans to ensure that the physical and behavioral health needs of these populations are met.

Electronic Health Records (EHRs) are being used to enhance effective delivery of care. The EHRs can be accessed by Amerigroup, physicians in the Amerigroup provider network, and DCH sister agencies, including the DFCS, regardless of where the child lives, even if the child experiences multiple placements.
Ombudsman and advocacy staff are in place at both DCH and Amerigroup to support caregivers and members, assisting them in navigating the health care system. Additionally, medication management will focus on appropriate monitoring of the use of psychotropic medications, to
include ADD/ADHD medications.
Providers can obtain additional information by contacting the Provider Service Line at 1-800-454-3730 or by contacting their Provider Relations representative.

To learn more about DCH and its dedication to A Healthy Georgia, visit www.dch.georgia.gov

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GEORGIA DEPARTMENT OF COMMUNITY HEALTH

DIVISION OF MEDICAID

Published January 1, 2015

COMMUNITY HEALTH SEAL

PART III
CHAPTERS 1300 – 3100
POLICIES
AND
PROCEDURES
FOR
NEW OPTIONS WAIVER PROGRAM (NOW)
FORMERLY MENTAL RETARDATION WAIVER PROGRAM SERVICES

PART III, POLICIES AND PROCEDURES
FOR
NEW OPTIONS WAIVER PROGRAM (NOW)

TABLE OF CONTENTS

CHAPTER 1300 Adult Occupational Therapy Services XIII

Section 1301 General

Section 1302 Special Requirements of Participation
Section 1303 Licensure

Section 1304 Special Eligibility Conditions

Section 1305 Prior Approval

Section 1306 Covered Services

Section 1307 Non-Covered Services

Section 1308 Basis for Reimbursement

Section 1309 Participant-Direction Options

CHAPTER 1400 Adult Physical Therapy Services XIV

Section 1401 General

Section 1402 Special Requirements of Participation
Section 1403 Licensure

Section 1404 Special Eligibility Conditions

Section 1405 Prior Approval

Section 1406 Covered Services

Section 1407 Non-Covered Services

Section 1408 Basis for Reimbursement

Section 1409 Participant-Direction Options
CHAPTER 1500 Adult Speech and Language Therapy Services XV
Section 1501 General

Section 1502 Special Requirements of Participation
Section 1503 Licensure

Section 1504 Special Eligibility Conditions

Section 1505 Prior Approval

Section 1506 Covered Services

Section 1507 Non-Covered Services

Section 1508 Basis for Reimbursement

Section 1509 Participant-Direction Options

CHAPTER 1600 Behavioral Supports Consultation Services XVI
Section 1601 General

Section 1602 Special Requirements of Participation
Section 1603 Licensure

Section 1604 Special Eligibility Conditions

Section 1605 Prior Approval

Section 1606 Covered Services

Section 1607 Non-Covered Services

Section 1608 Basis for Reimbursement

Section 1609 Participant-Direction Options
CHAPTER 1700 Community Access Services XVII

Section 1701 General

Section 1702 Special Requirements of Participation
Section 1703 Special Eligibility Conditions

Section 1704 Prior Approval

Section 1705 Covered Services

Section 1706 Non-Covered Services

Section 1707 Basis for Reimbursement

Section 1708 Participant-Direction Options

CHAPTER 1800 Community Guide Services XVIII

Section 1801 General

Section 1802 Special Requirements of Participation
Section 1803 Special Eligibility Conditions

Section 1804 Prior Approval

Section 1805 Covered Services

Section 1806 Non-Covered Services

Section 1807 Basis for Reimbursement

Section 1808 Participant-Direction Options

CHAPTER 1900 Community Living Supports (CLS) Services XIX

Section 1901 General

Section 1902 Special Requirements of Participation
Section 1903 Licensure

Section 1904 Special Eligibility Conditions

Section 1905 Prior Approval

Section 1906 Covered Services

Section 1907 Non-Covered Services

Section 1908 Basis for Reimbursement

Section 1909 Participant-Direction Options

CHAPTER 2000 Environmental Accessibility Adaptation XX

Section 2001 General

Section 2002 Special Requirements of Participation
Section 2003 Licensure

Section 2004 Special Eligibility Conditions

Section 2005 Prior Approval

Section 2006 Covered Services

Section 2007 Non-Covered Services

Section 2008 Basis for Reimbursement

Section 2009 Participant-Direction Options

CHAPTER 2100 Financial Support Services XXI

Section 2101 General

Section 2102 Special Requirements of Participation
Section 2103 Licensure

Section 2104 Special Eligibility Conditions

Section 2105 Prior Approval

Section 2106 Covered Services

Section 2107 Non-Covered Services

Section 2108 Basis for Reimbursement

Section 2109 Participant-Direction Options

CHAPTER 2200 Individual Goods and Services XXII

Section 2201 General

Section 2202 Special Requirements of Participation
Section 2203 Licensure

Section 2204 Special Eligibility Conditions

Section 2205 Prior Approval

Section 2206 Covered Services

Section 2207 Non-Covered Services

Section 2208 Basis for Reimbursement

Section 2209 Participant-Direction Options

CHAPTER 2300 Natural Supports Training Services XXIII

Section 2301 General

Section 2302 Special Requirements of Participation
Section 2303 Licensure

Section 2304 Special Eligibility Conditions

Section 2305 Prior Approval

Section 2306 Covered Services

Section 2307 Non-Covered Services

Section 2308 Basis for Reimbursement

Section 2309 Participant-Direction Options

CHAPTER 2400 Prevocational Services XXIV

Section 2401 General

Section 2402 Special Requirements of Participation
Section 2403 Special Eligibility Conditions

Section 2404 Prior Approval

Section 2405 Covered Services

Section 2406 Non-Covered Services

Section 2407 Basis for Reimbursement

Section 2408 Participant-Direction Options

CHAPTER 2500 Respite Services XXV

Section 2501 General

Section 2502 Special Requirements of Participation
Section 2503 Licensure

Section 2504 Special Eligibility Conditions

Section 2505 Prior Approval

Section 2506 Covered Services

Section 2507 Non-Covered Services

Section 2508 Basis for Reimbursement

Section 2509 Participant-Direction Options

CHAPTER 2600 Specialized Medical Equipment Services XXVI

Section 2601 General

Section 2602 Special Requirements of Participation
Section 2603 Licensure

Section 2604 Special Eligibility Conditions

Section 2605 Prior Approval

Section 2606 Covered Services

Section 2607 Non-Covered Services

Section 2608 Basis for Reimbursement

Section 2609 Participant-Direction Options

CHAPTER 2700 Specialized Medical Supplies Services XXVII

Section 2701 General

Section 2702 Special Requirements of Participation
Section 2703 Licensure

Section 2704 Special Eligibility Conditions

Section 2705 Prior Approval

Section 2706 Covered Services

Section 2707 Non-Covered Services

Section 2708 Basis for Reimbursement

Section 2709 Participant-Direction Options

CHAPTER 2800 Support Coordination Services XXVIII

Section 2801 General

Section 2802 Special Requirements of Participation
Section 2803 Participant Flexibility

Section 2804 Prior Approval

Section 2805 Covered Services

Section 2806 Non-Covered Services

Section 2807 Basis for Reimbursement

Section 2808 Participant-Direction Options

CHAPTER 2900 Supported Employment Services XXIX

Section 2901 General

Section 2902 Special Requirements of Participation
Section 2903 Special Eligibility Conditions

Section 2904 Prior Approval

Section 2905 Covered Services

Section 2906 Non-Covered Services

Section 2907 Basis for Reimbursement

Section 2908 Participant-Direction Options

CHAPTER 3000 Transportation Services XXX

Section 3001 General

Section 3002 Special Requirements of Participation
Section 3003 Licensure

Section 3004 Special Eligibility Conditions

Section 3005 Prior Approval

Section 3006 Covered Services

Section 3007 Non-Covered Services

Section 3008 Basis for Reimbursement

Section 3009 Participant-Direction Options

CHAPTER 3100 Vehicle Adaptation Services XXXI

Section 3101 General

Section 3102 Special Requirements of Participation
Section 3103 Licensure

Section 3104 Special Eligibility Conditions

Section 3105 Prior Approval

Section 3106 Covered Services

Section 3107 Non-Covered Services

Section 3108 Basis for Reimbursement

Section 3109 Participant-Direction Options

APPENDIX A REIMBURSEMENT RATES FOR ‘NOW’ SERVICES

APPENDIX B GUIDELINES FOR SUPPORTING ADULTS WITH CHALLENGING BEHAVIORS IN COMMUNITY SETTING

APPENDIX C PROCEDURES FOR BILLING AND DOCUMENTING PERSONAL ASSISTANCE RETAINER

PART III – CHAPTER 1300

SPECIFIC PROGRAM REQUIREMENTS
FOR
ADULT OCCUPATIONAL THERAPY SERVICES

SCOPE OF SERVICES

1301 General

Adult Occupational Therapy Services are evaluation and therapeutic services that are not otherwise covered by Medicaid State Plan services. These services address the occupational therapy needs of the adult participant that result from his or her developmental disability. Adult Occupational Therapy Services include occupational therapy evaluation, participant/family education, occupational therapy activities to improve functional performance, and sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands.

Adult Occupational Therapy Services are provided by a Georgia licensed occupational therapist and by order of a physician. These services may be provided in a participant’s own or family home, the Occupational Therapist’s office, outpatient clinics, facilities in which Community Access or Prevocational Services are provided, Supported Employment work sites, or other community settings specific to community-based therapy goals specified in the Individual Service Plan. Adult Occupational Therapy Services may not be provided to participants receiving Community Residential Alternative Services in the Comprehensive Supports Waiver.

1302 Special Requirements of Participation

1302.1 Individual Provider

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 NOW Program, Adult Occupational Therapy Services providers must meet the following requirements:

1. Service Provision: Adult Occupational Therapy Services are provided by a Georgia licensed occupational therapist and by order of a physician. Physician orders must be on letterhead or as a prescription from the physician and must indicate either the
Rev. 07 2010
frequency of OT therapy services or an OT evaluation to determine the frequency of OT therapy services.

2. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving Adult Occupational Therapy Services:

a. Specific evaluation, training or therapeutic 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 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.
Rev. 10 2009

f. Adult Occupational Therapy Providers must maintain documentation for the identified need of therapies, frequency and duration of therapy, interventions to be provided, and goals addressing therapies.

3. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for individual providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

4. Adult Occupational Therapy Services at Community Access and Prevocational Service Facilities:
Providers can provide Adult Occupational Therapy Services at facilities where Community Access and Prevocational Services are rendered; however, the services must be documented and billed separately, and any waiver participant receiving multiple services may not receive these services at the same time of the same day.

1302.2 Provider Agencies

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 NOW Program, Adult Occupational Therapy Services provider agencies must meet the following requirements:

1. Service Provision: Adult Occupational Therapy Services are provided by a Georgia licensed occupational therapist and by order of a physician. Physician orders must be on letterhead or as a prescription from the physician and must indicate either the frequency of OT therapy services or an OT evaluation to determine the frequency of OT therapy services.

2. Types of Agencies: Agencies that provide Adult Occupational Therapy Services are:

a. Accredited or Certified DD Service Agencies;

b. Home Health Agencies.

3. Staffing Qualifications and Responsibilities:

a. Accredited or Certified DD Service Agencies rendering Adult Occupational Therapy Services must have staffing that meets the following requirements:
1) A designated agency director who must:
Rev 01 2013

. 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 these 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

2) 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.

3) At least one agency employee or professional under contract with the agency must be a Developmental Disability Professional (DDP) (for definition, see Part II Policies and Procedures for NOW, Appendix I;

4) The same individual may serve as both the agency director and the Developmental Disability Professional;

5) 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 Adult Occupational Therapy Services;

. Conducting functional assessments; and

. Supervising high intensity services.

6) Provider agencies must have available a sufficient number of employees or professionals under contract that are Georgia licensed occupational therapists to provide Adult Occupational Therapy Services as specified in the Individual Service Plans of participants served.

7) Duties of the occupational therapists include all covered services in Section 1306.

b. Home Health Agencies rendering Adult Occupational Therapy Services must have staffing that meets the conditions of participation in the Medical Assistance Program as outlined in PART II, Chapter 600 Policies and Procedures for Home Health Services.

4. Agency Policies and Procedures: Each provider agency must develop written policies and procedures to govern the operations of Adult Occupational Therapy services, which follow the Standards for the Georgia Department of Behavioral Health and Developmental Disabilities, set forth in Part II Policies and Procedures for NOW.

5. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving Adult Occupational Therapy Services:

a. Specific evaluation, training or therapeutic 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 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.
Rev 10 2009

f. Adult Occupational Therapy Providers must maintain documentation for the identified need of therapies, frequency and duration of therapy, interventions to be provided, and goals addressing therapies.

6. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

7. Adult Occupational Therapy Services at Community Access and Prevocational Service Facilities: Providers can provide Adult Occupational Therapy Services at facilities where Community Access and Prevocational Services are rendered; however, the services must be documented and billed separately, and any waiver participant receiving multiple waiver services may not receive these services at the same time of the same day.

8. Georgia Department of Behavioral Health and Developmental Disabilities Contract/LOA and DBHDD Community Service Standards: 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 the DBHDD (see Part II Policies and Procedures for NOW, Chapter 603.)

1303 Licensure

A. Adult Occupational Therapy Services are provided by a licensed Occupational Therapist in accordance with the applicable Georgia license as required under OCGA Title 43-28-1.

B. Home Health Agencies providing Adult Occupational Therapy services must have a Home Health Agency License (State of Georgia Rules and Regulations 290-5-38)

1304 Special Eligibility Conditions

A. Adult Occupational Therapy Services are not available until the waiver participant’s 21st birthday.

B. The need for Adult Occupational Therapy Services must be reflected in the Intake and Evaluation Team approved Individual Service Plan (ISP).

C. There is a reasonable expectation by the licensed occupational therapist that the participant can achieve the goals in the necessary time frame.

D. All services must be ordered by a physician.

1305 Prior Approval

Adult Occupational Therapy Services must be authorized prior to service delivery by the operating agency at least annually in conjunction with the Individual Service Plan development and with any ISP revisions. The need for Adult Occupational Therapy must be an identifiable assessed need in the ISP and directly related to the disability.

1306 Covered Services

Reimbursable Adult Occupational Therapy Services include the following based on the assessed need of the participant and as specified in the approved ISP:

1. Occupational therapy evaluation.

2. Therapeutic activities to improve functional performance.

3. Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands.

4. Participant/family education.

1307 Non-Covered Services

1. Services that duplicate any family education or training provided through Natural Supports Training (NST) Services.
2. Services that occur simultaneously or on the same day as NST Services.
3. Adult Occupational Therapy Services do not include in-home therapeutic services for the treatment of an illness or injury that are covered in Home Health Services under the regular Medicaid State Plan.
4. Adult Occupational Therapy Services may not be provided at Community Residential Alternative Services sites.
5. Transportation to and from these services is not included in the rate.
6. Group Therapy Activities.
7. Not covered for conditions not related to DD diagnosis.
8. Services that have not been ordered by a physician.
9. Services in a hospital.
10. 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.

Rev 01 2013

1308 Basis for Reimbursement

The reimbursement rates for Adult Occupational Therapy Services are found in Appendix A.

The rate cannot exceed the established Medicaid rates for the Children Intervention Services Program.

1. Unit of service for OT evaluation is one (1) evaluation and for OT Therapeutic Activities and OT Sensory Integrative Techniques is fifteen (15) minutes.
2. The annual maximum of units for OT Evaluation (97003 and 97003 UC) is one (1) unit.
3. The daily maximum number of units for OT Therapeutic Activities (97530-GO and 97530-GO/UC) and for OT Sensory Integrative Techniques (97553-GO and 97553-GO/UC) is four (4) units.
4. $1,800.00 annual maximum for all adult therapy waiver services (including PT, OT, and SLT).

1309 Participant-Direction Options

A. Participants can choose the self-direction option with Adult Occupational Therapy Services.

B. An individual serving as a representative for a waiver participant in self-directed services is not eligible to be a participant-directed provider of Adult Occupational Therapy Services.

C. For details on participant-direction, see Part II Policies and Procedures for NOW, Chapter 1200.
PART III – CHAPTER 1400

SPECIFIC PROGRAM REQUIREMENTS
FOR
ADULT PHYSICAL THERAPY SERVICES

SCOPE OF SERVICES

1401 General

Adult Physical Therapy Services are evaluation and therapeutic services that are not otherwise covered by Medicaid State Plan services. These services address the physical therapy needs of the adult participant that result from his or her developmental disability. Adult Physical Therapy Services include physical therapy evaluation, participant/family education, and therapeutic exercises to develop sitting and standing balance, strength and endurance, and range of motion and flexibility. Adult Physical Therapy Services also consist of muscle strengthening and endurance to facilitate transfers from wheelchairs and the use of other equipment.

Adult Physical Therapy Services are provided by a Georgia licensed physical therapist and by order of a physician. These services may be provided in a participant’s own or family home, the Physical Therapist’s office, outpatient clinics, facilities in which Community Access or Prevocational Services are provided, Supported Employment work sites, or other community settings specific to community-based therapy goals specified in the Individual Service Plan. Adult Physical Therapy Services may not be provided to participants receiving Community Residential Alternative Services in the Comprehensive Supports Waiver.

1402 Special Requirements of Participation

1402.1 Individual Provider

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 NOW Program, Adult Physical Therapy Services providers must meet the following requirements:

Rev. 07 2010
1. Service Provision: Adult Physical Therapy Services are provided by a Georgia licensed physical therapist and by order
of a physician. Physician orders must be on letterhead or as a prescription from the physician and must indicate either the frequency of PT therapy services or a PT evaluation to determine the frequency of PT therapy services.
2. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving Adult Physical Therapy Services:

a. Specific evaluation, training or therapeutic 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 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.
Rev. 10 2009

f. Adult Physical Therapy providers maintain documentation for: the identified need of therapies, frequency and duration of therapy, interventions to be provided, and goals addressing therapies.

3. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for individual providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

4. Adult Physical Therapy Services at Community Access and Prevocational Service Facilities: Providers can provide Adult Physical Therapy Services at facilities where Community Access and Prevocational Services are rendered; however, the services must be documented and billed separately, and any waiver participant receiving multiple waiver services may not receive these services at the same time of the same day.

1402.2 Provider Agencies

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 NOW Program, Adult Physical Therapy Services provider agencies must meet the following requirements:

1. Service Provision: Adult Physical Therapy Services are provided by a Georgia licensed physical therapist and by order of a physician. Physician orders must be on letterhead or as a prescription from the physician and must indicate either the frequency of PT therapy services or a PT evaluation to determine the frequency of PT therapy services.

2. Types of Agencies: Agencies that provide Adult Physical Therapy Services are:
Rev. 07 2010

a. Accredited or Certified DD Service Agencies;
b. Home Health Agencies.
3. Staffing Qualifications and Responsibilities:
Rev 01 2013

a. Accredited or Certified DD Service Agencies rendering Adult Physical Therapy Services must have staffing that meets the following requirements:

1) 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 these 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

2) 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.

3) At least one agency employee or professional under contract with the agency must be a Developmental Disability Professional (DDP) (for definition, see Part II Policies and Procedures for NOW, Appendix I);

4) The same individual may serve as both the agency director and the Developmental Disability Professional;

5) 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 Adult Physical Therapy Services;

. Conducting functional assessments; and

. Supervising high intensity services.

6) Provider agencies must have available a sufficient number of employees or professionals under contract that are Georgia licensed physical therapists to provide Adult Physical Therapy Services as specified in the Individual Service Plans of participants served.

7) Duties of the physical therapists include all covered services in Section 1406.

b. Home Health Agencies rendering Adult Physical Therapy Services must have staffing that meets the conditions of participation in the Medical Assistance Program as outlined in PART II, Chapter 600 Policies and Procedures for Home Health Services.

4. Agency Policies and Procedures: Each provider agency must develop written policies and procedures to govern the operations of Adult Physical Therapy services, which follow the Standards for the Georgia Department of Behavioral Health and Developmental Disabilities (see Part II Policies and Procedures for NOW, Chapter 603).

5. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving Adult Physical Therapy Services:

a. Specific evaluation, training or therapeutic 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 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.

Rev 10 2009

f. Adult Physical Therapy providers maintain documentation for: the identified need of therapies, frequency and duration of therapy, interventions to be provided, and goals addressing therapies.
6. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

7. Adult Physical Therapy Services at Community Access and Prevocational Service Facilities: Providers can provide Adult Physical Therapy Services at facilities where Community Access and Prevocational Services are rendered; however, the services must be documented and billed separately, and any waiver participant receiving multiple
services may not receive these services at the same time of the same day.

8. DBHDD Contract/LOA and DBHDD Community Service Standards: 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 the DBHDD (refer to Part II Policies and Procedures for NOW).

1403 Licensure

A. Adult Physical Therapy Services are provided by a licensed Physical Therapist in accordance with the applicable Georgia license as required under OCGA Title 43-33-1.
B. Home Health Agencies providing Adult Physical Therapy services must have a Home Health Agency License (State of Georgia Rules and Regulations 290-5-38).
1404 Special Eligibility Conditions

A. Adult Physical Therapy Services are not available until the waiver participant’s 21st birthday.
B. The need for Adult Physical Therapy Services must be reflected in the Intake and Evaluation Team approved Individual Service Plan (ISP).
C. There is a reasonable expectation by the licensed physical therapist that the participant can achieve the goals in the necessary time frame.
D. All services must be ordered by a physician.
1405 Prior Approval

Adult Physical Therapy Services must be authorized prior to service delivery by the operating agency at least annually in conjunction with the Individual Service Plan development and with any ISP revisions. The need for Adult Physical Therapy must be an identifiable assessed need in the ISP and directly related to the disability.

1406 Covered Services

Reimbursable Adult Physical Therapy Services include the following based on the assessed need of the participant and as specified in the approved ISP:

1. Physical therapy evaluation.

2. Therapeutic procedures.

3. Therapeutic exercises to develop strength and endurance, and range of motion and flexibility.

4. Participant/family education.

5. Therapeutic exercise programs including muscle strengthening, neuromuscular facilitation, sitting and standing balance and endurance and increased range of motion

6. Muscle strengthening and endurance to facilitate transfers from wheelchairs and the use of other equipment.

1407 Non-Covered Services

1. Services that duplicate any family education or training provided through Natural Supports Training (NST) Services.
2. Services that occur simultaneously or on the same day as NST Services.
3. Adult Physical Therapy Services do not include in-home therapeutic services for the treatment of an illness or injury that are covered in Home Health Services under the regular Medicaid State Plan.
4. Adult Physical Therapy Services may not be provided at Community Residential Alternative Services sites.
5. Transportation to and from these services is not included in the rate.
6. Group Therapy Activities.
7. Not covered for conditions not related to DD diagnosis.
8. Services that have not been ordered by a physician.

9. Services in a hospital.

10. 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.
Rev 01 2013

1408 Basis for Reimbursement

The rate cannot exceed the established Medicaid rates for the Children Intervention Services Program.

The reimbursement rates for Adult Physical Therapy Services are found in Appendix A.

A. Unit of service for PT evaluation is one (1) evaluation and for PT Therapeutic Practices is fifteen (15) minutes.

B. The annual maximum of units for PT Evaluation (97001 and 97001-UC) is one (1) unit.

C. The daily maximum number of units for PT Therapeutic Practices (97110 and 97110-UC) is four (4) units.

D. $1,800.00 annual maximum for all adult therapy waiver services (including PT, OT, and SLT).

1409 Participant-Direction Options

A. Participants can choose the self-direction option with Adult Physical Therapy Services.

B. An individual serving as a representative for a waiver participant in self-directed services is not eligible to be a participant-directed provider of Adult Physical Therapy Services.

C. For details on participant-direction (see Part II Policies and Procedures for NOW, Chapter 1200).

PART III – CHAPTER 1500

SPECIFIC PROGRAM REQUIREMENTS
FOR
ADULT SPEECH AND LANGUAGE THERAPY SERVICES

SCOPE OF SERVICES

1501 General

Adult Speech and Language Therapy Services cover evaluation and therapeutic services that are not otherwise covered by Medicaid State Plan services. These services address the speech and language therapy needs of the adult participant that result from his or her developmental disability. Adult Speech and Language Therapy Services include the evaluation of speech language, voice, and language communication, auditory processing, and/or aural rehabilitation status. Adult Speech and Language Therapy Services also consist of participant/family education, speech language therapy, and therapeutic services for the use of speech-generating devices, including programming and modification.

Adult Speech and Language Therapy Services are provided by a Georgia licensed speech and language pathologist and by order of a physician. These services may be provided in a participant’s own or family home, the Speech and Language Pathologist’s office, outpatient clinics, facilities in which Community Access or Prevocational Services are provided, Supported Employment work sites, or other community settings specific to community-based therapy goals specified in the Individual Service Plan. Adult Speech and Language Therapy Services may not be provided to participants receiving Community Residential Alternative Services in the Comprehensive Supports Waiver.

1502 Special Requirements of Participation

1502.1 Individual Provider

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 NOW Program, Adult Speech and Language Therapy Services providers must meet the following requirements:

1. Service Provision: Adult Speech and Language Therapy Services are provided by a Georgia licensed speech and language pathologist and by order of a physician. Physician orders must be on letterhead or as a prescription from the physician and must indicate either the frequency of speech and language therapy services or a speech and language evaluation to determine the frequency of speech and language therapy services.
Rev. 07 2010

2. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving Adult Speech and Language Therapy Services:

a. Specific evaluation, training or therapeutic 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 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.
Rev 10 2009

f. Adult Speech and Language Therapy providers maintain documentation for: the identified need of therapies, frequency and duration of therapy, interventions to be provided, and goals addressing therapies.

3. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for individual providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

4. Adult Speech and Language Therapy Services at
Community Access and Prevocational Service Facilities: Providers can provide Adult Speech and Language Therapy Services at facilities where Community Access and Prevocational Services are rendered; however, the services must be documented and billed separately, and any waiver participant receiving multiple services may not receive these services at the same time of the same day.

1502.2 Provider Agencies

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 NOW Program, Adult Speech and Language Therapy Services provider agencies must meet the following requirements:

A. Service Provision: Adult Speech and Language Therapy Services are provided by a Georgia licensed speech and language pathologist and by order of a physician. Physician orders must be on letterhead or as a prescription from the physician and must indicate either the frequency of speech and language therapy services or a speech and language evaluation to determine the frequency of speech and language therapy services.
Rev. 07 2010

Rev 01 2013
B. Types of Agencies: Agencies that provide Adult Speech and Language Therapy Services are:

a. Accredited or Certified DD Service Agencies;

b. Home Health Agencies.

i. Staffing Qualifications and Responsibilities:

1. Accredited or Certified DD Service Agencies rendering Adult Speech and Language Therapy Services must have staffing that meets the following 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 these 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 with the agency must be a Developmental Disability Professional (DDP) (for definition, see Part II Policies and Procedures for NOW, Appendix I);

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 Adult Speech and Language Therapy Services;

. Conducting functional assessments; and

. Supervising high intensity services.

f. Provider agencies must have available a sufficient number of employees or professionals under contract
that are Georgia licensed speech and language pathologists to provide Adult Speech and Language Therapy Services as specified in the Individual Service Plans of participants served.

g. Duties of the Speech and Language Pathologist include all covered services in Section 1506.

h. Home Health Agencies rendering Adult Speech and Language Therapy Services must have staffing that meets the conditions of participation in the Medical Assistance Program as outlined in PART II, Chapter 600 Policies and Procedures for Home Health Services.

C. Agency Policies and Procedures: Each provider agency must develop written policies and procedures to govern the operations of Adult Speech and Language Therapy services, which follow the Standards for the Georgia Department of Behavioral Health and Developmental Disabilities as stated in Part II Policies and Procedures for NOW.

D. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving Adult Speech and Language Therapy Services:

a. Specific evaluation, training or therapeutic 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 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.

Rev. 10 2009

f. Adult Speech and Language Therapy providers maintain documentation for: the identified need of therapies, frequency and duration of therapy, interventions to be provided, and goals addressing therapies.
E. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

F. Adult Speech and Language Therapy Services at Community Access and Prevocational Service Facilities: Providers can provide Adult Speech and Language Therapy Services at facilities where Community Access and Prevocational Services are rendered; however, the services must be documented and billed separately, and any waiver participant receiving multiple waiver services may not receive these services at the same time of the same day.

G. DBHDD Contract/LOA and DBHDD Community Service Standards: 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 the DBHDD (see Part II Policies and Procedures for NOW, Chapter 603).

1503 Licensure

A. Adult Speech and Language Therapy Services are provided by a licensed Speech and Language Pathologist in accordance with the applicable Georgia license as required under OCGA Title 43-44-1.

B. Home Health Agencies providing Adult Speech and Language Therapy services must have a Home Health Agency License (State of Georgia Rules and Regulations 290-5-38)

1504 Special Eligibility Conditions

A. Adult Speech and Language Therapy Services are not available until the waiver participant’s 21st birthday.

B. The need for Adult Speech and Language Therapy Services must be reflected in the Intake and Evaluation Team approved Individual Service Plan (ISP).
C. There is a reasonable expectation by the licensed speech and language pathologist that the participant can achieve the goals in the necessary time frame.

D. All services must be ordered by a physician.

1505 Prior Approval

Adult Speech and Language Therapy Services must be authorized prior to service delivery by the operating agency at least annually in conjunction with the Individual Service Plan development and with any ISP revisions. The need for Adult Speech and Language Therapy must be an identifiable assessed need in the ISP and directly related to the disability.

1506 Covered Services

Reimbursable Adult Speech and Language Therapy Services include the following based on the assessed need of the participant and as specified in the approved ISP:

1. Evaluation of speech language, voice, and language communication, auditory processing, and/or aural rehabilitation.

2. Individual treatment of speech, language, voice, communication, and/or auditory processing.

3. Therapeutic services for the use of speech-generating device, including programming and modification.

4. Participant/family education.

1507 Non-Covered Services

1. Services that duplicate any family education or training provided through Natural Supports Training (NST) Services.

2. Services that occur simultaneously or on the same day as NST Services.

3. In-home therapeutic services for the treatment of an illness or injury that are covered in Home Health Services under the regular Medicaid State Plan.

4. Adult Speech and Language Therapy Services may not be provided at Community Residential Alternative Services sites.

5. Transportation to and from these services is not included in the rate.

Group Therapy Activities.

6. Not covered for conditions not related to DD diagnosis.

7. Services that have not been ordered by a physician.

8. Services in a hospital.

9. 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.
Rev 01 2013

1508 Basis for Reimbursement

The reimbursement rates for Adult Speech and Language Therapy Services are found in Appendix A.

The rate cannot exceed the established Medicaid rates for the Children Intervention Services Program.

1. Unit of service for SLT evaluation is one (1) evaluation, and for SLT and Speech-Generating Device Therapy is one (1) session.
2. The annual maximum of units for Speech and Language Evaluation (92523 and 92523 UC) is one (1) unit.

Rev. 01 2014

3. The daily maximum number of units for SLT (92507-GN and 92507-GN/UC) and for Speech-Generating Device Therapy (92609 and 92609-UC) is one (1) unit.
4. $1,800.00 annual maximum for all adult therapy waiver services (including PT, OT, and SLT).

1509 Participant-Direction Options

1. Participants can choose the self-direction option with Adult Speech and Language Therapy Services.
2. An individual serving as a representative for a waiver participant in self-directed services is not eligible to be a participant-directed provider of Adult Speech and Language Therapy Services.
3. For details on participant-direction, see Part II Policies and Procedures for NOW, Chapter 1200.
PART III – CHAPTER 1600

SPECIFIC PROGRAM REQUIREMENTS
FOR
BEHAVIORAL SUPPORTS CONSULTATION SERVICES

SCOPE OF SERVICES

1601 General
Rev 01 2013

Behavioral Supports Consultation Services are professional consultation services that assist the participant with significant, intensive challenging behaviors that interfere with activities of daily living, social interaction, work or similar situations. These services consist of behavioral supports professional evaluation, training, and intervention services. Evaluation services by the Behavioral Supports professional consultant include functional assessment of behavior and other diagnostic assessment of behavior. Training and intervention services by the Behavioral Supports professional consultant comprise direct skills training of participants as well as family education and training on Positive Behavioral Supports.

Rev 07 2013
Behavioral Supports Consultation Services provide for the development of Behavioral Supports Plans for behavioral interventions for the reduction of maladaptive behaviors or the acquisition or maintenance of replacement behaviors for individuals with significant, intensive challenging behaviors. Intervention modalities described in plans must relate to the identified behavioral needs of the waiver participant, and specific criteria for remediation of the behavior must be established and specified in the plan.

Behavioral Supports Consultation services are provided by appropriately qualified individuals with expertise in behavioral supports evaluation and services for people with developmental disabilities. These services may be provided in a participant’s own or family home, the Behavioral Supports Consultant’s office, outpatient clinics, facilities in which Community Access or Prevocational Services are provided, Supported Employment work sites, or other community settings specific to community-based behavioral supports goals specified in the Individual Service Plan.

1602 Special Requirements of Participation
Rev 01 2013

1602.1 Individual Provider

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 NOW Program, Behavioral Supports Consultation Services individual providers must meet the following requirements:

1. Provider Qualifications – Individual providers of Behavioral Supports Consultation services must meet the following Positive Behavioral Supports Specialist Standards:

a. Minimum of a Masters degree in psychology, education, social work or a related field;

b. Specialized training and education in behavioral analysis and positive behavioral supports for people with developmental disabilities by provision of evidence of a minimum of thirty-five (35) hours of training and education in behavior analysis and behavioral supports. The required hours must include support by college transcripts of a minimum of 12 semester hours of graduate course credits or 18 quarter hours of graduate course credits in behavior analysis, behavioral assessment, behavior modification, behavioral change procedures, behavior therapy, or behavioral practicum. The remaining required hours are supported by additional hours of graduate course credits in the courses listed above or in ethics in behavioral change procedures, and/or copies of training certificates for workshops approved as continuing education for behavioral professionals on topics of applied behavior analysis or behavioral supports for individuals with developmental disabilities. Evidence of national certification as a Board Certified Behavior Analyst through documentation of a certificate from the Behavior Analyst Certification Board will suffice for these criteria;
Rev 01 2013
Rev 4/2010
c. At least two years experience in behavioral supports evaluation and services for people with developmental disabilities, with at least one year supervised by a qualified professional (1 year is equal to 1200 work hours): A qualified professional is defined as an individual who meets the Developmental Disability Professional (DDP) definition of Behavior Specialist, Board Certified Behavior Analyst, or Psychologist (for DDP
Rev 01 2013
Rev 07 2013
definitions, see Part II Policies and Procedures for NOW, Appendix I);

d. Agree to or provide required documentation of a criminal records check.

Rev 01 2013
2. Licensed Professional Qualifications: All licensed professionals rendering Behavioral Supports Consultation Services must meet the Positive Behavioral Supports Consultant education, training, and experience standards specified above as well as hold current applicable professional license in the State of Georgia.

3. Guidelines Requirement: Providers of Behavioral Supports Consultation services must comply with the guidelines and requirements for the provision of behavioral supports to individuals with developmental disabilities in the DBHDD Guidelines for Supporting Adults with Challenging Behaviors in Community Settings and Best Practice Standards for Behavioral Support Services (see Guidelines in Appendix B and the Best Practice Standards at dbhdd.georgia.gov) in the delivery of these services; providers rendering Behavioral Supports Consultation services to participants under the age of eighteen years must comply with any guidelines and requirements in these DBHDD Guidelines that are applicable to children and adolescents with developmental disabilities.
Rev 01 2013

Rev 01 2013
Rev 07 2013
4. Behavioral Support Consultation Services at Community Access and Prevocational Service Facilities – Providers can provide Behavioral Supports Consultation Services at facilities where Community Access and Prevocational Services are rendered; however, the services must be documented and billed separately, and any waiver participant receiving multiple services at a Community Access and Prevocational service facility may not receive these services at the same time of the same day. The only exception is when a Behavioral Supports Consultant is conducting observation of a participant receiving Community Access or Prevocational Services at a facility for the development of a Behavioral Support Plan. The provider is responsible for documentation of the Behavioral Support Consultation Service at the facility as observation for the developmental of a Behavioral Support Plan.

5. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the
record of each participant receiving Behavioral Supports Consultation 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.
Rev. 10 2009

6. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

1602.2 Agency Provider
Rev 01 2013

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 NOW Program, Behavioral Supports Consultation Services agency providers must meet the following requirements:

1. Types of Agencies: Agencies that provide Behavior Supports Consultation Services are:

. Accredited or Certified DD Service Agencies

2. Staffing Qualifications and Responsibilities: Agencies rendering Behavior Supports Consultation service must have staffing that meets the following:

a. A designated agency director who must:

i. Have either a bachelor’s degree in a human
service field (such as social work, psychology, education, nursing, or a closely related field) and five years experience in service delivery to persons with developmental disabilities, with at least two of these years serving in a supervisory capacity; or

ii. Have an associate degree in nursing, education, or a related field and six years experience in service delivery to persons with developmental disabilities, with at least two of these years serving in a supervisory capacity

b. Duties of the Agency Director include, but are not limited to:

i. Oversees the day-to-day operation of the agency

ii. Manages the use of agency funds

iii. Ensures the development and updating of required policies of the agency

iv. Manages the employment of staff and professional contracts for the agency

v. Designates another staff member to oversee the agency, in his or her absence

c. At least one agency employee or professional under contract with the agency must be a Developmental Disability Professional (DDP) (for definition see Part II Policies and Procedures for NOW, Appendix I) who has a minimum of a Master’s degree in psychology, education, social work or a related field and meets the DDP definition of Behavior Specialist, Board Certified Behavior Analyst, or Psychologist.

Rev 07 2013

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:

i. Overseeing the services and supports provided to participants;

ii. Supervising the formulation of the participant’s plan for delivery of Behavior Supports Consultation Services;

iii. Supervising high intensity services

f. Provider agencies must have available a sufficient number of employees or professionals under contract that have been approved by the Division of Developmental Disabilities Behavior Supports Consultation approval process to provide Behavior Supports Consultation Services as specified in the Individual Service Plans of participants served.
g. Duties of the Behavioral Supports Consultants include all covered services in Section 1606
h. All employees within the agency or professionals under contract who provide the covered services must be approved by the Division of Developmental Disabilities Behavioral Supports Consultation approval process. The approval process requires providers to submit documentation (for review by the Division of Developmental Disabilities- Behavioral Services Unit) that the employee or professional under contract meets the following criteria and obtain written certification prior to billing for services provided by that consultant:
i. Minimum of a Masters degree in psychology, education, social work or a related field;

ii. Specialized training and education in behavioral analysis and positive behavioral supports for people with developmental disabilities by provision of evidence of a minimum of thirty-five (35) hours of training and education in behavior analysis and behavioral supports. The required hours must include support by college transcripts of a minimum of 12 semester hours of graduate course credits or 18 quarter hours of graduate course credits in behavior analysis, behavioral assessment, behavior modification, behavioral change procedures, behavior therapy, or behavioral practicum. The remaining required hours are supported by additional hours of graduate course credits in the courses listed above or in ethics in behavioral change procedures, and/or copies of training certificates for workshops approved as continuing education
for behavioral professionals on topics of applied behavior analysis or behavioral supports for individuals with developmental disabilities. Evidence of national certification as a Board Certified Behavior Analyst through documentation of a certificate from the Behavior Analyst Certification Board will suffice for these criteria;

iii. At least one year experience in behavioral supports evaluation and service for people with developmental disabilities

iv. Attestation that consultant has successfully passed criminal background check.

i. Licensed Professional Qualifications: All licensed professionals rendering Behavioral Supports Consultation Services must meet the Behavioral Supports Consultant education, training, and experience standards specified above as well as hold current applicable professional license in the State of Georgia.
j. Guidelines Requirement: Providers of Behavioral Supports Consultation services must comply with the guidelines and requirements for the provision of behavioral supports to individuals with developmental disabilities in the DBHDD Guidelines for Supporting Adults with Challenging Behaviors in Community Settings and Best Practice Standards for Behavioral Support Services (see Guidelines in Appendix B and the Best Practice Standards at dbhdd.georgia.gov) in the delivery of these services; providers rendering Behavioral Supports Consultation services to participants under the age of eighteen years must comply with any guidelines and requirements in these DBHDD Guidelines that are applicable to children and adolescents with developmental disabilities.
Rev 07 2013
k. Behavioral Support Consultation Services at Community Access and Prevocational Service Facilities: Providers can provide Behavioral Supports Consultation Services at facilities where Community Access and Prevocational Services are
rendered; however, the services must be documented and billed separately, and any waiver participant receiving multiple services at a Community Access and Prevocational Service facility may not receive these services at the same time of the same day. The only exception is when a Behavioral Supports Consultant is conducting observation of a participant receiving Community Access or Prevocational Services at a facility for the development of a Behavioral Support Plan. The provider is responsible for documentation of the Behavioral Support Consultation Service at the facility as observation for the developmental of a Behavioral Support Plan.

l. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving Behavioral Supports Consultation Services:

i. Specific activity, training, or assistance provided;

ii. Date and the beginning and ending time when the service was provided;

iii. Location where the service was delivered;

iv. Verification of service delivery, including first and last name and title (if applicable) of the person providing the service and his or her signature;
Rev. 10 2009

v. 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.

n. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for providers of participant-directed

services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

1603 Licensure

The provider of Behavioral Supports Consultation Services must have any applicable professional license as required by Georgia Code Title 43, for:

1. Psychologist (OCGA 43-39-1); or
2. Licensed Professional Counselor (OCGA 43-10A-1); or
3. Licensed Clinical Social Worker (OCGA 43-10A-1); or

4. Psychiatrist (OCGA 43-24-20).
1604 Special Eligibility Conditions

The need for Behavioral Supports Consultation Services must be related to the individual participant’s disability, therapeutic in nature, and tied to a specific goal in the Intake and Evaluation Team approved Individual Service Plan (ISP).

1605 Prior Approval

Behavioral Supports Consultation Services must be authorized prior to service delivery by the operating agency at least annually in conjunction with the Individual Service Plan (ISP) development and with any ISP revisions.

1606 Covered Services

Reimbursable Behavioral Supports Consultation Services include the following based on the assessed need of the participant and as specified in the approved ISP:
Rev 01 2013

1. Functional assessment of behavior and other diagnostic assessment of behavior.
2. Development, training, and monitoring of Positive Behavioral Supports plans with specific criteria for the acquisition and maintenance of appropriate behaviors for community living and behavioral intervention for the reduction of maladaptive behaviors.
3. Intervention modalities related to the identified behavioral needs of the participant.
4. Participant-specific skills or replacement behavior acquisition training.
5. Family education and training on Positive Behavioral Supports.

1607 Non-Covered Services

1. Services that duplicate any family education or training provided through Natural Supports Training (NST) Services.

2. Services that occur simultaneously or on the same day as NST Services.

3. Services to participants receiving Community Residential Alternative Services in the Comprehensive Supports Waiver.

4. Services in a hospital.

5. Restrictive behavioral interventions, including chemical or mechanical restraints and seclusion, prohibited by state law or regulations.

6. Transportation to and from these services is not included in the rate.

7. 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 NOW, Chapter 900.

8. 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.
Rev 01 2013

Rev 01 2013
9. Services provided by an agency staff member who has not been approved prior to Behavioral Supports Consultation service delivery by the DBHDD, Division of Developmental Disabilities Behavioral Supports Consultation approval process.

1608 Basis for Reimbursement

The reimbursement rate for Behavioral Supports Consultation Services is found in Appendix A.
A. A unit of service is 15 minutes.

B. The annual maximum number of units is 104.

C. The annual maximum is $2,450.24.

Self-Directed
Rev. 07 2014
Limit: 1 unit = $1.00
Annual maximum = $2,450

1609 Participant-Direction Options

1. Participants can choose the self-direction option with Behavioral Supports Consultation Services.
2. An individual serving as a representative for a waiver participant in self-directed services is not eligible to be a participant-directed provider of Behavioral Supports Consultation Services.
3. For details on participant-direction, see Part II Policies and Procedures for NOW, Chapter 1200.

PART III – CHAPTER 1700

SPECIFIC PROGRAM REQUIREMENTS
FOR
COMMUNITY ACCESS SERVICES

SCOPE OF SERVICES

1701 General

Community Access Services has three distinct categories, Community Access Individual, Community Access Participant Directed Activity, and Community Access Group. Community Access services are individually planned to meet the participant’s needs and preferences for active community participation. Community Access services are provided outside the participant’s place of residence. These services can occur during the day, the evenings, and weekends. Services include design of activities and environments for the participant to learn and/or use adaptive skills required for active community participation and independent functioning. These activities include training in socialization skills as well as personal assistance as indicated in the Individual Service Plan (ISP).
Rev 01 2013

Community Access Individual (CAI) services are provided to an individual participant, with a one-to-one staff to participant ratio. CAI services are directly linked to goals and expectations of improvement in skills. The intended outcome of CAI services is to improve the participant’s access to the community through increased skills, increased natural supports, and/or less paid supports. CAI services are designed to be teaching and coaching in nature. These services assist the participant in acquiring, retaining, or improving socialization and networking, independent use of community resources, and adaptive skills required for active community participation outside the participant’s place of residence. CAI services may include programming to reduce inappropriate and/or maladaptive behaviors. CAI services are not facility-based.

Community Access Group (CAG) services are provided to groups of individuals, with a staff to individual ratio of one to two or more. The direct care staff to individual ratio for Community Access Group services cannot exceed one (1) to ten (10) and is determined based on individual need level of the participants in the group. CAG services are designed to provide oversight, assist with daily living, socialization, communication, and mobility skills building and supports in a group. CAG services may include programming to
reduce inappropriate and/or maladaptive behaviors. CAG services may be provided in a facility or a community as appropriate for the skill being taught or specific activity supported.

Community Access Participant Directed Activity services are for individuals who are participant directed and participate in authorized community activities as outlined in Section 1705—Covered Services in order to address functional impairment and/or therapeutic needs of the waiver participant.

Transportation to and from activities and settings primarily utilized by people with disabilities is included in Community Access services. Transportation provided through Community Access Services is included in the cost of doing business and incorporated in the administrative overhead cost. Transportation is to and from other community destinations and separate payment for transportation only occurs when the NOW’s distinct Transportation Services are authorized.

All Community Access Services do not include educational services otherwise available through a program funded under 20 USC Chapter 3, section 1400 of the Individuals with Disabilities Education Act (IDEA). Community Access services must not duplicate or be provided at the same period of the day as Community Living Support, Supported Employment, Prevocational Services or Transportation services. An individual serving as a representative for a waiver participant in self-directed services may not provide Community Access services. Community Access services must be authorized prior to service delivery by the operating agency at least annually in conjunction with the Individual Service Plan development and with any ISP revisions.

The NOW Program is intended for those goods and services that are not covered by the State Medicaid Plan or those instances in which a participant’s need exceeds State Plan coverage limits and exceptions to the coverage limits are not available. Community Access Services Providers offer (or arrange when needed) any of the standard services listed in section 1705 – Covered Services that are needed by the participants served and specified in the participants’ Individual Service Plans.

1702 Special Requirements of Participation

Rev. 04 2009
Note: Effective with June 1, 2009 Individual Service Plans and plans developed thereafter, Community Access Individual Services can not be provided in facilities.

1702.1 Individual Provider

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 NOW Program, Community Access Services providers must meet the following requirements:

1. Individual providers of Community Access services must:

a. Be 18 years or older;

b. Have current CPR and Basic First Aid certifications;

c. Have the experience, training, education or skills necessary to meet the participant’s needs for Community Access services as demonstrated:

(i) Direct Support Professional (DSP) Certification or
Rev. 01 2009

(ii) Copy of high school diploma/transcript or General Education Development (GED diploma; and at least six (6) months of experience providing behavioral health related service to individuals with developmental disabilities, or documented experience providing specific supports to individuals with disabilities.

d. Have evidence of an annual health examination with signed statement from a physician, nurse practitioner, or physician assistant that the person is free of communicable disease;

e. Agree to or provide required documentation of a criminal
records check, prior to providing Community Access services.

f Meet transportation requirements in NOW Part II Chapter, Section 905 if transporting participants
Rev. 04 2009

2 Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving Community Access 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;

Rev. 10 2009
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.

3. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for individual providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

1702.2 Provider Agencies

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 NOW Program, Community Access Services provider agencies must meet the following requirements:

1. Staffing Qualifications and Responsibilities
Rev 01 2013

Provider agencies rendering Community Access Services must have staffing that meets the following 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 these 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 with the agency must:

. Be a Developmental Disability Professional (DDP) (for definition, see Part II Policies and Procedures for NOW, Appendix I );
. Have responsibility for overseeing the delivery of Community Access 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 Access Services;

. Conducting functional assessments; and

. Supervising high intensity services.

f. A minimum of one (1) direct care staff member for every ten (10) participants served in Group Community Access Services and minimum of one (1) direct care staff members for every one (1) participant served in Individual Community Access Services;

g. Direct Care Staff must:

. Be 18 years or older;

. Has high school diploma/equivalent (General Educational Development or GED)
Rev. 01 2011

. Meet transportation requirements in NOW 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 Access Services, including related policies and procedures;
2) Confidentiality of individual information, both written and spoken;
3) Rights and responsibilities of individuals;
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

h. Duties of the Direct Care Staff include, but are not limited to:

. Provides direct assistance in self-help, socialization, and adaptive skills training, retention and improvement to individual participants and groups of participants;

. Provides direct assistance in training, retraining or improving the access to and use of community resources by individual participants or groups of participants;

. Implements the behavioral support plans of participants to reduce inappropriate and/or maladaptive behaviors and to acquire alternative adaptive skills and behaviors;

. Provides active support and direct assistance in participants’ participation in community social, recreational and leisure activities;

. Provides participant-specific assistance, such as assistance with personal care and self-administration of medications.

i. 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 facility-based or community-based Community Access services.

j. The type and number of all other staff associated with the organization (such as contract staff, consultants) are:

1) Properly trained or credentialed in the professional field as required;

2) Present in numbers to provide services and supports to participants as required;

3) Experienced and competent in the services and support they provide.

k. 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 Access services, which follow the Standards for the Georgia Department of Behavioral Health and Developmental Disabilities (see Part II Policies and Procedures for NOW, Chapter 603).

3. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving Community Access Services:

. Specific activity, training, or assistance provided;

. Date and the beginning and ending time when the service was provided;

. 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;

Rev. 10 2009
. 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. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

5. Co-Employer Provider Agencies: Co-Employer Provider Agencies cannot provide facility-based Community Access Service.

6. Community Access and Other Services in the Same Facility:

a. Providers rendering facility-based Community Access and other services (e.g., Prevocational Services and adult therapy services) can provide these services in the same facility; however, the services must be documented and billed separately, and any waiver participant receiving multiple services may not receive these services at the same time of the same day.

b. Providers may grant access to other Medicaid providers for the provision of services at the facility; however, the services must be documented and billed separately, and any waiver participant receiving multiple services may not receive these services at the same time of the same day.

7. Providers, except for providers of participant-directed services, must utilize methods, materials, and settings that meet the following:

a. Set positive expectations for life experiences of people with disabilities, which result in enhanced personal independence and productivity, greater active community participation, and/or increased community integration;
b. Facilitate the provision of participant-specific supports through a supports network;
c. Are appropriate to the chronological age of participants;
d. Are culturally normative as specified in each participant’s ISP.
8. Providers must meet the following requirements for staff-to-participant ratios:

a. Group Community Access Services: a staff to individual ratio of one to two or more, not to exceed one (1) to ten (10). Specialized or intense needs of participants may warrant a lower staff to participant ratio than the upper limit allowed. On site reviews of the service will focus on
Rev. 04 2009
the specialized needs of Group Community Access Services participants.

b. Individual Community Access Services: a one-to-one staff to participant ratio.

9. 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 the DBHDD (see Part II Policies and Procedures for NOW, Chapter 603).

10. Physical Environment

Providers who render facility-based Community Access Services must provide these services in a facility that meets the following requirements:

a. Accessibility: Is accessible to and usable by participants and meets Americans with Disabilities Act (ADA) accessibility requirements for facilities.

b. Building Construction and Maintenance: Is constructed, arranged, and maintained so as to provide adequately for health, safety, access, and wellbeing of the participants.

c. Building Codes: Is in compliance with all local building codes and other applicable codes;

d. Lighting: Provides adequate lighting for participants’ activities and safety;

e. Ventilation: Is adequately ventilated at all times by either mechanical or natural means to provide fresh air and the control of unpleasant odors;

f. Floor Space: Has adequate floor space to safely and comfortably accommodate the number of participants for all activities and services provided in that space;

g. Furnishings: Has sufficient furniture for use by participants, which provide comfort and safety; are appropriate for population served, including any participants with physical, visual, and mobility limitations;
and provide adequate seating and table space for participant activities in the facility, including dining if applicable; Is accessible to and usable by participants and meets Americans with Disabilities Act (ADA) accessibility requirements for facilities.

h. Environmental/Sanitation: Is in good repair and clean inside and outside of the facility, including being free from liter, extraneous materials, unsightly or injurious accumulations of items and free from pest and rodents;

i. Temperature Conditions: Has an adequate central heating and cooling system or its equivalent at temperature ranges that are consistent with the individual health needs and comfort of participants:

j. Equipment Maintenance: Maintains all essential mechanical, electrical, and participant activity, care and support equipment in safe operating condition;

k. Drinking Fountain: Must have drinking fountain(s) approved by the Georgia Department of Behavioral Health and Developmental Disabilities, Division of Public Health or provide access to single disposable cups to participants, with participants disposing of the used cups immediately after use;

l. Restrooms: Has a minimum of at least two toilets and lavatories available, with accessibility for individuals with physical and mobility limitations, including installed grab bars;

m. Participant Activities and Dining Space: Has one or more clean, orderly, and appropriate furnished rooms of adequate size designated for participant activities and, if applicable, dining. If the facility has a single room for participant activities and dining, the room provides sufficient space to accommodate both activities without interfering with each other;

n. Medication Storage: Assures that medications are:

1) Stored under lock and key at all times. A staff member may keep medications needed for frequent or emergency use. The provider stores medications that
require refrigeration in a locked container in the refrigerator;

2) Kept in original containers with original labels intake or in labeled bubble packs from a pharmacy;

3) Handled in accordance with current applicable State laws and regulations.

o. Documentation of Self-Administration of Medications: The facility maintains documentation of all self-administration of medications supervised by facility staff. The documentation record must include the name of the medication, dosage, date, time, and name of the staff person who assists the participants in the self-administration of medications by the participant.

p. Evacuation Plan: The facility formulates a plan for evacuation of the building in case of fire or disaster. This plan is posted in a clearly visible place in each room. All employees are instructed and kept informed of their duties under the plan.

q. Food Services: The following only apply if the facility stores, prepares, or distributes food:

a. The facility observes and complies with all of the Rules of Georgia Department of Behavioral Health and Developmental Disabilities, Public Health, Chapter 290-5-14, Food Service and any local health ordinances when engaged in the storage, preparation, and distribution of food.

Note. The Department will allow the facility to be exempted from the Food Service Permit requirement if all the facility does is use a microwave to heat up food participants bring to the facility.
Rev. 01 2009

This exception is allowed only if:

. The microwave oven is clean, in good repair, and free of unsanitary conditions

. The microwave oven is allowed for warming of permitted foods and beverages based on the provider’s internal policies and procedures.

. All food and utensils are handled in a sanitary manner.

b. Meals and snacks are prepared either on site or under subcontract with an outside vendor who agrees to comply with the food and nutritional requirements. The facility posts its current Food Service Permit and inspection report or the subcontracted vendor’s current Food Service Permit and inspection report.

c. The facility has a designated kitchen area for receiving food, facilities for warming or preparing cold food, and clean–up facilities including hot and cold running water. The facility provides palatable, nutritious and attractive meals and snacks that meet the nutritional requirements of each member.

11. Transportation: The participant’s family or representative may choose to transport the member to the Community Access facility.

12. Individual Site Enrollment: Part I Policies and Procedures for Medicaid/Peachcare for Kids require that each provider enroll at each location where services are provided to Medicaid members. Each individual, facility-based Community Access site must be individually enrolled. Individual site enrollment applies only to facility-based Community Access sites.
Rev 07 2013

1703 Special Eligibility Conditions

A. Community Access Services are only for participants for whom the service is not available under a program funded under 20 USC Chapter 3, section 1400 of the Individuals with Disabilities Education Act (IDEA).

B. The need for Community Access Services must be related to the individual disability; services must be therapeutic in nature; and tied to a specific goal in the Intake and Evaluation Team approved Individual Service Plan (ISP).

1704 Prior Approval

Community Access services must be authorized prior to service delivery by the operating agency at least annually in conjunction with the Individual Service Plan development and with any ISP revisions.

1705 Covered Services

Reimbursable Community Access Services for the distinct categories include the following based on the assessed need of the participant and as specified in the approved ISP:
Rev 01 2013

Community Access Group

1. Services in facility-based and community-based settings outside the participant’s own or family home or any other residential setting
2. Design and development of activities in any location outside the participant’s own or family home or any other residential setting that assist the participant to learn, use, and/or maintain adaptive skills required for active community participation and independent functioning, which includes services provided on behalf of a specific participant as well as direct services.
3. Assistance in acquiring, retaining, or improving self-help, socialization, and adaptive skills for active community participation and independent functioning outside the participant’s own or family home, such as assisting the participant with money management, teaching appropriate shopping skills, and teaching nutrition and diet information.
4. Assistance in acquiring, retaining, or improving access to and use of community resources that increases participation in integrated community activities, such as training and active support to use public transportation, banks, automated tellers, and restaurants.
5. Provision of oversight and assistance with daily living, socialization, communication, and mobility skills building and supports in a group.

Rev 01 2013

6. Implementation of behavioral support plans to reduce inappropriate and/or maladaptive behaviors and to acquire alternative adaptive skills and behaviors.
7. Recreational and leisure activities that support the participant’s active, local community participation and are specific to an ISP goal and therapeutic in nature, such as teaching a participant how to participate in and take advantage of community social and recreational activities or providing active support for a participant in community recreational and leisure activities.
8. Facilitating volunteer roles in the community and participation in self-advocacy type activities.
9. Other related, participant-specific assistance, such as assistance with personal care and self-administration of medications, and nursing services, and health maintenance activities as indicated in the approved Individual Service Plan.

Rev. 07 2011
Rev. 10 2011

Rev. 04 2009
Rev. 04 2010
10. Transportation is required between point of origin and activities in settings primarily utilized by people with disabilities (a reasonable amount of transportation, defined as up to one hour per day, is billable). Point of origin is defined as any location that participants are available for pick up that is safe and appropriate for the participant based on the approved Individual Service Plan.

Community Access Individual
Rev 01 2013

1. Services in non-facility, community-based settings outside the participant’s own or family home or any other residential setting
2. Design and development of activities in any non-facility, community-based location outside the participant’s own or family home or any other residential setting that assist the participant to learn, use, and/or maintain adaptive skills required for active community participation and independent functioning, which includes services provided on behalf of a specific participant as well as direct services.
3. Assistance in acquiring, retaining, or improving socialization, and adaptive skills for active community participation and independent functioning outside the participant’s own or family home, such as assisting the participant with money management, teaching appropriate shopping skills, using public transportation, and teaching nutrition and diet information.
4. Assistance in acquiring, retaining, or improving socialization and networking, independent use of community resources, and adaptive skills required for active community participation outside the participant’s place of residence.
5. Participant-specific teaching and coaching of skills for access to the community, including communication, mobility, money management, and shopping skills.
6. Implementation of behavioral support plans to reduce inappropriate and/or maladaptive behaviors and to acquire alternative adaptive skills and behaviors.
7. Teaching and coaching a participant how to participate in and take advantage of community social and recreational activities.
8. Facilitating volunteer roles in the community and participation in self-advocacy type activities.
9. Other related, participant-specific assistance, such as assistance with personal care and self-administration of medications, nursing services, and health maintenance activities as indicated in the approved Individual Service Plan.

Community Access Participant Directed Activity

1. Services for individuals who are participant directed and participate in community activities designed to address functional impairment and/or therapeutic needs of the waiver participant, which include therapeutic camp programs, therapeutic support groups, and physical fitness and weight reduction programs.

2. Services are tied to an ISP goal.

1706 Non-Covered Services

1. Educational services otherwise available through a program funded under 20 USC Chapter 3, section 1400 of the Individuals with Disabilities Education Act (IDEA), including private school tuition, Applied Behavior Analysis (ABA) in schools, school supplies, and tutors.

2. Activities, training, or services provided in the participant’s home or family home or family home, or host home/life sharing arrangement, foster home, personal care home, community living arrangement, group home, or any other residential setting..
Rev. 01 2009

3. Medically related services that are not allowable by State law, rules, and regulations.

4. Admission fees, Memberships, Subscriptions, Donations, or related items.

5. Registration Fees unless participant-directed services.

6. Out of state camps.

7. Community Access services must not duplicate or be provided at the same time of the same day as Community Living Support, Supported Employment, Prevocational Services or Transportation Services.

8. 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 NOW, Chapter 900.

Rev 10 2011
9. Non-covered health maintenance activities as defined in Rules and Regulations for Proxy Caregivers Used in Licensed Healthcare Facilities, Chapter 111-8-100.

10. 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.
Rev 01 2013

1707 Basis for Reimbursement

The reimbursement rate for Community Access Services is found in Appendix A. Transportation provided through Community Access Services is included in the cost of doing business and incorporated in the administrative overhead cost

Separate payment for transportation only occurs when the NOW’s distinct Transportation Services are authorized.

A. The unit of service is 15 minutes.

B. Community Access Group Limits:

1. 24 fifteen-minute units per day.

2. 504 fifteen-minute units per month.

3. 5760 fifteen-minute units per year.
C. Community Access Individual Limits:

1. 40 fifteen-minute units per day.

2. 1440 fifteen-minute units per year.
Self-Directed
Community Access Group Limits: 1 unit = $1.00
Annual limit is as authorized in the individual budget
up to an annual maximum of $17,510.

Community Access Individual Limits: 1 unit = $1.00
Annual limit is as authorized in the individual budget
up to an annual maximum of $10,454.

Note. The limits for daily dollars/units do not apply to Self-Directed Community Access Services.

1708 Participant-Direction Options

A. Participants can choose the self-direction or co-employer options with Community Access Services.

B. An individual serving as a representative for a waiver participant in self-directed services is not eligible to be a participant-directed provider of Community Access Services.

C. For details on participant-direction, see Part II Policies and Procedures for NOW, Chapter 1200.

PART III – CHAPTER 1800

SPECIFIC PROGRAM REQUIREMENTS
FOR
COMMUNITY GUIDE SERVICES

SCOPE OF SERVICES

1801 General

Community Guide Services are direct assistance to participants in skills building and information in meeting participant-direction responsibilities. These services are available only for participants who choose the participant-direction option for service delivery. The participant, with the Support Coordinator, determines the amount of Community Guide Services, if any, and the specific services that the Community Guide will provide. The specific Community Guide Services for the participant are specified in the Individual Service Plan. Participants may elect to receive Community Guide Services, and when elected, participants choose their Community Guide.

Community Guide Services are individualized services designed to assist participants in meeting their responsibilities in the participant-direction option for service delivery. Community Guides provide information, direct assistance, and training to participants in support of participant direction. The intended outcome of these services is to improve the participant’s knowledge and skills for participant direction.

Community Guides assist and train participants to build the skills required for participant direction, such as exploring and brokering available community resources, problem solving and decision-making, being an effective employer of support workers, developing and managing the individual budget, and record keeping. Information provided by the Community Guide helps the participant’s understanding of provider qualifications, record keeping, and other participant-direction responsibilities.

The scope, intensity, and frequency of Community Guide Services may change over time, based on the needs of the participant. Community Guide Services providers offer (or arrange when needed) any of the standard services listed in section 1805 – Covered Services that are needed by the participants served and specified in the participants’ Individual Service Plans.

1802 Special Requirements of Participation

1802.1 Individual Provider

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 NOW Program, Community Guide Services providers must meet the following requirements:

1. Individual Providers of Community Guide Services must:

a. Be 18 years or older;

b. Have a minimum of a bachelor’s degree in a human service field and experience in providing direct assistance to individuals with disabilities to network within a local community or comparable training, education or skills;

c. Agree to or provide required documentation of a criminal records check, prior to providing Community Guide services;

d. Be knowledgeable about resources in any local community in which the provider is a Community Guide;

e. Have demonstrated connections to the informal structures of any local community in which the provider is a Community Guide;

f. Have an understanding of Community Guide services, DD waiver participant-direction service delivery requirements, and strategies for working effectively and communicating clearly with individuals with DD and their families/representatives;

f. Attend all mandatory, DBHDD training.

2. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for individual providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

3. Duties of the Community Guide include but are not limited to the covered services in 1805.

1802.2 Provider Agencies

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 NOW Program, Community Guide Services provider agencies must meet the following requirements:

1. Staffing Qualifications and Responsibilities
Rev 01 2012

Provider agencies rendering Community Guide Services must have staffing that meets the following 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 these 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.

i. At least one agency employee or professional under contract with the agency must:

. Be a Developmental Disability Professional (DDP) (for definition, see Part II Policies and Procedures for NOW, Appendix I );
. Have responsibility for overseeing the delivery of Community Guide 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 Guide Services;

. Conducting functional assessments; and

. Supervising high intensity services.

f. Provider agencies must have available a sufficient number of employees that meet the Community Guide experience, training, education or skills qualification specified above for Individual Providers to provide all Community Guide Services that are needed by the participants served and specified in the participants’ Individual Service Plans. .

g. Duties of the Community Guide include but are not limited to the covered services in 1805.

2. Agency Policies and Procedures – Each provider agency must develop written policies and procedures to govern the operations of Community Guide Services, which follow the Standards for the Georgia Department of Behavioral Health and Developmental Disabilities (see Part II Policies and Procedures for NOW)

3. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

4. DBHDD Contract/LOA and DBHDD Community Service Standards: Providers must adhere to DBHDD Contract/LOA, DBHDD Core Requirements for All Providers and all other applicable DBHDD Standards, including accreditation by a national organization (CARF, JCAHO, The Council, Council on Accreditation) or certification by the DBHDD (see Part II Policies and Procedures for NOW, Chapter 603).

1803 Special Eligibility Conditions

A. Community Guide Services are only for participants who opt for participant-direction.

B. The participant determines the amount of Community Guide Services, if any, and the specific services that the Community Guide will provide.

C. The specific Community Guide Services for the participant are specified in the Individual Service Plan.

D. Participants may elect to receive Community Guide Services, and when elected, participants choose their Community Guide.

E. The need for Community Guide Services must be related to the individual disability and tied to a specific goal in the Intake and Evaluation Team approved Individual Service Plan (ISP).

1804 Prior Approval

Community Guide 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.

1805 Covered Services

Reimbursable Community Guide Services include the following based on the assessed need of the participant and as specified in the approved ISP:
:
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 promote 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.
1806 Non-Covered Services

1. Community Guide services cannot duplicate Support Coordination services.

2. Community Guides cannot provide other direct waiver services, including Support Coordination, to any waiver participant.

3. Community Guide agencies cannot provide Support Coordination services.

4. 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 NOW, Chapter 900.

5. 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.
Rev 01 2013

1807 Basis for Reimbursement

The reimbursement rate for Community Guide Services is found in Appendix A.

A. The unit of service is 15 minutes.

B. The daily maximum number of units is 32.

C. Annual maximum is $2,000.32.

Self-Directed
Limit: 1 unit = $1.00
Annual limit is as authorized in the individual budget up to an annual maximum of $2,000.

1808 Participant-Direction Options

A. Participants can choose the self-direction or co-employer options with Community Guide Services.

B. An individual serving as a representative for a waiver participant in self-directed services is not eligible to be a participant-directed provider of Community Guide Services.

C. For details on participant-direction, see Part II Policies and Procedures for NOW, Chapter 1200.

PART III – CHAPTER 1900
SPECIFIC PROGRAM REQUIREMENTS
FOR
COMMUNITY LIVING SUPPORT (CLS) SERVICES

SCOPE OF SERVICES

1901. General
Community Living Support (CLS) Services are individually tailored supports that assist with the acquisition, retention, or improvement in skills related to a participant; continued residence in his or her own or family home. Personal care/assistance may be a component part of CLS services but may not comprise the entirely of the services. CLS services are offered to participants who live in their own or family home.
Rev 01 2013

CLS services include training and assistance with activities of daily living (ADLs), such as bathing, dressing toileting, and transferring, with instrumental activities of daily living (IADLs), such as personal hygiene, light housework, laundry, meal, preparation, transportation, grocery shopping, using the telephone, and medication and money management. These services include transportation to facilitate the individual’s participation in grocery or personal shopping, banking and other community activities that support continued residence of the participant in his or her own or family home. CLS services may include medically related services, such as basic first aid, arranging and transporting participants to medically appointments, accompanying participants on medical appointments, documenting a participant’s food and/or liquid intake or output, reminding participants to take medication, assisting with or supervising self-administration of medication and other medically related activities, including health maintenance activities. Personal care/assistance may be a component part of CLS services but may not be the only service provided to a participant. The amount of personal care/assistance is specific to the individual needs of the participant, as determined by the Supports Intensity Scale, the Health Risk Screening Tool, and other participant-centered assessment data. The individual amount of personal care/assistance provided the participant is participant is specified in the Individual Service Plan.

A personal assistance retainer is a component of Community Living Support Services. The personal assistance retainer allows for continued payment for Community Living Support services while a participant is hospitalized or otherwise away from the home in order to ensure stability and continuity of care. This retainer allows continued payment to personal caregivers under the waiver for up to thirty (30) days per calendar year for absences of participant from his or her home.

CLS services may also include nursing services. These nursing services differ in scope from skilled nursing services offered as a component of Home Health services in the State Medicaid Plan. CLS nursing services are those services that are not included under exceptions to the nurse practice act. These nursing services are not stand alone services and can only be provided as a component of Community Living Support Services. CLS nursing services must be provided in accordance with State law, rules, and regulations.
Rev 01 2013

CLS services are only for participants who live in their own or family home. The types and intensity of services provided are specific to the individual participant and detailed in his or her Individual Service Plan. Community Living Support Services providers offer any of the standard services listed in section 1906 – Covered Services that are needed by the participants served and specified in the participants’ Individual Service Plans.

1902 Special Requirements of Participation

1902.1 Individual Provider of Community Support Habilitation Services

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 NOW Program, Community Living Support Services providers must meet the following requirements:

1. Individual providers of Community Living Support Habilitation Services must:

a. Be 18 years or older;

b. Have current CPR and Basic First Aid certifications;

c. Have the experience, training, education or skills necessary to meet the participant’s needs for Community Living Support services as demonstrated;

(i) Direct Support Professional (DSP) Certification; or
Rev. 01 2009

(ii) Copy of high school diploma/transcript or General Education Development (GED diploma; and at least six (6) months of experience providing behavioral health related
Rev. 01 2009
service to individuals with developmental disabilities, or documented experience providing specific supports to individuals with disabilities.

d. Have evidence of an annual health examination with signed statement from a physician, nurse practitioner, or physician assistant that the person is free of communicable disease;

e. Agree to or provide required documentation of a criminal records check, prior to providing Community Living Support services;

f. Meet transportation requirements in NOW Part II Chapter 900, Section 905 if transporting participants.
Rev. 04 2009

2. Individual providers of Community Living Support Nursing Services must:

a. Hold current Georgia professional license as a Licensed Practical Nurse if providing CLS LPN services and provide services under the supervision of a registered nurse, licensed to practice in the State of Georgia

b. Hold current Georgia professional license as a Registered Nurse if providing CLS RN services.

3. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving Community Living Support 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
Rev 10 2009
plan, and the amount/type of assistance/support in the Current Service Summary and the Health and Safety sections of the ISP.

Rev. 04 2010
4. Personal Assistance Retainer Documentation:
Providers must document the following in the record of each participant for whom a personal assistance retainer is a component of Community Living Support Habilitation Services:

a. Beginning and end date of absence.

b. Reason for absence.

c. Scheduled days and units per day for Community Living Support Habilitation Services as specified in the ISP
Rev. 04 2010

Note: See Part II Chapter 1200 of the New Options Waiver Program Manual for Participant-Directed Personal Assistance documentation requirement.
Rev. 04 2010

5. Participant-Directed Services Documentation and other Requirements: Documentation, including Personal Assistance Retainer documentation and other requirements for individual providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

1902.2 Provider Agencies

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 NOW Program, Community Living Support Services provider agencies must meet the following requirements:

1. Staffing Qualifications and Responsibilities
Rev 01 2013

Provider agencies rendering Community Living Support Services must have staffing that meets the following 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 these 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 with the agency must:
. Be a Developmental Disability Professional (DDP) (for definition, see Part II Policies and Procedures

for NOW, Appendix I);

. Have responsibility for overseeing the delivery of Community Living Support 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 Living Support Services;

. Conducting functional assessments; and

. Supervising high intensity services.

f. Direct Care Staff must:

. Be 18 years or older;

. Have high school diploma/equivalent (General Education Development or GED)
Rev. 01 2011

. Meet transportation requirements in NOW Part II Chapter 900, Section 9005 if transporting participants.
Rev. 04 2009

. Be provided with a basic orientation prior to direct contact with participants and show competence in:

a. The purpose and scope of Community Living Support Services, including related policies and procedures;
b. Confidentiality of individual information, both written and spoken;
c. Rights and responsibilities of individuals;
d. Requirements for recognizing and reporting suspected abuse, neglect, or exploitation of any individual:
i. The Adult Protective Services, Division of Aging Services, Department of Human Services
Rev 10 2011

ii. To the Department of Behavioral Health and Development Disabilities;

iii. Within the organization;

iv. To appropriate regulatory or licensing agencies; and

v. To law enforcement agencies

g. Duties of the Direct Care Staff include, but are not limited to:

. Provides direct assistance to the participant in self-help, socialization, and adaptive skills training, retention and improvement;

. Provides personal care and protective oversight and supervision;

. Implements the behavioral support plans of participants to reduce inappropriate and/or maladaptive behaviors and to acquire alternative adaptive skills and behaviors;

. Provides assistance and training on independent community living skills, such as personal hygiene, light housework, laundry, meal preparation, transportation, grocery shopping, using the telephone, and medication and money management.

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 services.
The type and number of all other staff associated with the organization (such as contract staff, consultants) are:

i. Properly trained or credentialed in the professional field as required;

ii. Present in numbers to provide services and supports to participants as required;

iii. Experienced and competent in the services and support they provide.

i. CLS nursing staff must:

. Hold current Georgia professional license as a Licensed Practical Nurse if providing CLS LPN services and 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 CLS RN services.

j. Duties of CLS nursing staff include CLS nursing services as defined in Section 1906.

k. CLS nursing services rendered by a CLS enrolled provider agency are provided by individual nurses employed by, OR
Rev 07 0210
Rev. 07 2011
under professional contract with the CLS enrolled provider agency OR by subcontract with another provider agency. When CLS nursing services are provided by subcontract with another provider agency, the CLS enrolled provider agency must meet ALL of the following:

(1) Maintenance of a personnel file on each nurse providing CLS 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 CLS services must be provided by an employee of enrolled CLS provider agency or by an individual obtained through an employment agency with the exception of CLS nursing services and participant-directed CLS services.
Rev. 10 2011

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 Living Support services, which follow the Standards for the Georgia Department of Behavioral Health and Developmental Disabilities as stated in Part II Policies and Procedures for NOW.

3 Documentation Requirement: Providers, except for providers of participant-directed services, must document the following
in the record of each participant receiving Community Living Support Services:
Rev. 04 2010

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;

Rev. 10 2009
Rev. 04 2010
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.
Rev 04 2010
4. Personal Assistance Retainer Documentation:
Providers must document the following in the record of each participant for whom a personal assistance retainer is a component of Community Living Support Habilitation Services:

a. Beginning and end date of absence.

b. Reason for absence.

c. Scheduled days and units per day for Community Living Support Habilitation Services as specified in the ISP.

Note: See Part II Chapter 1200 of the New Options Waiver Program Manual for Participant-Directed Personal Assistance documentation requirement
Rev 4/01/2010
5. Participant-Directed Services Documentation and other Requirements: Documentation, including Personal Assistance Retainer documentation and other requirements for providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

6. 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 the DBHDD (see Part II Policies and Procedures for NOW, Chapter 603).

1903 Licensure

A. Provider agencies that render CLS Services must have a Private Home Care Provider License from the Georgia Department of Community Health, Healthcare Facilities Regulation Division (HFR) if providing covered services as required by HFR (State of Georgia Rules and Regulations 290-4-54).
Rev. 04 2010

B. CLS LPN services are provided by a License Practical Nurse in accordance with the applicable Georgia license as required under OCGA Title 43-26-32.
Rev. 04 2010

C. CLS RN services are provided by a licensed Registered Nurse in accordance with the applicable Georgia license as required under OCGA Title 43-26-3.
Rev. 04 2010

1904 Special Eligibility Conditions

A. CLS services are provided only to participants who require in-home supports.

B. The need for CLS services must be reflected in the Intake and Evaluation Team approved Individual Service Plan (ISP).

1905 Prior Approval

Community Living Support 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.

1906 Covered Services

Reimbursable Community Living Support Services include the following based on the assessed need of the participant and as specified in the approved ISP:
Rev. 07 2010

1. Social and leisure skills development that assists the participant in planning and engaging in social and leisure activities as a part of home living in a community.

Rev. 10 2009

Rev. 10 2009
2. Adaptive skills development that assists the participant in community activities that are a part of home living in a community, such as community navigation, mobility, communication, understanding community signs/clues, and safety in the community.
3. Training in, assistance with, and/or supervision of activities of daily living (ADLs), such as bathing, dressing, toileting, and transferring, and with instrumental activities of daily living (IADLs), such as personal hygiene, light housework, laundry, meal preparation, transportation, grocery shopping, using the telephone, and medication and money management. CLS services are provided in the person’s own home or family home to facilitate the enhanced functioning of a participant in his/her home environment. ADL assistance and/or supervision is a component of CLS Services but should not constitute the sole tasks.

Rev. 04 2009
Rev. 04 2009

4. Medically related services, such as basic first aid, arranging and transporting participants to medical appointments, accompanying participants on medical appointments, making or reminding a participant of medical appointments. documenting a participant’s food and/or liquid intake or output, reminding participants to take medication, and assisting with self-administration of medication and other medically related activities, including health maintenance activities.

Rev. 04 2009

Rev. 10 2011
5. Implementation of the behavioral support plan of a participant to reduce inappropriate and/or maladaptive behaviors and to acquire alternative adaptive skills and behaviors.
6. Transportation is required for participants living in their own home to facilitate the individual’s participation in grocery or personal shopping, banking, medical appointments and other community activities that support continued home living; transportation is provided as specified in the ISP for participants living in their own home.

Rev. 07 2010

7. CLS 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 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.

Rev. 04 2010

8. CLS LPN services defined as only routine nursing services that are integral to meeting the daily needs of the participant in his or her

Rev. 04 2010
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.

1907 Non-Covered Services

Rev. 07 2010
Rev. 10 2013
1. Community Living Support services may not be delivered to a person living in a home leased or owned by the service delivery agency, by an employee or contractor of the service delivery agency, or by support staff hired under participant direction.

2. Community Living Support services may not be delivered in a rental room/apartment/home for the individual participant where access to the kitchen is restricted and there is no access to at least one bathroom.
Rev 10 2013

3. Community Living Support services may not be delivered in foster homes, host homes, personal care homes, community living arrangements, or any other home/residence other than the participant’s own or family home, but in no instance, can the own or family home be licensed Personal Care Home, a licensed Community Living Arrangement, a host home/life sharing arrangement that provides Community Residential Alternative Services, or a home leased or owned by the service delivery agency or by support staff hired under participant direction.
Rev. 10 2009
Rev. 01 2011

4. Educational and related services needed by children for whom the Department of Education is responsible.

5. CLS services that duplicate or are provided at the same time of the same day as Community Access or Supported Employment services.

6. Payment is not made for the cost of room and board, including the cost of building maintenance, upkeep and improvement.

7. Payment is not made, directly or indirectly, to members of the individual’s immediate family.
Rev. 04 2009

8. Medically related services that are not allowable by State law, rules, and regulations.

9. Payment is not made for Personal Assistance Retainer outside of scheduled days and units per day for Community Living Support Services as specified in the ISP.
10. Payment of Personal Assistance retainer is not allowable for absences due to services that are reimbursable as other waiver and Medicaid State Plan services except for admissions to a general hospital or nursing facility in accordance with requirements specified below in Section 1908, Basis for Reimbursement.
11. Payment of Personal Assistance retainer beyond allowable days indicated below in Section 1908, Basis for Reimbursement.
12. Payment of Personal Assistance retainer for CLS nursing services.

Rev. 04 2010

13. CLS nursing services that are not provided in accordance with State law, rules, and regulations.

Rev. 04 2010

14. Non-Covered health maintenance activities as defined the Rules and Regulations for Proxy Caregivers Used in Licensed Healthcare Facilities, Chapter 111-8-100.

Rev. 10 2011

Rev 01 2013
15. 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.
1908 Basis for Reimbursement

Reimbursement Rate: Reimbursement rates for CLS services, including CLS nursing services, are found in Appendix A. Note: Reimbursement for all CLS services, including nursing, can not exceed the annual maximum for this service or any annual amount associated with an exceptional rate.
Rev 01 2013

Transportation is included in the rate for CLS services.

A personal assistance retainer is a component of CLS services. The personal retainer allows continued payment for Community Living Support services while a participant is hospitalized or otherwise away from the home in order to ensure stability and continuity of care. This retainer allows continued payment to personal caregivers under the waiver up to thirty (30) days per calendar year for other absences of the participant from his or her home. The personal assistance retainer only allows continued payment for the scheduled days and amounts of CLS services as indicated in the ISP. The provider must document specific days and units billed under the personal assistance retainer (see Appendix C for Procedures for Billing and Documenting Personal Assistance Retainer).

A. The unit of service is 15 minutes.
Rev 10 2009

B. The annual maximum number of 15-minutes units is 4650 for CLS Habilitation.
Rev. 04 2010
Rev. 01 2011

Rev. 04 2010
C. Total amount of CLS habilitation fifteen-minute units billed per day cannot exceed $128.52.

Rev 01 2013
D. All CLS services. Including CLS Habilitation, CLS LPN, and CLS RN services are provided within the annual maximum.

Self-Directed
Rev. 07 2014
Community Living Support: 1 unit = $1.00
Annual limit is as authorized in the individual budget up to an annual maximum of $46,909.

1909 Participant-Direction Options

A. Participants can choose the self-direction or co-employer options with CLS services.

B. An individual serving as a representative for a waiver participant in self-directed services is not eligible to be a participant-directed provider of CLS services.

C. For details on participant-direction, see Part II Policies and Procedures for NOW, Chapter 1200.

PART III – CHAPTER 2000

SPECIFIC PROGRAM REQUIREMENTS
FOR
ENVIRONMENTAL ACCESSIBILITY ADAPTATION SERVICES

SCOPE OF SERVICES

2001 General

Environmental Accessibility Adaptation Services include adaptations and technical assistance to individually or family owned private residences which are designed to enable individuals to interact more independently with their environment thus enhancing their quality of life and reducing their dependence on physical support from others. These services include physical adaptations to the participant’s or family’s home which are necessary to ensure the health, welfare and safety of the individual, or enable the individual to function with greater independence in the home and without which, the participant would require institutionalization. Environmental Accessibility Adaptations consist of the installation of ramps and grab-bars, widening of doorways, modification of bathroom facilities, or installation of specialized electric and plumbing systems which are necessary to accommodate the medical equipment and supplies necessary for the welfare of the participant and are of direct medical or remedial benefit to the participant.

Any item billed under Environmental Accessibility Adaptation Services must not be available under the State Medicaid Plan. These services must also be documented to be the payer of last resource. The NOW does not cover items that have been denied through the DME and other programs for lack of medical necessity.

2002 Special Requirements of Participation

2002.1 Individual Provider
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 NOW Program, individual providers of Environmental Accessibility Adaptations must meet the following requirements:

1. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving Environmental Accessibility Adaptation Services:

a. The efforts of the participant’s Support Coordinator to substantiate payer of last resource, including available community, State Plan, or other resources.
b. Verification of Environmental Accessibility Adaptation service delivery, including date, location, and specific environmental accessibility adaptations provided.
c. Associated administration costs for Environmental Accessibility Adaptation service delivery that delineates line item sources of costs; billing of associated administration costs can not exceed eight to ten (8 to 10) percent of any billing for Environmental Accessibility Adaptation services.

Rev. 04 2009

2. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for individual providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

2002.2 Provider Agencies

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 NOW Program, Environmental Accessibility Adaptation Services provider agencies must meet the following requirements:

1. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving Environmental Accessibility Adaptation Services:

a. The efforts of the participant’s Support Coordinator to substantiate payer of last resource, including available community, State Plan, or other resources.

b. Verification of Environmental Accessibility Adaptation service delivery, including date, location, and specific environmental accessibility adaptations provided.
c. Associated administration costs for Environment Accessibility Adaptation services delivery that delineates line item sources of cost; billing of associated administration costs can not exceed Eight to ten (8 to 10) percent of billing for Environment Accessibility Adaptation services.
a. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for individual providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200

b. DBHDD Contract/LOA and MHDDD Community Service Standards: Providers must adhere to DBHDD Contract Standards, DBHDD Core Requirements for All Providers and all other applicable DBHDD Standards, including accreditation by a national organization (CARF, JCAHO, The Council, Council on Accreditation) or certification by the DBHDD (see Part II Policies and Procedures for NOW, Chapter 603).

2003 Licensure

Environmental Accessibility Adaptations are made by building, plumbing or electrical contractors with applicable Georgia license (OCGA 43-14-2 or 43-41-2) or individual builders, plumbers or electricians with applicable Georgia business license as required by the local, city or county government in which the services are provided.

2004 Special Eligibility Conditions

1. The need for Environmental Accessibility Adaptation services must be related to the individual disability and specified in the Health and Safety Section of the Intake and Evaluation Team approved Individual Service Plan (ISP).
Rev. 10 2009

Rev. 10 2009
2. When a participant only receives specialized services, a specific goal must be in the ISP for specialized services, which includes Environmental Accessibility Adaptation.

3. Medical Necessity for Environmental Accessibility Adaptation Services must be documented through an order by the Georgia Licensed Physician.
Rev. 10 2009

2005 Prior Approval

1. Environmental Accessibility Adaptation Services must relate to specific individual goals and must be required to meet the needs of the participant.

2. Environmental Accessibility Adaptation Services must be authorized prior to service delivery by the applicable DBHDD Regional Office at least annually in conjunction with the ISP development and any ISP revisions.

2006 Covered Services

Reimbursable Environmental Accessibility Adaptation Services include the following based on the assessed need of the participant and as specified in the approved ISP:

1. Environmental Accessibility Adaptation Services consist of physical adaptations to the participant’s or family’s home in which the participant resides and 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 and without which, the participant would require institutionalization.

2. Environmental Accessibility Adaptations consist of the installation of ramps and grab-bars, widening of doorways, modification of bathroom facilities, or installation of specialized electric and plumbing systems which are necessary to accommodate the medical equipment and supplies necessary for the welfare of the participant and are of direct medical or remedial benefit to the participant.

2007 Non-Covered Services

1. Environmental Accessibility Adaptation Services will not be approved for modifications made to homes that are licensed by the State as Personal Care Homes or Community Living Arrangements.

2. Adaptations that add to the total square footage of the home are excluded from this benefit except when necessary to complete an adaptation (e.g., in order to improve entrance/egress to a residence or to configure a bathroom to accommodate a wheelchair).

3. Adaptations that are not of direct medical or remedial benefit to the participant, such as carpeting, roof repair, central air conditioning, etc.

4. Adaptations that are made to leased property.

5. Comfort, convenience, or recreational adaptations.

6. Installations or adaptations for alarm systems, chairlifts, elevators, burglar bars, security cameras, personal emergency response systems, deadbolt locks, fences, hot tubs, whirlpool tubs, portable pools and spas, lap pools, and indoor ceiling lift systems.

7. 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 NOW, Chapter 900.

8. 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.
Rev 01 2013

2008 Basis for Reimbursement

A. Lifetime maximum is $10,400 per participant.

B. Reimbursement Rate: Reimbursement rate for Environmental Accessibility Adaptation is the lower of three price quotes or the lifetime maximum. The reimbursement rates for all specialized services are found in Appendix A.

Limit: 1 Unit = $1.00

2009 Participant-Direction Options

A. Participants may choose the self-direction option with Environmental Accessibility Adaptation.
B. For details on participant-direction, see Part II Policies and Procedures for NOW, Chapter 1200.

PART III – CHAPTER 2100

SPECIFIC PROGRAM REQUIREMENTS
FOR
FINANCIAL SUPPORT SERVICES

SCOPE OF SERVICES

2101 General

Financial Support Services (FSS) are designed to perform fiscal and related finance functions for the participant or representative who elects the participant-direction option for service delivery and supports. FSS assure that the funds to provide services and supports, outlined in the Individual Service Plan (ISP) and to be implemented through a self-directed approach, are managed and distributed as intended.

Financial Support 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 Support Services are mandatory and integral to participant-direction (budget authority).

2102 Special Requirement 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 NOW Program, Financial Support Services providers must meet the following:

1. Provider Qualifications:

a. Be a Fiscal Intermediary Agency;

b. Be approved by the IRS under procedure 70-6 and meet requirements and functions as established by IRS code, Section 3504;

c. Hold and execute Medicaid provider agreements and function as an Organized Health Care Delivery System (OHCDS) or as authorized under a written agreement with the Department of Community Health;

d. Understand the laws and rules that regulate the expenditure of public resources;

e. Have at least two years of basic accounting and payroll experience;

f. Have a surety bond issued by a company authorized to do business in the State of Georgia in an amount equal to or greater than the monetary value of the participants’ business accounts managed but not less than $250,000;

g. Be approved by the IRS (under IRS Revenue Procedure 70-6) and meet requirements and functions as established by the IRS code, section 3504;

h. Not be enrolled to provide any other Medicaid services in the State of Georgia.

2. Service Delivery Requirements:

a. Receive and disburse funds for the payment of participant-directed services under an agreement with the Department of Community Health, the State Medicaid agency.

b. File claims through the Medicaid Management Information System (MMIS) for participant directed goods and services.

c. Utilize accounting systems that operate effectively on a large scale and have the capacity to track individual budgets;

d. Adhere to the timelines for payment that meet the individual participant’s needs within Department of Labor standards;

e. Develop, implement and maintain an effective payroll system that adheres to all related tax obligations for both payment and reporting;

f. Maintain separate, individual accounts for each participant’s funds to be used for participant-directed waiver services;

g. Establish procedures for conducting and paying for up to five (5) local and national criminal background checks, and for completing age verification on service support workers;

h. Establish procedures for generating service management, and statistical information and reports during each payroll cycle;

i. Develop materials for startup training and technical assistance to participants, their representatives, and others as required to include, but not limited to, timesheets and payroll forms.

j. Establish procedures for processing and maintaining all unemployment records;

k. Provide an electronic process for reporting and tracking timesheets and expense reports;

l. Establish procedures to execute and hold the Medicaid provider agreements as authorized under a written agreement with the Department of Community Health, the State Medicaid Agency.

m. Monitor expenditures of individual budgets on a regular basis to ensure that payments to not exceed the total units amount and the total dollar amount allocated for each participant in the participant’s approved budget;

n. Provide all necessary employment and budget forms to Participants (employers) to include but not limited to timesheets, W-2s and a financial orientation package;

o. Provide financial instruction and technical assistance to Participants (employers);

p. Supply a fax machine to participant or participant’s representative upon enrollment.

2103 Licensure

Provider agencies that render Financial Support Services must hold the applicable business license as required by the local, city, or county government in which the services are provided.

2104 Special Eligibility Conditions

A. Only participants who opt for participant-direction of services are eligible to receive Financial Support Services.

B. The need for Financial Support Services must be reflected in the Individual Service Plan approved by the Intake and Evaluation Team.

C. Financial Support Services are not available to participants or representatives who choose the Co-Employer model for self-directed services and supports.

2105 Prior Approval

Financial Support 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 revisions.

2106 Covered Services

Based on the assessed need of the participant and as specified in the approved ISP, the Financial Support Services Provider:

1. Conducts and pays for criminal background checks (local and national) and completes age verification on service support workers.
2. Receives and disburses funds for payment of participant-directed services, in accordance with all related tax obligations, unemployment records, and worker compensation on earned income.
3. Generates service management, statistical information, and reports during each payroll cycle.
4. Provides startup training and technical assistance to participants, their representatives, and others as required.
5. Process and maintain all unemployment records.

2107 Non-Covered Services

1. Supplies and maintenance for fax machine.

2. The FSS provider can only provide Financial Support Services and must not be enrolled to provide any other Medicaid services in Georgia.

3. Financial Support Services are not available to participants or representatives who choose the Co-Employer model for self-directed services and supports.

4. 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.
Rev 01 2013

2108 Basis for Reimbursement

A. One unit per month per member.

B. Reimbursement Rate
The reimbursement rate for Financial Support Services is found in Appendix A.

2109 Participant-Direction Options

A. Financial Support Services is a mandatory and non-negotiable for participants who choose the participant-directed option for service delivery.

B. When the participant is the employer of record, the FSS provider is the Internal Revenue Service approved Fiscal Employer Agent (FEA).

C. For details on participant-direction, see Part II Policies and Procedures for NOW, Chapter 1200.

PART III – CHAPTER 2200

SPECIFIC PROGRAM REQUIREMENTS
FOR
INDIVIDUAL DIRECTED GOODS AND SERVICES

SCOPE OF SERVICES

2201 General

Individual Directed Goods and Services are goods and services not otherwise provided through the NOW or the Medicaid State Plan but are identified by the waiver participant/representative who opts for participant direction and the Support Coordinator or interdisciplinary team. These services are available only for participants who choose the participant-direction option for service delivery. Individual Directed Goods and Services must be clearly linked to an assessed need of the individual participant due to his or her disability and be documented in the participant’s Individual Service Plan.

Individual Directed Goods and Services are purchased from the participant-directed budget and cover services that include improving and maintaining the participant’s opportunities for full membership in the community. Goods and services purchased under this coverage may not circumvent other restrictions on NOW services, including the prohibition against claiming for the costs of room and board. Individual Directed Goods and Services must be authorized by the operating agency prior to service delivery.

The Individual Directed Goods and Services must:

. Decrease the need for other Medicaid services; AND

. Not be available through another source, including the participant not having the funds to purchase the item or service; AND

. Promote inclusion in the community; OR

. Increase the participant’s safety in the home environment;

The participant/representative must submit a request to the Support Coordinator for the goods or service to be purchased that includes the supplier/vendor name and identifying information and the cost of the service/goods. A paid invoice or receipt that provides clear evidence
of the purchase must be on file in the participant’s records to support all goods and services purchased. Authorization for these services requires Support Coordinator documentation that specifies how the Individual Directed Goods and Services meet the above-specified criteria for these services. Participants receiving flexible support coordination are required to follow these same procedures.

2202 Special Requirements of Participation

2202.1 Individual Provider

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 NOW Program, Individual Directed Goods and Services providers must meet the following requirements:

1. Individual Providers of Individual Directed Goods and Services must:

a. Must be 18 years or older;

b. Have a minimum of a high school diploma or GED Equivalent;

c. Must have two years of professional work experience in the area of purchasing or related experience; OR

d. Have an applicable business license for goods provided.

2. Authorization Documentation: The vendor for Individual Directed Goods and Services assures receipt of a copy of the required Support Coordinator documentation for authorization of these services prior to service provision.

3. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for individual providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

4. Documentation of Services and Goods Purchased: A paid invoice or receipt that provides clear evidence of the purchase
must be on file in the participant’s records to support all goods and services purchased.

2202.2 Provider Agencies

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 NOW Program, Individual Directed Goods and Services provider agencies must meet the following requirements:

1. Agency Providers of Individual Directed Goods and Services must:

a. Have employees providing services that meet the above requirements for individual providers; OR

b. Have an applicable business license for goods provided.

2. Authorization Documentation: The agency vendor for Individual Directed Goods and Services assures receipt of a copy of the required Support Coordinator documentation for authorization of these services prior to service provision.

3. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

4. Documentation of Services and Goods Purchased: A paid invoice or receipt that provides clear evidence of the purchase must be on file in the participant’s records to support all goods and services purchased.

2203 Licensure

Individual Directed Goods and Services are provided by vendors with the applicable Georgia business license as required by the local, city or county government in which the services are provided.

2204 Special Eligibility Conditions

A. Individual Directed Goods and Services are only for participants who opt for participant-direction.

B. The specific goods and services provided under Individual Directed Goods and Services must be clearly linked to an assessed need of the individual participant due to his or her disability and be documented in the participant’s Intake and Evaluation approved Individual Service Plan (ISP).

C. The participant/representative must submit a request to the Support Coordinator for the goods or service to be purchased that will include the supplier/vendor name and identifying information and the cost of the service/goods.

2205 Prior Approval

1. Authorization for these services requires Support Coordinator documentation that specifies how the Individual Directed Goods and Services meet the requirements for purchase of this coverage specified below:
a) The goods or services are not covered through the NOW Program or Medicaid State Plan; AND

b) The participant does not have the funds to purchase the item or service or the item or service is not available through another source; AND

c) The item or service would decrease the need for other Medicaid services; AND

d) Promote inclusion in the community; OR

e) Increase the participant’s safety in the home environment.

2. The Support Coordinator provides a copy of the above documentation to the vendor prior to service provision.
3. The above authorization procedures for the Support Coordinator must be followed for participants receiving flexible support coordination.
4. Individual Directed Goods and Services must be authorized prior to service delivery by the applicable DBHDD Regional Office at least annually in conjunction with the ISP development and any ISP revisions.

2206 Covered Services

Reimbursable Individual Directed Goods and Services include the following based on the assessed need of the participant and as specified in the approved ISP:
Rev 07 2010

1. Goods that specifically relate to the participant’s needs due to his or her disability and are not otherwise provided through the NOW or the Medicaid State Plan.

2. Services that specifically relate to the participant’s needs due to his or her disability and are not otherwise provided through the NOW or the Medicaid State Plan.

2207 Non-Covered Services

1. Services or goods not related to the needs of the individual participant due to his or her disability.

2. Experimental or prohibited treatments.

3. Costs for room and board and other restrictions on NOW services.

4. Services otherwise provided through the NOW or the Medicaid State Plan, including additional units or costs beyond the maximum allowable for any NOW or Medicaid State Plan service.

5. Items denied through the Durable Medical Equipment and other Medicaid State Plan programs due to the lack of medical necessity.

6. Educational services otherwise available through a program funded under 20 USC Chapter 3, section 1400 of the Individuals Education Act (IDEA), including private school tuition, Applied Behavior Analysis (ABA) in schools, school supplies, tutors, and home schooling activities and supplies.

7. Services that are available under a program funded under section 110 of the Rehabilitation Act of 1973.

8. Incentive payments, subsidies, or unrelated vocational training expenses.

9. Supervisory activities rendered as a normal part of the business setting.

10. Medically related services that are not allowable by State law, rules, and regulations.

11. Admission fees, Memberships, Subscriptions, Donations, or related items.

12. Training paid caregivers.

13. Services in a hospital.

14. Any item listed as non-covered for the NOW Specialized Medical Supplies, Specialized Medical Equipment, Vehicle Adaptations, and Environmental Accessibility Adaptation Services.

15. Services reimbursable by any other source.
16. Costs of travel, meals and overnight lodging for families and natural support network members to attend a training event or conference.
17. 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 NOW, Chapter 900.
2208 Basis for Reimbursement

Reimbursement Rate: The reimbursement rate is the lower of three price quotes or the annual maximum. The reimbursement rate for Individual Directed Goods and Services is found in Appendix A.

A. The annual maximum number of units is 20.

B. Annual maximum is $1500.00.

C. Limit: 1 unit = $1.00

2209 Participant-Direction Options

A. Individual Directed Goods and Services are only for participants who opt for the self-direction option.
B. An individual serving as a representative for a waiver participant in self-directed services is not eligible to be a participant-directed provider of Individual Directed Goods and Services.
C. For details on participant-direction, see Part II Policies and Procedures for NOW, Chapter 1200.

PART III – CHAPTER 2300

SPECIFIC PROGRAM REQUIREMENTS
FOR
NATURAL SUPPORT TRAINING SERVICES

SCOPE OF SERVICES

2301 General

Natural Support Training (NST) Services provide training and education to individuals who provide unpaid support, training, companionship or supervision to participants. For purposes of this service, individual is defined as any person, family member, neighbor, friend, companion, or co-worker who provides uncompensated care, training, guidance, companionship or support to a person served on the waiver. These services must relate to the individual participant’s needs due to his or her disability and tie to a specific goal in the Individual Service Plan. All training for individuals who provide unpaid support to the participant provided through NST Services must be included in the participant’s ISP.

NST Services include individualized training of families and members of the participants’ natural support networks for the acquisition or enhancement of their ability to support the waiver participant. This training consists of instruction about treatment regimens and other services included in the ISP. NST Services comprise training on the use of equipment as specified in the ISP. There services may include updates in training required to maintain the participant safely at home. NST Services encompass the costs of registration and training fees associated with formal instruction in areas relevant to the participant’s disability needs identified in the ISP. These services do not include the costs of travel, meals, and overnight lodging to attend a training event or conference.

NST Services are provided by Developmental Disability Professionals (see Appendix A for definition). These services may be provided in a participant’s own or family home, the Developmental Disability Professional’s office, outpatient clinics, Supported Employment work sites, or other community settings specific to community-based Natural Support Training goals specified in the Individual Service Plan. Natural Support Training Services Providers offer (or arrange when needed) any of the standard services listed in section 2306 – Covered Services that are needed due to the disability of the participants served and specified in the participants’ Individual Service Plans.

2302 Special Requirements of Participation

2302.1 Individual Provider
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 NOW Program, Natural Support Training providers must meet the following requirements:

1. Individual Providers of Natural Support Training Services must meet the requirements for a Developmental Disability Professional (DDP). For definition of DDP, see Part II Policies and Procedures for NOW, Appendix I.

2. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving Natural Support Training 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. Verification of registration and certificate of attendance at any formal training;

f. 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.
Rev 10 2009

3. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for
individual providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

2302.2 Provider Agencies

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 NOW Program, Natural Support Training Services provider agencies must meet the following requirements:

1. Staffing Qualifications and Responsibilities
Rev 01 2013

Provider agencies rendering Natural Support Training Services must have staffing that meets the following 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 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 with the agency must:
. Be a Developmental Disability Professional (DDP) (for definition, see Part II Policies and Procedures for NOW, Appendix I);

. Have responsibility for delivering Natural Support Training 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:

. Providing individualized training to families and members of participants’ natural support networks;

. Providing instruction about treatment regimens and other services included in the participant’s ISP;

. Instructing families and members of participants’ natural support networks on the use of equipment specified in the participant’s ISP;

. Formulating the plan for delivery of Natural Support Training Services;

. Overseeing plans for formal instruction in areas relevant to the participant’s disability needs identified in the ISP.

f. Provider agencies must have available a sufficient number of employees or professionals under contract that meet the DDP definition to provide Natural Support Training Services as specified in the Individual Service Plans of participants served.

g. Provider agencies must assure that employees or professionals under contract providing NST services hold applicable professional licenses as required by Georgia Code Title 43.
2. Agency Policies and Procedures – Each provider agency must develop written policies and procedures to govern the
operations of Natural Support Training services, which follow the Standards for the Division of Mental Health, Developmental Disabilities and Addictive Diseases as stated in Part II Policies and Procedures for NOW.

3. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving Natural Support Training 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.
Rev. 10 2009

4. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

5. DBHDD Contract/LOA and DBHDD Community Service Standards: Providers must adhere to DBHDD Contract/LOA, DBHDD Core Requirements for All Providers and all other applicable DBHDD Standards, including accreditation by a national organization (CARF, JCAHO, The Council, Council on Accreditation) or certification by the DBHDD (see Part II Policies and Procedures for NOW, Chapter 603).

2303 Licensure

The Developmental Disability Professional (DDP) providing NST services must have any applicable professional license as required by Georgia Code Title 43, for:

1. Psychologist (OCGA 43-39-1); or
2. Physician (OCGA 43-34-20); or
3. Physician Assistant (OCGA 43-34-21); or
4. Advanced Practice or Registered Nurse (OCGA 43-26-3); or
5. Social Worker or Professional Counselor (OCGA 43-10-A-1); or
6. Physical Therapist (OCGA 43-33-1); or
7. Occupational Therapist (OCGA 43-28-1); or
8. Speech and Language Pathologist (OCGA 43-44-1).
2304 Special Eligibility Conditions

The need for NST services must be related to the individual participant’s disability and tied to a specific goal in the Intake and Evaluation Team approved Individual Service Plan (ISP).

2305 Prior Approval

NST services must be authorized prior to service delivery by the applicable DBHDD Regional Office at least annually in conjunction with the ISP development and any ISP revisions.

2306 Covered Services

Reimbursable Natural Support Training Services include the following based on the assessed need of the participant and as specified in the approved ISP:
Rev. 07 2010

1. Individualized, direct training of families and natural support networks for acquisition or enhancement of their ability to support the waiver participant.

2. Instruction about treatment regimens and other services included in the ISP.

3. Training on the use of equipment specified in the ISP.

4. Updates in training required to maintain the participant safely at home.

5. The costs of registration and training fees associated with formal instruction in areas relevant to the individual participant’s needs due to his or her disability and as identified in the ISP.

2307 Non-Covered Services

1. Training paid caregivers.
2. Services reimbursable by any other source.
3. Costs of travel, meals and overnight lodging to attend a training event or conference.
4. Services not related to the needs of the individual participant due to his or her disability.
5. NST Services must not duplicate any family education or training provided through Adult Physical Therapy Services, Adult Occupational Therapy Services, Adult Speech and Language Therapy Services, or Behavioral Supports Consultation Services.
6. NST Services may not occur simultaneously or on the same day as Professional Therapeutic Services or Behavioral Supports Consultation Services.
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.

Rev 01 2013

2308 Basis for Reimbursement

Reimbursement Rate
The reimbursement rate for Natural Support Services is found in Appendix A.

NST Services include the costs of registration and training fees associated with formal instruction only in areas relevant to the individual participant’s needs due to his or her disability and as identified in the Individual Service Plan.

A. Unit of service is 15 minutes.

B. The annual maximum number of units is 86.

C. Annual maximum is $1,787.08.

Self-Directed
1 Unit = $1.00
Annual limit is as authorized in the individual budget up to annual maximum of $1,787.

2309 Participant-Direction Options

A. Participants can choose the self-direction option with Natural Support Training Services.
B. An individual serving as a representative for a waiver participant in self-directed services is not eligible to be a participant-directed provider of Natural Support Training Services.
C. For details on participant-direction, see Part II Policies and Procedures for NOW, Chapter 1200.
PART III – CHAPTER 2400

SPECIFIC PROGRAM REQUIREMENTS
FOR
PREVOCATIONAL SERVICES

SCOPE OF SERVICES

2401 General

Prevocational Services prepare a participant for paid or unpaid employment. These services are for the participant not expected to be able to join the general work force within one year as documented in the Individual Service Plan. If compensated, individuals are paid in accordance with the requirements of Part 525 of the Fair Labor Standards Act.
Rev. 07 2009

Prevocational Services occur in facility-based settings or at community sites outside the facility for small groups of participants, called mobile crews, who travel from the facility to these community sites. Mobile crews receive Prevocational Services by performing tasks, such as cleaning or landscaping, at community sites other than the participant’s home or family home or any residential setting.

The emphasis of Prevocational Services is directed to habilitative rather than explicit employment objectives. These services include teaching participants individual concepts necessary to perform effectively in a job in the community. Activities included in these services are directed at teaching concepts such as rule compliance, attendance, task completion, problem solving, endurance, work speed, work accuracy, increased attention span, motor skills, safety, and appropriate social skills.

The intended outcome of these services is to prepare the participant for paid or unpaid employment through increased skills. Prevocational Services are individually planned to meet the participant’s needs for preparation for paid or unpaid employment. These services are provided either facility-based or at community sites other than the participant’s home or family home or any other residential setting.

Prevocational Services are provided to groups of participants at a facility or to small groups of participants who travel to sites outside the facility, referred to as mobile crews. The staff to participant ratio for facility-based Prevocational Services cannot exceed one (1) to ten (10). The staff to participant ratio for Mobile Crew Prevocational Services cannot exceed one (1) to six (6). Prevocational Services Providers offer (or arrange when needed) any of the standard services
listed in section 2405 – Covered Services that are needed by the participants served and specified in the participants’ Individual Service Plans.

2402 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 NOW Program, Prevocational Services providers must meet the following requirements:

1. Staffing Qualifications and Responsibilities
Rev 01 2012

Provider agencies rendering Prevocational Services must have staffing that meets the following 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 these 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 with the agency must:

. Be a Developmental Disability Professional (DDP) (for definition, see Part II Policies and Procedures for NOW, Chapter 1200, Appendix I);
. Have responsibility for overseeing the delivery of Prevocational 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 Prevocational Services;

. Conducting functional assessments; and

. Supervising high intensity services.

f. A minimum of one (1) direct care staff member for every ten (10) participants served in facility-based Prevocational Services and a minimum of one (1) direct care staff members for every six (6) participants served in Prevocational Services provided as mobile crews;

g. Direct Care Staff must:

. Be 18 years or older;

. Has high school diploma/equivalent (General Educational Development or GED).
Rev. 01 2011

. Meet transportation requirement NOW Part II Chapter 900, Section 905 if transporting participants.
Rev. 01 2009

. Be provided with a basic orientation prior to direct contact with participants and show competence in:

a. The purpose and scope of Prevocational Services, including related policies and procedures;
b. Confidentiality of individual information, both written and spoken;
c. Rights and responsibilities of individuals;
d. 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

h. Duties of the Direct Care Staff include, but are not limited to:

. Provides direct assistance in teaching such concepts as rule compliance, attendance, task completion, problem solving, endurance, work speed, work accuracy, increased attention span, motor skills, and safety to groups of participants;

. Provides direct assistance in training appropriate social interaction skills required in the workplace to groups of participants;

. Implements the behavioral support plans of participants to reduce inappropriate and/or maladaptive behaviors and to acquire alternative adaptive skills and behaviors;

. Provides participant-specific assistance, such as assistance with personal care and self-administration of medications.

i. 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 facility-based or mobile crew Prevocational Services.

j. The type and number of all other staff associated with the organization (such as contract staff, consultants) are:

1) Properly trained or credentialed in the professional field as required;

2) Present in numbers to provide services and supports to participants as required;

3) Experienced and competent in the services and support they provide.

k. 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 Prevocational Services, which follow the Standards for the Georgia Department of Behavioral Health and Developmental Disabilities as stated in Part II Policies and Procedures for NOW.

3. Documentation Requirement: Providers must document the following in the record of each participant receiving Prevocational Services:

. Specific activity, training, or assistance provided;

. Date and the beginning and ending time when the service was provided;

. 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;

. 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.
Rev. 10 2009

4. Prevocational Services and Other Services in the Same Facility:

a. Providers rendering facility-based Prevocational Services and other services (e.g., Community Access Services and adult therapy services) can provide these services in the same facility; however, the services must be documented and billed separately, and any waiver participant receiving multiple services may not receive these services at the same time of the same day.

b. Providers may grant access to other Medicaid providers for the provision of services at the facility; however, the services must
be documented and billed separately, and any waiver participant receiving multiple waiver services may not receive these services at the same time of the same day.

5. Providers must meet the following requirements for staff-to-participant ratios:

a. Facility-Based Prevocational Services: a staff to participant ratio of one to two or more, not to exceed one (1) to ten (10).

b. Mobile Crew Prevocational Services: a staff to participant ratio of one to two or more, not to exceed one (1) to six (6).

c. The staff to participant ratio may be more intense than the upper limit indicated above; the actual ratio must be as indicated by the individualized needs of the participant as indicated on the ISP.
Rev 04 2009

6. DBHDD Contract/LOA and DBHDD Community Service Standards: 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 the DBHDD (see Part II Policies and Procedures for NOW, Chapter 603).

7. Fair Labor Standards Act Requirements: Providers must adhere to the requirements of Part 525 of the Fair Labor Standards Act as follows:

a. Meet all requirements for time rates, piece rates, commensurate wages and fair business practices.

b. Maintain Department of Labor certificates appropriate to the program provided and/or the individual if sub-minimum wage employment is provided.

c. Determine Special Minimum Wage as specified in the Fair Labor Standards Act.
Rev. 04 2009

8. Continuation of Prevocational Services: Effective July 1, 2009, any Individual Service Plan (ISP) for a participant who has a birthdays on or after November 1st, 2009 and has received at least a year (12 months) of Prevocational Services must document the following assessment of necessity and adequacy of the continuation of Prevocational Services for the participant:
Rev. 07 2009

a. Consideration of the following by the support coordinator and interdisciplinary team developing the ISP:

(1) Amount of time receiving Prevocational Services.

(2) Progress on any or all Prevocational Services goals in prior ISP.

(3) Interest of the participant in working.

(4) Any prior receipt of Supported Employment Services.

b. Determination by the support coordinator and interdisciplinary team of continuance or discontinuance of Prevocational Services for the participant based on the above assessment.

c. The provider of Prevocational Services for any participant for whom this section is applicable must maintain a copy of the required documentation in the participant’s record.

9. Physical Environment

Providers who render facility-based Prevocational Services must provide these services in a facility that meets the following requirements:

a. Accessibility: Is accessible to and usable by participants and meets Americans with Disabilities Act (ADA) accessibility requirements for facilities.

b. Building Construction and Maintenance: Is constructed, arranged, and maintained so as to provide adequately for health, safety, access, and wellbeing of the participants.

c. Building Codes: Is in compliance with all local building codes and other applicable codes;

d. Lighting: Provides adequate lighting for participants’ activities and safety;

e. Ventilation: Is adequately ventilated at all times by either mechanical or natural means to provide fresh air and the control of unpleasant odors;

f. Floor Space: Has adequate floor space to safely and comfortably accommodate the number of participants for all activities and services provided in that space;

g. Furnishings: Has sufficient furniture for use by participants, which provide comfort and safety; are appropriate for population served, including any participants with physical, visual, and mobility limitations; and provide adequate seating and table space for participant activities in the facility, including dining if applicable; Is accessible to and usable by participants and meets Americans with Disabilities Act (ADA) accessibility requirements for facilities.

h. Environmental/Sanitation: Is in good repair and clean inside and outside of the facility, including being free from liter, extraneous materials, unsightly or injurious accumulations of items and free from pest and rodents;

i. Temperature Conditions: Has an adequate central heating and cooling system or its equivalent at temperature ranges that are consistent with the individual health needs and comfort of participants:

j. Equipment Maintenance: Maintains all essential mechanical, electrical, and participant activity, care and support equipment in safe operating condition;

k. Drinking Fountain: Must have drinking fountain(s) approved by the Georgia Department of Behavioral Health and Developmental Disabilities, Division of Public Health or provide access to single disposable cups to participants, with participants disposing of the used cups immediately after use;

l. Restrooms: Has a minimum of at least two toilets and lavatories available, with accessibility for individuals with physical and mobility limitations, including installed grab bars;

m. Participant Activities and Dining Space: Has one or more clean, orderly, and appropriate furnished rooms of adequate size designated for participant activities and, if applicable, dining. If the facility has a single room for participant activities and dining, the room provides sufficient space to accommodate both activities without interfering with each other;

n. Medication Storage: Assures that medications are:

1) Stored under lock and key at all times. A staff member may keep medications needed for frequent or emergency use. The provider stores medications that require refrigeration in a locked container in the refrigerator;

2) Kept in original containers with original labels intake or in labeled bubble packs from a pharmacy;

3) Handled in accordance with current applicable State laws and regulations.

o. Documentation of Self-Administration of Medications: The facility maintains documentation of all self-administration of medications supervised by facility staff. The documentation record must include the name of the medication, dosage, date, time, and name of the staff person who assists the participants in the self-administration of medications by the participant.

p. Evacuation Plan: The facility formulates a plan for evacuation of the building in case of fire or disaster. This plan is posted in a clearly visible place in each room. All employees are instructed and kept informed of their duties under the plan.

q. Food Services: The following only apply if the facility stores, prepares, or distributes food:

1) The facility observes and complies with all of the Rules of Georgia Department of Behavioral Health and Developmental Disabilities, Public Health, Chapter 290-5-14, Food Service and any local health ordinances when engaged in the storage, preparation, and distribution of food.
2) Meals and snacks are prepared either on site or under subcontract with an outside vendor who agrees to comply with the food and nutritional requirements. The facility posts its current Food Service Permit and inspection report or the subcontracted vendor’s current Food Service Permit and inspection report.

Note. The Department will allow the facility to be exempted from the Food Service Permit requirement if all the facility does is use a microwave to heat up food participants bring to the facility. This exception is allowed only if:
. The microwave oven is clean, in good repair, and free of unsanitary conditions

. The microwave oven is allowed for warming of permitted foods and beverages based on the provider’s internal policies and procedures.

. All food and utensils are handled in a sanitary manner.
Rev. 01 2009

3) The facility has a designated kitchen area for receiving food, facilities for warming or preparing cold food, and
4) clean–up facilities including hot and cold running water. The facility provides palatable, nutritious and attractive meals and snacks that meet the nutritional requirements of each member.
10. Transportation: The participant’s family or representative may choose to transport the member to the Prevocational Services facility.

11. Individual Site Enrollment: Part I Policies and Procedures for Medicaid/Peachcare for Kids require that each provider enroll at each location where services are provided to Medicaid members. Each individual, facility-based Prevocational Services site must be individually enrolled.
Rev 07 2013

2403 Special Eligibility Conditions

A. Prevocational Services are available only for participants for whom the service is not available under a program funded under section 110 of the Rehabilitation Act of 1973 or the IDEA (20 U.S.C. 1401 et seq.). Documentation is maintained in the file of each participant receiving Prevocational Services that these services are not available through any of these programs.

B. Prevocational Services are for participants not expected to be able to join the general work force within one year as documented in the Individual Service Plan.

C. The need for Prevocational Services must be related to the individual disability; services must be therapeutic in nature; and tied to a specific goal in the Intake and Evaluation Team approved Individual Service Plan (ISP).

2404 Prior Approval

Prevocational Services must be authorized prior to service delivery by the applicable DBHDD Regional Office at least annually in conjunction with the Individual Service Plan (ISP) development and with any ISP revisions.

2405 Covered Services

Reimbursable Prevocational Services include the following based on the assessed need of the participant and as specified in the approved
Rev 07 2010
ISP:

1. Teaching such concepts as rule compliance, attendance, task completion, problem solving, endurance, work speed, work accuracy, increased attention span, motor skills, and safety.
2. Instruction in appropriate social interaction skills required in the workplace.
3. Participant-specific assistance, such as assistance with personal care and self-administration of medications, as identified in the Individual Service Plan.
4. Facility-based training and/or assistance.
5. Mobile crews, which consist of a group of participants who engage in prevocational services by performing tasks, such as cleaning or landscaping, at community sites at sites outside the facility.
6. Transportation is required to and from the facility site (a reasonable amount of transportation, defined as up to one hour per day, is billable).

Rev. 04 2009
Rev 07 2010

2406 Non-Covered Services

1. Prevocational Services are distinct from and do not occur at the same time of day as Community Access or Supported Employment services.

2. Services that are available under a program funded under section 110 of the Rehabilitation Act of 1973 or the IDEA (20 U.S.C. 1401 et seq.).

3. Medically related services that are not allowable by State law, rules, and regulations.

4. Prevocational Services may not be delivered in a participant’s own or family home or any residential site.

5. 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 NOW, Chapter 900.

Rev 01 2013
6. 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.

2407 Basis for Reimbursement

A. A Unit of service is 15 minutes.

B. The daily maximum number of units is 24.

C. The monthly maximum number of units is 504.

D. The annual maximum number of units is 5,760.

E. Transportation provided through these services is included in the cost of doing business and incorporated in the administrative overhead cost.

F. Reimbursement Rate: The reimbursement rate for Prevocational Services is found in Appendix A.

2408 Participant-Direction Options

1. Prevocational Services are not eligible for any participant-direction option.
2. For details on participant-direction, see Part II Policies and Procedures for NOW, Chapter 1200.

PART III – CHAPTER 2500

SPECIFIC PROGRAM REQUIREMENTS
FOR
RESPITE SERVICES

SCOPE OF SERVICES

2501 General
Rev 01 2013

Respite Services provide brief periods of support or relief for caregivers of individuals with disabilities. Respite is provided in the following situations:
1) When families or the usual caretakers are in need of additional support or relief;

2) When the participant needs relief or a break from the caretaker;

3) When a participant is experiencing severe behavioral challenges and needing structured, short-term support;

4) When relief from care giving is necessitated by unavoidable circumstances, such as a family emergency.

Planned or scheduled respite, or Maintenance Respite, provides brief periods of support or relief for caregivers or participants. Respite Services might also be needed to respond to emergency situations. Emergency Respite is intended to be a short- term service for a participant who requires a period of structured support, or when respite services are necessitated by unavoidable circumstances, such as a family emergency. Maintenance Respite and Emergency Respite may be provided In-Home (provider delivers service in participant’s home) or Out-Of-Home (participant receives service outside of their home).

Respite Services may be provided in the participant’s own or family home, or outside the participant’s home in a private residence of a Respite Services provider (i.e., a home that is owned or rented by the provider or an employee of the provider) or in a licensed Personal Care Home, Community Living Arrangement, or Child Caring Institution. Respite Services include short-term services during a day or overnight services. Respite Services Providers offer any of the standard services listed in section 2506 – Covered Services that are needed by the participants served and specified in the participants’ Individual Service Plans.

2502 Special Requirements of Participation

2502.1 In-Home Respite Services Provider
Providers who render Respite Services in the participant’s own or family home must meet the following requirements:

1. Individual Provider of In-Home Respite Services
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 NOW Program, individual providers of in-home Respite Services must meet the following requirements:

a. Individual providers of in-home Respite Services must:

1) Be 18 years or older;

2) Have high school diploma/equivalent (General Education Development or GED)
Rev 01 2011

3) Have current CPR and Basic First Aid certifications;

4) Have the experience, training, education or skills necessary to meet the participant’s needs for Respite Services as demonstrated by;

(i) Direct Support Professional (DSP) Certification; or
Rev. 01 2009
(ii) Copy of high school diploma/transcript or General Education Development (GED diploma; and at least six (6) months of experience providing behavioral health related service to individuals with developmental disabilities, or documented experience providing specific supports to individuals with disabilities.

5) Have evidence of an annual health examination with signed statement from a physician, nurse practitioner, or physician assistant that the person is free of communicable disease;

6) Agree to or provide required documentation of a criminal records check, prior to providing Respite services;

7) Meet transportation requirement in NOW Part II Chapter 900, Section 905 if transporting participants.
Rev. 04 2009

.b. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving Respite Services:

1) Specific activity, training, or assistance provided;

2) Date and the beginning and ending time when the service was provided;

3) Location where the service was delivered;

4) Verification of service delivery, including first and last name and title (if applicable) of the person providing the service and his or her signature;

5) 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.
Rev. 10 2009

c. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for individual providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter
1200.

2. Provider Agencies of In-Home Respite Services

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 NOW
Program and in addition to the staffing requirements for Private Home Care Licensure, provider agencies who render in-home Respite Services must meet the following requirements:

a. Staffing Qualifications and Responsibilities

Rev 01 2013

Provider agencies rendering in-home Respite Services must have staffing that meets the following requirements:

1) 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 these 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

2) 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.

3) At least one agency employee or professional under contract with the agency must:

. Be a Developmental Disability Professional (DDP) (for definition, see Part II Policies

and Procedures for NOW, Appendix I);

. Have responsibility for overseeing the delivery of Respite Services to participants.
4) The same individual may serve as both the agency director and the Developmental Disability Professional;

5) 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 Respite Services;

. Conducting functional assessments; and

. Supervising high intensity services.

6) Direct Care Staff must:

. Be 18 years or older;

Rev. 04 2011
. Has high school diploma/equivalent (General Educational Development or GED)

. Meet transportation requirements in NOW Part II Chapter 900, Section 905 if transporting participants.

. Be provided with a basic orientation prior to direct contact with participants and show competence in:
Rev. 04 2009

i. The purpose and scope of Respite Services, including related policies and procedures;

ii. Confidentiality of individual information, both written and spoken;

iii. Rights and responsibilities of individuals;

iv. Requirements for recognizing and reporting suspected abuse, neglect, or exploitation of any individual:
1. To the DBHDD;

2. Within the organization;

3. To appropriate regulatory or licensing agencies; and

4. To law enforcement agencies
7) Duties of the Direct Care Staff include, but are not limited to:

. Provides participant-specific assistance, such as assistance with activities of daily living and self-administration of medications;

. Provides direct assistance in participants’ participation in community social, recreational and leisure activities;

. Implements the behavioral support plans of participants to reduce inappropriate and/or maladaptive behaviors and to acquire alternative adaptive skills and behaviors.

8) 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 Respite Services.

9) The type and number of all other staff associated with the organization (such as contract staff, consultants) are:

a) Properly trained or credentialed in the professional field as required;

b) Present in numbers to provide services and supports to participants as required;

c) Experienced and competent in the services and support they provide.

10) The agency must assure that participants have access to appropriate provider staff and access to 24 hour emergency services.

11) 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.

b. Agency Policies and Procedures – Each provider agency must develop written policies and procedures to govern the operations of Respite Services, which follow the Standards for the Division of Mental Health, Developmental Disabilities and Addictive Diseases refer to Part II Policies and Procedures for NOW.

c. Documentation Requirement: Providers must document the following in the record of each participant receiving Respite Services:

1) Specific activity, training, or assistance provided;

2) Date and the beginning and ending time when the service was provided;

3) Location where the service was delivered;

4) Verification of service delivery, including first and last name and title (if applicable) of the person providing the service and his or her signature;

5) Progress towards moving the participant towards independence by meeting the participant’s 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.
Rev. 04 2010

d. Participant-Directed Services Documentation Procedures and other Requirements:

Documentation procedures and other requirements for co-employer providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

e. 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 the DBHDD (see Part II Policies and Procedures for NOW, Chapter 603).

2502.2 Out-of-Home Respite Services Provider

Providers who render Respite Services outside the participant’s own or family home must meet the following requirements:

1. Individual Provider of Out-of-Home Respite Services

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 NOW Program, individual providers of out-of-home Respite Services must meet the following requirements:

a. Individual providers of Respite Services must:

1) Be 18 years or older;

2) Have current CPR and Basic First Aid certifications;

3) Have the experience, training, education or skills necessary to meet the participant’s needs for Respite Services as demonstrated;

(i) Direct Support Professional (DSP) Certification or
Rev. 01 2009
(ii) Copy of high school diploma/transcript or General Education Development (GED diploma; and at least six (6) months of experience providing behavioral health related service to individuals with developmental disabilities, or documented experience providing specific supports to individuals with disabilities.

4) Have evidence of an annual health examination with signed statement from a physician, nurse practitioner, or physician assistant that the person is free of communicable disease;

5) Agree to or provide required documentation of a criminal records check, prior to providing Respite services;

6) Meet transportation requirements in the NOW Part II Chapter 900, Section 905 if transporting participants.
Rev. 04 2009
b. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving Respite Services:

1) Specific activity, training, or assistance provided;

2) Date and the beginning and ending time when the service was provided;

3) Location where the service was delivered;

4) Verification of service delivery, including first and last name and title (if applicable) of the person providing the service and his or her signature;

5) 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.
Rev. 10 2009

c. Participant-Directed Services Documentation and other Requirements: Documentation and
other requirements for individual providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

d. Out-of-Home Respite Services Site: Individual providers render out-of-home Respite Services only in the private residence of the provider.

e. Respite Home Capacity Limit: Individual providers and providers of participant-directed services who render out-of-home Respite Services serve no more than one (1) individual in the home
at a time. Exceptions to the private residence capacity limit up to two (2) individuals when serving only individuals under the age of 18 may be granted through the DBHDD, Division of Developmental Disabilities (see Part II Policies and Procedures for NOW, Chapter 607).

f. Overnight Respite Home Physical Standards: With the exception of providers of participant-directed services, individual providers who render out-of-home, Overnight Respite Services must meet the following physical standards of the home:

a) Each home must be located in a residential community not solely inhabited by persons with disabilities.

b) The home must be accessible to the participant served.

c) The home is maintained in a condition to ensure the health and safety of the participant.

d) Hazardous items are not accessible to the participant.

e) Sleeping arrangements, such that

i. Only a bedroom is used as sleeping space for a participant.
ii. No participant under the age of eighteen (18) years sleeps in a room with an adult.
iii. There must be no more than two individuals per bedroom, and these individuals must be the same gender.
g. Overnight Respite Home Site Inspections: With the exception of providers of participant-directed services, individual providers who render out-of-home, Overnight Respite Services must meet the following requirements:

1) Initial Site Inspection: Designated DBHDD Regional Office staff conduct the initial inspection for the above Physical Standards requirements of private residences of an individual provider prior to
Rev. 01 2009
the rendering of Overnight Respite Services and send approval documentation to the DBHDD Regional Coordinator or designee.

2) Re-Inspections of Site: Individual providers who render out-of-home Respite Services must re-inspect semiannually the private residence service site for the above Physical Standards requirements, document the meeting of these requirements, and make available documentation for review by Support Coordinators, and DBHDD and DCH staff.

2. Provider Agencies of Out-of-Home Respite Services

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 NOW Program, provider agencies who render out-of-home Respite Services must meet the following requirements:

a. Staffing Qualifications and Responsibilities

Rev 01 2013

Provider agencies rendering out-of-home Respite Services must have staffing that meets the following requirements in addition to any applicable licensure requirements:

1) 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 these 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

2) 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.

3) At least one agency employee or professional under contract with the agency must:

. Be a Developmental Disability Professional (DDP) (for definition, see Part II Policies and Procedures for NOW, Appendix I);
. Have responsibility for overseeing the delivery of Respite Services to participants.
4) The same individual may serve as both the agency director and the Developmental Disability Professional;

5) 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 Respite Services;

. Conducting functional assessments; and

. Supervising high intensity services.

6) Direct care staff to participant ratio will be based on the individual needs of the participant as specified in the ISP but a minimum of one (1)
direct care staff member for every four (4) participants;

7) Direct Care Staff must:

. Be 18 years or older;

. Has high school diploma/equivalent (General Educational Development or GED)
Rev. 01 2010

. Meet transportation requirements in NOW Part II Chapter 900, 905 if transporting participants.
Rev. 04 2009

. Be provided with a basic orientation prior to direct contact with participants and show competence in:

a) The purpose and scope of Respite Services, including related policies and procedures;

b) Confidentiality of individual information, both written and spoken;

c) Rights and responsibilities of individuals;

d) 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

8) Duties of the Direct Care Staff include, but are not limited to:

. Provides participant-specific assistance, such as assistance with activities of daily living and self-administration of medications;

. Provides direct assistance in participants’ participation in community social, recreational and leisure activities;

. Implements the behavioral support plans of participants to reduce inappropriate and/or maladaptive behaviors and to acquire alternative adaptive skills and behaviors.

9) 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 Respite Services.

10) The type and number of all other staff associated with the organization (such as contract staff, consultants) are:

a) Properly trained or credentialed in the professional field as required;

b) Present in numbers to provide services and supports to participants as required;

c) Experienced and competent in the services and support they provide.

11) The agency must assure that participants have access to appropriate provider staff and access to 24 hour emergency services.

12) 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.

b. Agency Policies and Procedures: Each provider agency must develop written policies and procedures to govern the operations of Respite Services, which follow the Standards for the Georgia Department of Behavioral Health and Developmental Disabilities refer to Part II Policies and Procedures for NOW.

c. Documentation Requirement: Providers, except for co-employer providers of participant-directed services, must document the following in the record
of each participant receiving Respite 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;

Rev. 10 2009
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.

d. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for co-employer providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

e. 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 the DBHDD (see Part II Policies and Procedures for NOW, Chapter 603).

f. Out-of-Home Respite Services Site: Co-employer providers of participant-directed services render out-of-home Respite Services only in the private residence of the provider (i.e., a home owned or rented by the provider or an employee of the provider).

g. Respite Home/Facility Capacity Limit:

1) Respite Services provided in the private residence of a provider serve no more than one (1) individual in the home at a time.

2) Exceptions to the private residence capacity limit up to two (2) individuals when serving only individuals under the age of 18 may be granted through the DBHDD, Division of Developmental Disabilities (see Part II Policies and Procedures for NOW, Chapter 607).

3) Respite Services provided in Personal Care Homes, Community Living Arrangements, and Child Caring Institutions serve no more than a total of four (4) individuals at a time.
Rev 01 2013

h. Respite Services in Personal Care Home or Community Living Arrangement: Respite services in personal care homes and community living arrangements must meet the following requirements:
Rev. 07 2010
Rev 01 2013

. Respite services can only be rendered in personal care homes and community living arrangement in which all residents are adults with intellectual and developmental disabilities.

. Each individual Personal Care Home or Community Living Arrangement site in which Respite services are rendered must be individually enrolled.

i. Overnight Respite Home Physical Standards: With the exception of co-employer providers of participant-directed services, agency providers who provide Overnight Respite Services outside the participant’s home must meet the following physical standards requirements for homes:
Rev 01 2013

. Agency providers who render Respite Services in a Personal Care Home meet the requirements of Section i. of these policies by maintaining licensure (State of Georgia Rules and Regulations111-8-62).

. Agency providers who render Respite Services in a Community living Arrangement meet the requirements of Section i of these policies by maintaining licensure (State of Georgia Rules and Regulations 290-9-37).

. Agency providers who render Respite Services in a Child Caring Institutions meet the requirements of Section i. of these policies by maintaining licensure (State of Georgia Rules and Regulations 290-2-5).

. Provider agencies that render out-of-home Respite Services in foster care settings for participants under the age of 19 years meet the requirements of Section i. of these policies by maintaining a Child Placing Agency License (State of Georgia Rules and Regulations 290-9-2).

. Agency providers who render Respite Services outside the participant’s home in a private residence of the provider must meet the following requirements:

1) Each home must be located in a residential community not solely inhabited by persons with disabilities.

2) The home must be accessible to the participant served.

3) The home is maintained in a condition to ensure the health and safety of the participant.

4) Hazardous items are not accessible to the participant.

5) Sleeping arrangements, such that

a) Only a bedroom is used as sleeping space for a participant.
b) No participant under the age of eighteen (18) years sleeps in a room with an adult.
c) There must be no more than two individuals per bedroom, and these individuals must be the same gender.
j. Overnight Respite Home Site Inspections: With the exception of co-employer providers of participant-directed services and providers rendering Overnight Respite Services in Personal Care Homes, agency providers must meet the following requirements:

1) Initial Site Inspection: Support Coordinators/Planning List Administrators (or other designated DBHDD Regional Office staff) conduct the initial inspection for the above Physical Standards requirements of a private residence of the provider or an employee of the provider prior to the rendering of Overnight Respite Services and send approval documentation to the DBHDD Regional Coordinator or designee.

2) Re-Inspections of Site: Agency providers must re-inspect semiannually private residences of the provider or an employee of the provider for the above Physical Standards requirements, document the meeting of these requirements, and make available documentation for review by Support Coordinators, and DBHDD and DCH staff.

2503 Licensure

A. Provider agencies that render Respite Services in the participant’s own or family home must have a Private Home Care Provider License from the Georgia Department of Community Health , Healthcare Facility Regulation Division (HFR) if providing covered services as required by HFR (State of Georgia Rules and Regulations 290-5-54).

B. Provider agencies that render out-of-home Respite Services in a Personal Care Home must have a Personal Care Home Provider License from the Georgia Department of Community Health , HFR (State of Georgia Rules and Regulations111-8-62).

C. Provider agencies that render out-of-home Respite Services in a Community Living Arrangement must have a Community Living Arrangement License from the Georgia Department of Community Health, HFR (State of Georgia Rules and Regulations 290-9-37).

D. Provider agencies that render out-of-home Respite Services in a Child Caring Institution must have a Child Caring Institution License from the Georgia Department of Human Services, Office of Inspector General, Residential Child Care Section (State of Georgia Rules and Regulations 290-2-5).

E. Provider agencies that render out-of-home Respite Services in foster care setting for participants under the age of 19 years must have a Child Placing Agency License from the Georgia Department of Human Services, Office of Inspector General, Residential Child Care Section (State of Georgia Rules and Regulations 290-9-2).

2504 Special Eligibility Conditions

The need for Respite Services must be reflected in the Intake and Evaluation Team approved Individual Service Plan (ISP).

2505 Prior Approval

Respite Services must be authorized prior to service delivery by the operating agency at least annually in conjunction with the Individual Service Plan development and with any ISP revisions.

2506 Covered Services

Reimbursable Respite Services include the following based on the assessed need of the participant and as specified in the approved ISP:
Rev 07 2010

1. Planned or scheduled respite, or Maintenance Respite, that provides brief periods of support or relief for caregivers or participants (1) when families or the usual caretakers are in

need of additional support or relief; or (2) when the participant needs relief or a break for the caretaker.
2. Short-term Emergency Respite that provides a period of structured support for a participant experiencing severe behavioral challenges or brief periods of support for a participant due to unavoidable circumstances, such as a family emergency.
3. Maintenance Respite and Emergency Respite services are short-term services during a day or overnight services that include but are not limited to:
a. Participant-specific assistance, such as assistance with activities of daily living, self-administration of medications, and health maintenance activities;
b. Direct assistance in participants’ participation in community social, recreational and leisure activities;
c. Implementation of the behavioral support plans of participants to reduce inappropriate and/or maladaptive behaviors and to acquire alternative adaptive skills and behaviors.
2507 Non-Covered Services
Rev 01 2013

1. Services in a personal care home, community living arrangement, or child caring institution serving more than four individuals. .
2. Services in the private residence of a provider serving more than one participant, unless a waiver granted to serve two (2) participants under the age of 18.
3. Services provided in hospitals, ICF/ID facilities, psychiatric facilities, assisted living facilities, and nursing homes.
4. Services in a facility or host home providing residential services through the Comprehensive Supports Waiver (COMP).
5. Services rendered by an individual provider in a licensed Personal Care Home or Community Living Arrangement..
6. Medically related services that are not allowable by State law, rules, and regulations.
7. Services that duplicate or are provided at the same time of the same day as Community Living Support services.
8. 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 NOW, Chapter 900.
9. Non-covered health maintenance activities as defined in Rules and Regulations for Proxy Caregivers Used in Licensed Healthcare Facilities, Chapter 111-8-100.

Rev. 10 2011

10. 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.

Rev 01 2013

2508 Basis for Reimbursement

Reimbursement Rate: Reimbursement rates for Respite services are found in Appendix A.

A. The unit of service is 15 minutes or overnight.

B. Unit Limits:
1. 24 fifteen-minute units per day.

Rev. 10 2011
2. 889 fifteen-minute units per year or 39 overnight units per year.

C. Each overnight billing decreases the annual fifteen-minute maximum by 24 units.

D. Once a participant uses the annual maximum of fifteen-minute units, no additional Respite Services are billable for that participant for the remainder of the fiscal year.

E. $3,744 annual maximum.

Self-Directed and applies to 15 minutes, not overnight Respite
Rev. 07 2014
Respite: 1 unit = $1.00
Annual limit is as authorized in the individual budge up to the annual maximum of $3,744.

2509 Participant-Direction Options

A. Participants can choose the self-direction option with Respite Services.

B. An individual serving as a representative for a waiver participant in self-directed services is not eligible to be a participant-directed provider of Respite Services.

C. For details on participant-direction, see Part II Policies and Procedures for NOW, Chapter 1200.

PART III – CHAPTER 2600

SPECIFIC PROGRAM REQUIREMENTS
FOR
SPECIALIZED MEDICAL EQUIPMENT SERVICES

SCOPE OF SERVICES

2601 General

Specialized Medical Equipment (SME) Services include various devices, controls or appliances which are designed to enable individuals to interact more independently with their environment thus enhancing their quality of life and reducing their dependence on physical support from others. SME services also include assessment or training needed to assist participants with mobility, seating, bathing transferring, security or other skills such as operating a wheelchair, locks, door openers, or side lyers. These services additionally consist of customizing a device to meet a participant’s needs. The NOW is intended for those goods and services that are not covered by the State Medicaid Plan or those instances in which a participant’s needs exceed State Plan coverage limits and exceptions to the coverage limits are not available.

The NOW is the payer of last resource for items that are covered through the Durable Medical Equipment (DME), Orthotics and Prosthetics, and Hearing Services programs and other Medicaid State Plan programs. All items covered through these programs must be requested through the respective programs. Specialized Medical Equipment services must be documented to be the payer of last resource. The DME program prior approval process is used to determine medical necessity for medical equipment. The NOW does not cover items that have been denied through the DME and other programs for lack of medical necessity.

Providers for Specialized Medical Equipment should refer to Part II, Policies and Procedures for Durable Medical Equipment, Part II, Policies and Procedures for Orthotics and Prosthetics and Part III, Hearing Services for additional information about coverage of these services.

2602 Special Requirements of Participation

2602.1 Individual Vendor or Dealer
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 NOW Program, individual vendors and dealers in Specialized Medical Equipment must meet the following requirements:

1. Documentation Requirement: Documentation of administration costs for SME services delivery, that delineates lines item sources of cost; billing of associated administration cost can not exceed eight of ten (8 to 10) percent of original billing for SME services. Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving SME services:
Rev 04 2009

a. The efforts to substantiate payer of last resource, including available community, State Plan, or other resources by the participant’s support coordinator.
b. State Plan denial of coverage documentation received by the DME Program.

Rev. 01 2009

c. Verification of SME service delivery, including date, location, and specific equipment and assessment, training, customizing, or special circumstances repair of equipment provided.
2. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for individual providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

2602.2 Provider Agencies

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 NOW Program, Specialized Medical Equipment Services provider agencies must meet the following requirements:

Rev. 04 2009
1. Documentation Requirement: Documentation of providers, except for providers of participant-directed services, must document the following in the record of each participant receiving SME services:

a. The efforts to substantiate payer of last resource, including available community, State Plan, or other resources by the participant’s support coordinator.
Rev. 04 2009

b. State Plan denial of coverage received by the DME Program.

Rev. 01 2009

c. Verification of SME service delivery, including date, location, and specific equipment and assessment, training, customizing, or special circumstances repair of equipment provided. Documentation of associated administration costs for SME service delivery that delineates line item sources of costs; billing of associated administration costs can not exceed eight of ten (8 to ten) percent of any billing for SME services.

Rev. 04 2009

2. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for individual providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

3. DBHDD Contract/LOA and MHDDD Community Service Standards: Providers must adhere to DBHDD Contract Standards, DBHDD Core Requirements for All Providers and all other applicable DBHDD Standards, including accreditation by a national organization (CARF, JCAHO, The Council, Council on Accreditation) or certification by the DBHDD (see Part II Policies and Procedures for NOW, Chapter 603).

2603 Licensure

Specialized Medical Equipment vendors must hold the applicable Georgia business license as required by the local, city or county government in which the services are provided.

2604 Special Eligibility Conditions

1. The need for SME services must be related to the individual disability and specified in the Health and Safety Section of Intake and Evaluation Team approved Individual Service Plan (ISP).
Rev 10 2009

Rev. 10 2009
2. When a participant only receives specialized services, a specific goal must be in the ISP for any specialized services, which includes SME.

3. Medical necessity for SME services must be documented through an order by a Georgia licensed physician.
Rev. 10 2009

2605 Prior Approval

1. Participant receives recommendation in writing from physician stating a need for SME
Rev. 01 2009

2. Participant takes recommendation in writing to a DME vendor.

a. Support Coordination may assist with locating/accessing an appropriate DME vendor.
3. DME vendor submits a prior approval request to the Department of Community Health using the prior approval process outlined in the policy manual for Durable Medical Equipment, Section 803, found on the web portal at www.mmis.georgia.gov

4. The Department’s contractor approves or denies prior approval based on medical necessity criteria and notifies DME through electronic format of determination.
a. If there is not enough information to make the determination, the Department’s contractor will request additional documentation from the appropriate party.
b. If approved as a State Plan Service, the DME vendor then submits a claim and provides the medically necessary equipment to the participant.
c. If denied for not meeting medical necessity criteria, the waiver will not pay for the SME.
d. If denied for reasons other than medical necessity criteria, the waiver will pay for the SME. Some DME items are allowable but only through the prior approval process described in Chapter 800 of the DME Program Policy Manual. (Section 802 of this chapter reviews which items require prior approval. The following sections of the chapter describe the procedures for obtaining prior approval. Denial of prior approval for these items allows
for billing to the waiver).
e. If the DME vendor is unable to submit a prior authorization or obtain a denial because the medically necessary item is not a State Plan covered item, the provider maintains in the participant record a copy of the DME Policy Manual Section 902, 903, 904, or 905, substantiating the item as non-covered. This documentation will be accepted in lieu of a formal denial for the equipment. With this documentation, the item can be purchased through the waiver

Rev. 04 2010
5. If the waiver will pay for the SME, the SME services must be authorized prior to service delivery by the applicable DBHDD Regional Office agency at least annually in conjunction with the Individual Service Plan development and with any ISP revision.

2606 Covered Services

Reimbursable SME services include the following based on the assessed need of the participant and as specified in the approved ISP:

1. Purchase of equipment or the lease of equipment when cost effective.

2. 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, including costs of assessment or training needed to assist participants with use of devices, controls, or appliances, such as operating a wheelchair, locks, door openers, or side lyers.

3. Computers necessary for operating communication devices, scanning communicators, speech amplifiers, control switches, electronic control units, wheelchairs, locks, door openers, or side lyers.

4. Customizing a device to meet a participant’s needs.

5. Replacement or repair of equipment is covered in cases of special circumstances (e.g., from fire), normal wear and tear, or when the participant’s condition changes.

2607 Non-Covered Services

1. Equipment that has been denied through the DME and other programs for lack of medical necessity.
2. Equipment covered under the Durable Medical Equipment (DME), Orthotics and Prosthetics, and Hearing Services programs and other Medicaid non-waiver programs.
3. Environmental control equipment (e.g., air conditioners, dehumidifiers, air filters or purifiers).
4. Comfort or convenience equipment (e.g., vibrating beds, over-the-bed trays, chair lifts).
5. Institutional-type equipment (e.g., cardiac or breathing monitors).
6. Equipment designed specifically for use by a physician and trained medical personnel (e.g., EKG monitor, oscillating bed and laboratory testing equipment).
7. Physical fitness equipment (e.g., exercise cycle, exercise treadmill).
8. Furnishing-type equipment (e.g., infant cribs).
9. Home security items, (e.g., alarm systems, burglar bars, security cameras, personal emergency response systems and deadbolt locks).
10. Elevators, chair lifts, and indoor ceiling lift systems.
11. Equipment considered experimental or under investigation by the Public Health Service.
12. Equipment associated with experimental medical practices or treatments.
13. Infant and child car seats.
14. Blood pressure monitors and weight scales.
15. Computers, such as desktop and personal computers.
16. Cell phones and minutes.
17. Hot tubs, spas, and whirlpool tubs.
18. Items that add value to a property, such as a fence.
19. Equipment commonly used for recreational purposes, including but not limited to bicycles, trampolines, swimming pools, swing sets, slides, stereos, radios, televisions, and MP3 players.
20. Equipment for education and related services by children for whom the Department of Education has primary responsibility (i.e., private schools, ABA in school, home-schooling, tutors).
21. Equipment replacement or repair that is necessitated by participant neglect, wrongful disposition, intentional misuse or abuse. Equipment will not be replaced due to the participant’s negligence and/or abuse (e.g., a wheelchair left outside). Equipment will not be replaced before its normal life expectancy has been attained unless supporting medical documentation of change in the physical or developmental condition of the participant.
22. Extended warranties and/or maintenance agreement.
23. Payment is not made, directly or indirectly, to members of the individual’s immediate family, except as approved as indicated in Chapter 900.
Rev 01 2013
24. 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.
2608 Basis for Reimbursement

A. Lifetime maximum is $13,474.76 per participant.
B. Annual maximum is $5,200.
C. Reimbursement Rate

The reimbursement rate for the purchase, replacement or repair for Specialized Medical Equipment is the established Medicaid rate, or in the absence of a Medicaid rate, the lower of three price quotes or the annual maximum. Price quotes are not required for purchases, replacements, or repairs under $200.00. The reimbursement rate is inclusive of equipment and any necessary technical assistance in its usage. The reimbursement rates for all specialized services are
found in Appendix A.

2609 Participant-Direction Options

A. Participants may choose the self-direction option with Specialized Medical Equipment Services.

B. If the participant (or representative, if applicable) opts for participant direction of SME services, then this equipment will be purchased through participant-directed service delivery.

C. For details on participant-direction, see Part II Policies and Procedures for NOW, Chapter 1200.
PART III – CHAPTER 2700

SPECIFIC PROGRAM REQUIREMENTS
FOR
SPECIALIZED MEDICAL SUPPLIES SERVICES

SCOPE OF SERVICES

2701 General

Specialized Medical Supplies (SMS) Services include various supplies that enable individuals to interact more independently with their environment and contribute to an enhanced quality of life, as well a reduced dependence on physical support from others. SMS includes items such as food supplements, special clothing, diapers, bed wetting protective chucks, and other supplies that are specified in the approved Individual Service Plan and are not available under the other Medicaid non-waiver programs. Ancillary supplies necessary for the proper functioning of approved devices are also included in this service. The NOW is intended for those goods and services that are not covered by the other Medicaid programs or those instances in which a participant’s needs exceed coverage limits in the other Medicaid programs and exceptions to the coverage limits are not available.
Rev. 04 2010

Medical supplies can be obtained through the waiver if the supplies needed are not offered through the Durable Medical Equipment (DME) program (e.g. diapers and formula for individual 21 or older). When the medical supplies are not covered by the DME program it is not necessary to first submit a request to the DME program before requesting SMS.

The NOW is the payer of last resource for items that are covered through the Durable Medical Equipment (DME), Orthotics and Prosthetics (O&P), and Hearing Services programs and other Medicaid non-waiver programs All items covered through Medicaid non-waiver programs (e.g. dental, DME services, etc.) must be requested through the respective programs. Certain DME and other specialized medical supplies services may require prior approval through the related Medicaid Program. If the specialized medical supplies services are non-covered through the related Medicaid Program, the services being requested through the NOW must be supported by:

. Documentation of NOW as payor of last

. Services not being covered through the other Medicaid programs or documentation evidencing that coverage for the service has been exhausted in the other Medicaid programs
. The need for the services being reflected in the Intake and Evaluation Team approved Individual Service Plan (ISP)

The NOW does not cover items that have been denied through the DME or other Medicaid programs for lack of medical necessity. Supplies requested through the State DME program must comply with the guidelines outlined in Chapter 700 & 900 of Part II Policies and Procedures of Durable Medical Equipment.

For specific benefit coverage and limitations, providers of DME or other specialized medical supplies and services should refer to Part II, Policies and Procedures for Durable Medical Equipment (DME), Part II, Policies and Procedures for Orthotics and Prosthetics (O&P) and Part III, Hearing Services.

2702 Special Requirements of Participation

2702.1 Individual Vendor or Dealer
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 NOW Program, individual vendors and dealers in Specialized Medical Supplies must meet the following requirements:

1. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving SMS services:

a. The efforts to substantiate payer of last resource, including available community, State Plan, or other resources by the participant’s support coordinator.

b. State Plan denial of coverage documentation received from the DME Program.
Rev. 01 2009

The following items do not require State Plan denial of coverage documentation:

Diapers
Chucks (used to line the bed for incontinent people)
Diaper wipes
Nutritional supplements for adults
Medication not covered by Medicaid
Hearing aides
Eye glasses
Rev. 04 2010
Catheter condoms

c. Verification of SMS service delivery, including date, location, and specific supplies provided.

d. Documentation of associated administration costs for SMS service delivery that delineates line item sources of costs; billing of associated administration costs can not exceed eight to ten (8 to 10) percent of any billing for Specialized Medical Supplies.
Rev. 07 2009
Rev 07 2010

2. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for individual providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

3. Transfer of Specialized Medical Supplies with Transition to New Provider: Specialized Medical Supplies billed for a participant must transfer with the participant when the participant transitions to a new waiver provider of SMS services (e.g., SMS purchased in bulk for the participant for the entire quarter or year). This transfer of SMS includes all Specialized Medical Supplies billed for the participant but not yet provided to or used by the participant.

2702.2 Provider Agencies

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 NOW Program, Specialized Medical Supplies Services provider agencies must meet the following requirements:

1. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving SMS services:

a. The efforts to substantiate payer of last resource, including available community, State Plan, or other resources by the participant’s support coordinator.

b. State Plan denial of coverage documentation received from the DME Program.
Rev. 01 2009

The following items do not require State Plan denial of coverage documentation:

Diapers
Chucks (used to line the bed for incontinent people)
Diaper wipes
Nutritional supplements for adults
Medication not covered by Medicaid
Hearing aides
Eye glasses
Catheter condoms
Rev. 04 2010

c. Verification of SMS service delivery, including date, location, and specific supplies provided.

d. Documentation of associated administration costs for SMS service delivery that delineates line item sources of costs; billing of associated administration costs can not exceed eight to ten (8 to 10) percent of any billing for SMS services.

2. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for individual providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 900.

3. DBHDD Contract/LOA and MHDDD Community Service Standards: Providers must adhere to DBHDD Contract Standards, DBHDD Core Requirements for All Providers and all other applicable DBHDD Standards, including accreditation by a national organization (CARF, JCAHO, The Council, Council on Accreditation) or certification by the DBHDD (see Part II Policies and Procedures for NOW, Chapter 603).

4. Transfer of Specialized Medical Supplies with Transition to New Provider: Specialized Medical Supplies billed for a participant must transfer with the participant when the participant transitions to a new waiver provider of SMS services (e.g., SMS purchased in bulk for the participant for the entire quarter or year). This transfer of SMS includes all Specialized Medical Supplies billed for the participant but not yet provided to or used by the participant.
2703 Licensure

Specialized Medical Supplies vendors must hold the applicable Georgia business license as required by the local, city or county government in which the services are provided.

2704 Special Eligibility Conditions

1. The need for SMS services must be related to the individual disability and specified in the Health and Safety Section of the Intake and Evaluation Team approved Individual Service Plan (ISP).

2. When a participant only receives specialized services, a specific goal must be in the ISP for any specialized services, which includes SMS.
Rev. 10 2009
Rev. 10 2009

Rev. 10 2009
3. Medical necessity for SMS services must be documented through an order by a Georgia licensed physician, except for incontinent supplies which are approved by the Level of Care Nurse in the review of the ISP.

2705 Prior Approval

Rev. 01 2009
Rev. 04 2010
1. Participant receives recommendation in writing from physician stating a need for SMS, except for incontinent supplies which are approved by the Level of Care Nurse in the review of the ISP as indicated in Section 2704.

2. Participant takes recommendation in writing to a DME vendor unless DME Program prior approval is not required as indicated in Item 6 below.
Rev. 01 2009
Rev. 04 2010
a. Support Coordination may assist with locating/accessing an appropriate DME vendor

3. DME vendor submits a prior approval request to Department of Community Health using the prior approval process outlined in the policy manual for Durable medical Equipment, Section 803, found on the web portal at www.mmis.georgia.gov.
Rev. 04 2010

4. The Department’s contractor approves or denies prior approval based on medical necessity criteria and notifies DME through electronic format of determination.

a. If there is not enough information to make the determination, the Department’s contractor will request additional documentation from the appropriate party.
b. If approved as a State Plan Service, the DME vendor then submits a claim and provides the medically necessary supplies to the participant.

c. If denied for not meeting medical necessity criteria, the waiver will not pay for the SMS.

d. If denied for reasons other than medical necessity criteria, the waiver will pay for the SMS. Some DME items are allowable but only through the prior approval process described in Chapter 800 of the DME Program Policy Manual. Section 802 of this chapter reviews which items require prior approval. The following sections of the chapter describe the procedures for obtaining prior approval. Denial of prior approval for these items allows for the billing of the waiver.

e. If the DME vendor is unable to submit a prior authorization or obtain a denial because the medically necessary item is not a State Plan covered item, the provider maintains in the participant record a copy of the DME Policy Manual Section 902, 903, 904, or 905, substantiating the item as non-covered. This documentation will be accepted in lieu of a formal denial for the supplies. With this documentation, the item can be purchased through the waiver.

5. If the waiver will pay for the SMS, the SMS services must be authorized prior to service delivery by the applicable DBHDD Regional Office agency at least annually in conjunction with the Individual Service Plan development and with any ISP revision.
Rev. 04 2010

Rev. 04 2010
Rev. 01 2011
6. Prior approval through the DME Program will not be required for items listed above in 2701.1 (1b) and 2702.1 (1b).

2706 Covered Services

Reimbursable SMS services include the following based on the assessed need of the participant and as specified in the approved ISP:

1. Specialized Medical Supplies are various supplies, which enable individuals to interact more independently with their environment thus enhancing their quality of life and reducing their dependence on physical support from others.
2. Nutritional supplements, such as Ensure, Isomil, and Boost, for participants 21 years of age or older.

3. Nutritional supplements, such as Ensure, Isomil, and Boost, for participants under the age of 21 years only if State Plan coverage is exhausted.
4. Special clothing, such as specially designed vests to assist with wheelchair transfers and re-positioning, adaptive clothing for individuals with limited mobility, clothing designed with G-tube access openings, and other easy access clothing specifically designed for individuals with disabilities.
5. Diapers, bed wetting protective chucks, and other incontinent supplies.
6. Other supplies with documented medical necessity that are related to the participant’s disability, such as supplies for ongoing medical or nursing care of the participant.
7. Ancillary supplies necessary for the proper functioning of approved devices are also included in this service.
8. Infection control supplies, such as non-sterile gloves, aprons, masks and gowns, when services are provided by an individual. Supplies used by agencies are customarily included in the agency’s reimbursement rate for services. However, when supplies are required in quantity, for recurring need and are included in the ISP for a specific participant, these supplies would be considered as a separate billable item under this program. Supplies that are considered as separate billable items must meet the following criteria:
a. The supply is directly identifiable to an individual participant.
b. The item furnished at the direction of the participant’s physician and is specifically identified in the ISP.
9. Over-the-counter (OTC) medications when prescribed by a physician and related to a diagnosed condition.

Rev 10 2013

10. Medications not covered by the Medicaid State Plan when written documentation from the pharmacy for non-coverage of the medication through the State Medicaid Plan is in the participant’s record.
Rev 10 2013

2707 Non-Covered Services

1. Items covered under the Durable Medical Equipment (DME), Orthotics and Prosthetics, and Hearing Services programs and other Medicaid non-waiver programs.

2. Items that have been denied through the DME and other programs for lack of medical necessity.

3. Environmental control items (e.g., air conditioners, dehumidifiers, air filters or purifiers).
4. Comfort or convenience items.

5 Physical fitness items (e.g., exercise cycle, exercise treadmill).

6. Supplies considered experimental.

7. Experimental medicines, practices, or treatments.

8. Infant and child car seats.

9. Blood pressure monitors and weight scales.

10. Computer supplies (printers, cartridges, speakers and other supplies).

11. Cell phones and minutes.

12. Ancillary supplies for the proper functioning of non-approved devices or equipment.

13. Supplies for education and related services by children for whom the Department of Education has primary responsibility (i.e., private schools, ABA in school, home-schooling, tutors).

Rev. 10 2011
Rev. 10 2013
14. Vitamins, herbal supplement, nutritional oils, and other non-nutritional supplements are not covered except when prescribed by a physician and related to a diagnosed condition.

15. 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 NOW, Chapter 900.

16. 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.
Rev. 10 2013
17. Medications covered by the Medicaid State Plan are not allowed.

Rev. 10 2013
18. Co-pays for medications.

2708 Basis for Reimbursement

A. $1,734.48 annual maximum.

B. Reimbursement Rate

Reimbursement rate for Specialized Medical Supplies is participant specific up to the annual maximum. The reimbursement rates for all specialized services are found in Appendix A.

2709 Participant-Direction Options

A. Participants may choose the self-direction option with Specialized Medical Supplies Services.

B. If the participant (or representative, if applicable) opts for participant direction of SMS services, then these supplies will be purchased through participant-directed service delivery.

For details on participant-direction, see Part II Policies and Procedures for NOW, Chapter 1200.
PART III – CHAPTER 2800

SPECIFIC PROGRAM REQUIREMENTS
FOR
SUPPORT COORDINATION SERVICES

SCOPE OF SERVICES

2801 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 2805 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 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.

2802 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 NOW 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 aging population, and demonstrate success in supporting individuals in community inclusion and person centered planning;
Rev 10 2013

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;
Rev 10 2013

c. Have experience and demonstrated success with outcome based planning, and developing plans based on the individual’s goals, choices and direction;
Rev 10 2013

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;

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:

Be a Developmental Disability Professional (DDP) (for definition, see Part II Policies and Procedures for NOW, Appendix I);

. 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;

. 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 are addressed; and
Rev. 01 2009

. 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 2805.

j. The agency has adequate Support Coordinator staffing to provide the covered services in 2805 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, serving as the primary liaison to the DBHDD Regional Office 24 hours a day, 7 days a week.
Rev. 01 2009

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 DBHDD Division of Developmental Disabilities staff.

4. Assessment and Individual Service Plan Requirements
Rev 07 2013

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 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 Disease, 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 Screenings Tool must be reviewed by the Support Coordinator and DBHDD Regional clinical staff within 120 days prior to the expiration of an existing exceptional rate in order to validate continued need for an exceptional rate.
Rev 01 2015

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 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.
Rev. 01 2009
Rev. 07 2010

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;

Rev. 10 2009
. 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:

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 contacts:
Rev. 10 2010
Rev 04 2011

. Person has an exceptional rate for Community Access Group. Visits are made monthly to day program, in addition to other requirements.
Rev. 10 2010
Rev 04 2011

. Person has had 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 Coordination may go back to regularly scheduled visits.
Rev 10 2010
Rev 10 2010
Rev. 01 2011
Rev 04 2011

. Person is on the NOW waiver and a parent has requested more than quarterly visit or phone contacts: visits need to be made more frequently based on participant’s needs.
Rev. 01 2010
Rev. 04 2011

7. Monitoring Requirements

Support Coordination Providers must meet the following monitoring requirements:

a. Support Coordinators complete the monitoring report for each required face-to-face contact and provide a summary rating of the services provided according to the following scale:

Rev. 04 2009

. 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;

Rev. 01 2009

8. Incident Reporting Requirements: In addition to the incident reporting requirements for all providers specified in Part II Policies and Procedures for NOW,, 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.

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.
Rev. 01 2009

10. Reporting Requirements
Rev. 01 2009

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.
Rev. 01 2009

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 NOW).
Rev. 01 2009

2803 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.
Rev. 01 2009

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.

2804 Prior Approval

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.

2805 Covered Services
Rev 07 2013

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

a) 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.
b) 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.
c) Coordinating and facilitating ISP development among both professionals and non-professionals who provide individualized supports.
d) Documenting action plans or ISP team discussion on record addressing issues of conflict between preferences and issues of health and safety.
e) Request additional services for a participant due to the following circumstances, including but not limited to, emergency services are required to address changes 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).

Rev 07 2013

3. Referral and Related Activities

a) Assisting each participant in coordinating all services, whether Medicaid reimbursed services or services provided by other funding sources.

b) Linking the participant to needed services to address identified needs and to achieve goals specified in the ISP.

c) Providing information and assistance that help the participant and his or her family or representative in making informed decisions about the participant-direction option.

d) Assisting each participant who opts for participant-direction with enrollment in this option.

4. Monitoring and Follow-up Activities

a) Contacting participants based on individual needs and service mix as specified in the ISP.

b) Contacting participants as needed to address any identified health and safety risks and/or identified issues with the service provider.

c) Contacting the participant’s family or representative by phone.

d) 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.

e) Contacting the participant’s service providers.

f) 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.

g) Reviewing the quality and outcome of services.

h) Evaluation of the satisfaction of participants and their families with the ISP and its implementation.

2806 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 NOW, 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.

Rev 01 2015

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.

2807 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.

2808 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 NOW, Chapter 1200.

PART III – CHAPTER 2900

SPECIFIC PROGRAM REQUIREMENTS
FOR
SUPPORTED EMPLOYMENT SERVICES

SCOPE OF SERVICES

2901 General

Supported Employment services are ongoing supports that enable participants, for whom competitive employment at or above the minimum wage is unlikely absent the provision of supports, and who, because of their disabilities, need supports, to perform in a regular work setting. Supported Employment services are conducted in a variety of settings, particularly work sites where persons without disabilities are employed. The scope and intensity of Supported Employment supports may change over time, based on the needs of the participant. Supported Employment services are conducted in a variety of settings, particularly work sites where persons without disabilities are employed participants who receive Supported Employment services must require long-term, direct or indirect job-related support in job supervision, adapting equipment, adapting behaviors, transportation assistance, peer support, and/or personal care assistance during the work day. Supported Employment services consist of activities needed to obtain and sustain paid work by participants, including job location, job development, supervision, training, and services and supports that assist participants in achieving self-employment through the operation of a business, including helping the participant identify potential business opportunities, assisting in the development of a business plan, identifying the supports that are necessary for the participant to operate a business, and ongoing assistance, counseling and guidance once the business has been launched. These services do not include the supervisory activities rendered as a normal part of the business setting.
Rev. 07 2011

The planned outcomes of these services are to increase the hours worked by each participant toward the goal of forty hours per week and to increase the wages of each participant toward the goal of increased financial independence. Supported Employment services are based on the individual participant’s needs, preferences, and informed choice. These services allow for flexibility in the amount of support a participant receives over time and as needed in various work sites.

Supported Employment Group services are provided to groups of participants, with a staff to participant ratio of one to two or more. The staff to participant ratio for Supported Employment Group services cannot exceed one (1) to ten (10). Supported Employment Individual services are provided to an individual participant, with a one-to-one staff to participant ratio. Supported Employment Services Providers offer (or arrange when needed) any of the standard services listed in section 2905 – Covered Services that are needed by the participants served and specified in the participants’ Individual Service Plans.

2902 Special Requirements of Participation

2902.1 Individual Provider
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 NOW Program, Supported Employment Services providers must meet the following requirements:

1. Individual providers of Supported Employment services must meet the following requirements for Supported Employment Specialists:

a. Be 18 years or older;

b. Have current CPR and Basic First Aid certifications;

c. Have the experience, training, education or skills necessary to meet the participant’s needs for Supported Employment services as demonstrated by:

(1) Direct Support Professional (DSP) certification, and at least six (6) months of experience in supported employment of individuals with disabilities; or

(2) Copy of high school diploma/transcript or General Education Development (GED) diploma and at least six (6) months of experience in supported employment of individuals with disabilities and fifteen (15) hours of training in providing supported employment of individuals with disabilities; or high school diploma or GED and one (1) year experience in providing supported employment to individuals with disabilities;
Rev. 01 2009
or documented experience providing specific supports to individuals with disabilities related to the supported employment of those individuals.

2. Agree to or provide required documentation of a criminal records check prior to providing Supported Employment services.

3. Meet transportation requirements in NOW Part II Chapter 900, Section 905 if transporting participants.
Rev. 04 2009

2. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving Supported Employment 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;

Rev. 10 2009
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.

3. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for individual providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

2902.2 Provider Agencies

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 NOW Program, Supported Employment Services provider agencies must meet the following requirements:

1. Staffing Qualifications and Responsibilities

Rev 01 2013

Provider agencies rendering Supported Employment Services must have staffing that meets the following 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 these 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 with the agency must:

1. Be a Developmental Disability Professional (DDP) (for definition, see Part II Policies and Procedures for NOW, Appendix I);

2. Have responsibility for overseeing the delivery of Supported Employment 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 Supported Employment Services;

. Conducting functional assessments; and

. Supervising high intensity services.

f. Must have a minimum of one (1) employee that meets the Supported Employment Specialist experience, training, education or skills qualifications specified above for Individual Providers for every five (5) direct care staff members.

g. Duties of the Supported Employment Specialist include, but are not limited to:

1) Provides direct supervision of Direct Care Staff in their performance of Supported Employment services for participants;

2) Develops, acquires, and maintains work opportunities for participants;

3) Conducts necessary additional assessments at the work site;

4) Helps participants choose appropriate jobs or a specific employment option;

5) Applies training techniques which enhance the social and vocational functioning of participants;

6) Monitors wages, hours, and productivity of participants on an ongoing basis;

7) Assists the participant, if applicable, in achieving self-employment through the operation of a business by:

i. Aiding the participant to identify potential business opportunities;
ii. Assisting in the development of a business plan, including potential sources of business financing and other assistance in developing and launching a business;
iii. Identifying the supports that are necessary for the participant to operate a business;
iv. Providing ongoing assistance, counseling and guidance once the business has been launched.
h. A minimum of one (1) direct care staff member or Supported Employment Specialist for every ten (10) participants served in Group Supported Employment Services and minimum of one (1) direct care staff member or Supported Employment Specialist for every one (1) participant served in Individual Supported Employment Services;

i. Direct Care Staff must:

. Be 18 years or older;

. Has high school diploma/equivalent (General Educational Development or GED)
Rev. 01 2011

. Meet transportation requirements in NOW Part II Chapter 900, Section 905 if transporting participants.
Rev. 04 2009

. Be provided with a basic orientation prior to direct contact with participants and show competence in:

1) The purpose and scope of Supported Employment Services, including related policies and procedures;
2) Confidentiality of individual information, both written and spoken;
3) Rights and responsibilities of individuals;
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

j. Duties of the Direct Care Staff include, but are not limited to:

. Provides direct assistance in activities needed for the individual participant or a group of participants to sustain work, including job coaching, supervision and training;

. Provides direct assistance in training, retraining or improving the social and vocational functioning of the individual participant worker or groups of participant workers;

. Implements the behavioral support plans of participants to reduce inappropriate and/or maladaptive behaviors and to acquire alternative adaptive skills and behaviors;

. Provides active support and direct assistance in facilitating natural supports at the work site;

. Provides other support services at or away from the work site, such as transportation and personal assistance services.

k. The type and number of all other staff associated with the organization (such as contract staff, consultants) are:

1) Properly trained or credentialed in the professional field as required;

2) Present in numbers to provide services and supports to participants as required;
3) Experienced and competent in the services and support they provide.

l. 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 Supported Employment services, which follow the Standards for the Georgia Department of Behavioral Health and Developmental Disabilities refer to Part II Policies and Procedures for NOW.

3. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving Supported Employment Services:

. Specific activity, training, or assistance provided;

. Date and the beginning and ending time when the service was provided;

. 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;

. 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.
Rev. 10 2009

4. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

5. Providers must meet the following requirements for staff-to-participant ratios:

a. Group Supported Employment Services: a staff to participant ratio of one to two or more, not to exceed one (1) to ten (10).
b. Individual Supported Employment Services: a one-to-one staff to participant ratio.
6. Providers must develop and plan Supported Employment services and supports:

a. Based on the individual participant’s needs, preferences, and informed choice;

b. To allow for flexibility in the amount of support a participant receives over time and as needed in various work sites;

c. With attention to the health and safety of the participant;

d. In accordance with the Fair Labor Standards Act, if applicable, to include documentation of sub-minimum wage;

e. With planned outcomes, which include:

1) Increases in hours worked by each participant toward the goal of 40 hours per week;
2) Frequent opportunities for each participant to interact with non-disabled peers during the normal performance of the job and/or during breaks, lunch periods, or travel to and from work;
3) Increases in wages of each participant toward the goal of increased financial independence.
7. 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 the DBHDD (see Part II Policies and Procedures for NOW, Chapter 603).
2903 Special Eligibility Conditions

A. Supported Employment Services are available only for participants for whom the service is not available under a program funded under section 110 of the Rehabilitation Act of 1973 or the IDEA (20 U.S.C. 1401 et seq.). Documentation is maintained in the file of each participant receiving Supported Employment Services that these services are not available through any of these programs.
B. The need for Supported Employment Services must be related to the individual disability and tied to a specific goal in the Intake and Evaluation Team approved Individual Service Plan (ISP).

2904 Prior Approval

Supported Employment Services must be authorized prior to service delivery by the operating agency at least annually in conjunction with the Individual Service Plan (ISP) development and with any ISP revisions.

2905 Covered Services

Reimbursable Supported Employment Services include the following based on the assessed need of the participant and as specified in the approved ISP:
Rev. 07 2010

1. Assisting the participant to locate a job or develop a job on behalf of the participant.

2. Activities needed to sustain paid work by participants, including supervision and training.

3. Services and supports that assist the participant in achieving self-employment through the operation of a business and may include:

a. Aiding the participant to identify potential business opportunities;
b. Assistance in the development of a business plan, including potential sources of business financing and other assistance in developing and launching a business;
c. Identification of the supports that are necessary for the participant to operate the business; and
d. Ongoing assistance, counseling and guidance once the business has been launched. Payment is not made to defray the expenses associated with starting up or operating a business.
4. Adaptations, supervision, and training required by participants receiving Supported Employment services as a result of their disabilities, when theses services are provided in a work site where persons without disabilities are employed.

5. Transportation of two or more participants to community work sites is provided as specified in the ISP for participant receiving Supported Employment Group services.
Rev 07 2010

Rev 10 2009
6. Job Maintenance activities to maintain a participant in 60 to 80 or more hours of work per month.

2906 Non-Covered Services

1. Incentive payments, subsidies, or unrelated vocational training expenses such as the following:
a. Incentive payments made to an employer to encourage or subsidize the employer’s participation in Supported Employment program;

b. Payments that are passed through to users of Supported Employment programs; or

c. Payments for training that is not directly related to an individual’s Supported Employment program.

2. Supervisory activities rendered as a normal part of the business setting.
3. Supported Employment Services are distinct from and do not occur at the same time of the same day as Community Access, Prevocational or Transportation Services, with the exception of non face-to-face Supported Employment job development. The exception for Supported Employment job development must be documented sufficiently to demonstrate no duplication of services for an individual participant and a service provided in preparation for transition of an individual participant to Supported Employment Services.

Rev. 10 2009

4. Services that are available under a program funded under section 110 of the Rehabilitation Act of 1973 or the IDEA (20 U.S.C. 1401 et seq.).
5. 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 NOW, Chapter 900.
6.Supported Employment Services do not include sheltered work or other similar types of vocational services furnished in specialized facilities, such as service centers for individuals with intellectual/developmental disabilities.
Rev. 07 2011

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.
Rev 01 2013

2907 Basis for Reimbursement

The reimbursement rate for Supported Employment Services is found in Appendix A

Transportation provided through these services is included in the cost of doing business and incorporated in the administrative overhead cost. Separate payment for transportation only occurs when the NOW’s distinct Transportation Services are authorized.

A. A Unit of service is 15 minutes.

B. Supported Employment Individual Limits:

1. 40 fifteen-minute units per day.

2. 1,440 fifteen-minute units per year

C. Supported Employment Group Limits:

1. 320 fifteen-minute units per month.

2. 3,840 fifteen-minute units per year.

D. Supported Employment Job Maintenance

1. Supported Employment Job Maintenance is billed as actual hours worked from 60 hours up to a maximum of 80 hours per month, even if the participant works more than 80 hours.

2. Supported Employment Job Maintenance is billed under Supported Employment Group from 240 units up to a maximum of 320 units per month.

3. Supported Employment Group Services other than Job Maintenance can not be billed in any month in which Supported Employment Job Maintenance is billed.
Rev 10 2009
4. Supported Employment Individual Services can not be billed in any month in which Supported Employment Job Maintenance is billed.

Rev. 07 2014
Self-Directed
Supported Employment Group Limits: 1 unit = $1.00
Annual limit is as authorized in the individual budget up to an annual maximum of $6,912.

Supported Employment Individual Limits: 1 unit = $1.00
Annual limit is authorized in the individual budget up to an annual maximum of $10,454.

2908 Participant-Direction Options

A. Participants can choose the self-direction or co-employer options with Supported Employment Services.

B. An individual serving as a representative for a waiver participant in self-directed services is not eligible to be a participant-directed provider of Supported Employment Services.

C. For details on participant-direction, see Part II Policies and Procedures for NOW, Chapter 1200.

PART III – CHAPTER 3000

SPECIFIC PROGRAM REQUIREMENTS
FOR
TRANSPORTATION SERVICES

SERVICES

3001 General

Transportation Services enable waiver participants to access non-medical services, activities, resources, and organizations typically utilized by the general population. These services are only provided as independent, stand-alone waiver services when transportation is not otherwise included as an element of another waiver service. Transportation services are not intended to replace available formal or informal transit options for participants. Whenever possible, family, neighbors, friends or community agencies, which can provide this service, without charge, are to be utilized. The need for Transportation Services and the unavailability of other resources for transportation must be documented in the Individual Service Plan (ISP).

Transportation Services provide transportation for the participant to waiver services and other community services, activities, resources, and organizations typically utilized by the general population. These services include:

(1) One-way or round trips provided by Georgia licensed drivers and/or DD Service Agencies; and

(2) Transit by commercial carrier available to the community at large.

Transportation Services must not be available under the Medicaid Non-Emergency Transportation Program, State Plan, Individual with Disabilities Education Act (IDEA), or the Rehabilitation Act. These services do not include transit provided through Medicaid non-emergency transportation. Transportation Services are not available to transport an individual to school (through 12th grade). These services do not include transportation that is included as an element of another waiver service as follows:

. Community Living Support Services

. Prevocational Services

. Supported Employment Group Services
. Community Access Group or Individual Services, which entail activities and settings primarily utilized by people with disabilities, such as transportation to and from a Mental Retardation Service Center or other day center.

Transportation Services are only for participants
who do not have formal or informal transit options
available. The type and amount of Transportation
Services provided are specific to the individual
participant and detailed in his or her Individual
Service Plan. Transportation Services providers
offer any of the standard services listed in section
3006—Covered Services that are needed by the
participants served and specified in the participants’
Individual Service Plans.

3002 Special Requirements of Participation

3002.1 Individual Provider
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 NOW Program, Transportation Services providers must meet the following requirements:

1. Transportation Provided: Individual providers rendering Transportation Services provide one-way or round trip transportation for participants.

2. Individual providers of Transportation must:

a. Be 18 years or older;

b. Have a valid, Class C license as defined by the Georgia Department of Driver Services;

c. Have current mandatory insurance;

d. Have no more than two chargeable accidents, moving violations, or any DUI’s in a three (3) year period within
Rev. 04 2009
the last five (5) years of the seven (7) year Motor Vehicle Record (MVR) period;

Rev. 01 2009
NOTE: The Department will allow an exception to Out-of-State Driver’s License and MVP record under the following circumstances: (1) the individuals is on active duty in Georgia; (2) the individual is a college student enrolled at a Georgia college or university; or (3) the individual’s place of residence is a neighboring state on the border of Georgia. For individual to be granted this exception, he or she must:
. Have a valid, Class C license

. Have no convictions for substance abuse, sexual crime or crime of violence for five (5) years prior to providing the service

. Have current, valid insurance

 

e. Have evidence of an annual health examination with signed statement from a physician, nurse practitioner, or physician assistant that the person is free of communicable disease;

f. Agree to or provide required documentation of a criminal records check, prior to providing Transportation Services.

3. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving Transportation Services:

a. Specific type and purpose of transportation provided;

b. Date and the beginning and ending time when the service was provided;

c. Location of origin and that for destination of transportation services;

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.
Rev. 10 2009

4. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for individual providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter1200.

3002.2 Transportation Broker Provider Agencies

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 NOW Program, Transportation Broker Provider Agencies must meet the following requirements:

1. Community Commercial Carrier: Transportation Broker Provider Agencies rendering Transportation Services must provide commercial carrier services to the community at large or broker these services.

2. Agency Policies and Procedures: Each Transportation Broker Provider Agency must develop written policies and procedures to govern the operations of Transportation Services.

3. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving Transportation Services:

a. Specific type and purpose of transportation provided;

b. Date and the beginning and ending time when the service was provided;

c. Location of origin and that for destination of transportation services;

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.
Rev. 10 2009

4. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

5. DBHDD Provider Requirements: Transportation Broker Provider Agencies must adhere to DBHDD Contract/LOA, and any other applicable DBHDD Standards refer to Part II Policies and Procedures for NOW.

3002.3 DD Service Agencies

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 NOW Program, DD Service Agencies rendering Transportation Services must meet the following requirements:

1. Transportation Provided: DD Service Agencies rendering Transportation Services provide one-way or round trip transportation for participants.

2. Staffing Qualifications and Responsibilities
Rev 01 2013

DD Service Provider agencies rendering Transportation Services must have staffing that meets the following 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 these 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 with the agency must:

. Be a Developmental Disability Professional (DDP) (for definition, see Part II Policies and Procedures for NOW, Appendix I);
. Have responsibility for overseeing the delivery of Transportation 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 Transportation Services;
. Conducting functional assessments; and

. Supervising high intensity services.

f. Driver Staff must:

. Be 18 years or older;

. Be legally licensed in the State of Georgia with the class of license appropriate to the vehicle operated as follows:

1) Have a valid, Class C license as defined by the Georgia Department of Driver Services for any single vehicle with a gross vehicle weight rating not in excess of 26,000 pounds.

2) Have valid, Commercial Driver’s License (CDL) as defined by the Georgia Department of Driver Services if the vehicle operated falls into one of the following three classes:

i. If the vehicle has a gross vehicle weight rating of 26,001 or more pounds or such lesser rating as determined by federal regulation; or
ii. If the vehicle is designated to transport 16 or more passengers, including the driver.
. Have no more than two chargeable accidents, moving violations, or any DUI’s in a three (3) year period within the last five (5) years of the seven (7) year Motor Vehicle Record (MVR) period;
Rev 04 2009

NOTE: The Department will allow an exception to Out-of-State Driver’s License and MVP record under the following circumstances: (1) the individuals is on active duty in Georgia; (2) the individual is a college student enrolled at a Georgia college or university; or (3) the individual’s place of residence is a neighboring state on the border of Georgia. For individual to be granted this exception, he or she must:
. Have a valid, Class C license

. Have no convictions for substance abuse, sexual crime or crime of violence for five (5) years prior to providing the service

. Have current, valid insurance
Rev. 01 2009

Be provided with a basic orientation prior to direct contact with participants and show competence in:

1) The purpose and scope of Transportation Services, including related policies and procedures;
2) Confidentiality of individual information, both written and spoken;
3) Rights and responsibilities of individuals;
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 Driver Staff include, but are not limited to:

. Provides transportation for the participant to waiver services and other community services, activities, resources, and organizations;

. Provides assistance to the participant in entering or exiting the vehicle.
. Ensures transportation from the designated pick up point to the designated drop off point.

h. The agency has adequate driver staff with First Aid and CPR certifications to assure having at least one staff person with these certifications on duty during the provision of services.

i. The type and number of all other staff associated with the organization (such as contract staff, consultants) are:

1) Properly trained or credentialed in the professional field as required;

2) Present in numbers to provide services and supports to participants as required;

3) Experienced and competent in the services and support they provide.

j. 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 DD Service Provider Agency must develop written policies and procedures to govern the operations of Transportation Services, which follow the Standards for the Georgia Department of Behavioral Health and Developmental Disabilities refer to Part II Policies and Procedures for NOW.

3. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving Transportation Services:

a. Specific type and purpose of transportation provided;

b. Date and the beginning and ending time when the service was provided;

c. Location of origin and that for destination of transportation services;

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.
Rev. 10 2009

4. DHS Vehicle Requirements

DD Service Agency Providers who render Transportation Services in a vehicle owned by, titled to, or otherwise controlled by DHS must meet the policies and procedures for transportation and vehicle management in the DHS Transportation Manual, which is available at the following website: www.odis.dhr.state.ga.us.

5. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

6. DBHDD Contract/LOA and DBHDD Community Service Standards: DD Service 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 the DBHDD (see Part II Policies and Procedures for NOW, Chapter 603).

3003 Licensure

A. Individual Providers rendering Transportation Services must hold a valid Class C license as defined by the Georgia Department of Driver Services.

B. DD Service Provider Agency driver staff providing Transportation Services must hold the class of license appropriate to the vehicle operated as defined by the Georgia Department of Driver Services.

3004 Special Eligibility Conditions

A. The need for Transportation services must be reflected in the Intake and Evaluation Team approved Individual Service Plan (ISP).

B. The unavailability of other resources for transportation must be documented in the ISP.

3005 Prior Approval

Transportation Services must be authorized prior to service delivery by the applicable DBHDD Regional Office agency at least annually in conjunction with the Individual Service Plan development and with any ISP revisions.

Covered Services

Reimbursable Transportation Services include the following based on the assessed need of the participant and as specified in the approved ISP:
Rev 07 2010

1. One-way trip provided by Georgia licensed drivers or DD Service Agencies to waiver services and other community, non-medical services, activities, resources, and organizations typically utilized by the general population.

Rev. 04 2009

2. One-way trip provided by Georgia licensed drivers or DD Services Agencies of one participant to Supported Employment Services community work sites.

Rev. 04 2009

3. Brokering or provision of commercial carrier services available to the community at large.
3006 Non-Covered Services

1. Transportation of a waiver participant to school (through 12th grade).

2. Transportation that is included as an element of another waiver service as follows:

a. Community Living Support Services

b. Prevocational Services

c. Supported Employment Group Services

d. Community Access Group or Individual Services, which entail activities and settings primarily utilized by people with disabilities, such as transportation to and from a Mental Retardation Service Center or other day center.

3. Transit provided through Medicaid non-emergency transportation.

4. Transportation available under the State Medicaid Plan, including transportation to medical services, Individuals with Disabilities Education Act (IDEA), or the Rehabilitation Act.

5. 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 NOW, Chapter 1200.

6. Transportation services are not intended to replace available formal or informal transit options for participants

Rev. 04 2009
7. Payment for mileage or vehicle maintenance.

3007 Basis for Reimbursement

The reimbursement rate for transportation services is found in Appendix A.

A. Unit of service: encounter/one-way trip or commercial carrier/multipass.

B. Annual maximum is 203 units for encounter/one-way trip.

C. Annual maximum for all Transportation Services, including encounter/one-way and commercial carrier/multipass, is $2,797.34 per participant.

1 unit = $1.00
Annual limit is as authorized in the individual budget up to annual maximum for all self-directed Transportation Services of $2,797.

3008 Participant-Direction Options

A. Participants may choose the participant-direction or co-employer options with Transportation Services.

B. An individual serving as a representative for a waiver participant in self-directed services is not eligible to be a participant-directed provider of Supported Employment Services.

C. For details on participant-direction, see Part II Policies and Procedures for NOW, Chapter 1200.
PART III – CHAPTER 3100

SPECIFIC PROGRAM REQUIREMENTS
FOR
VEHICLE ADAPTATION SERVICES

SCOPE OF SERVICES

3101 General

Vehicle Adaptation Services include various adaptations and technical assistance to individually or family owned vehicles which are designed to enable individuals to interact more independently with their environment thus enhancing their quality of life and reducing their dependence on physical support from others. Vehicle Adaptations are limited to a participant’s or his or her family’s privately owned vehicle and include such things as a hydraulic lift, ramps, special seats and other interior modifications to allow for access into and out of the vehicle as well as safety while moving. The adapted or to be adapted vehicle must be the participant’s primary means of transportation.

Any item billed under Vehicle Adaptation Services must not be available under the State Medicaid plan. These services must also be documented to be the payer of last resource. The NOW does not cover items that have been denied through the DME and other programs for lack of medical necessity.

3102 Special Requirements of Participation

3102.1 Individual Provider
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 NOW Program, individual vendors and dealers in Vehicle Adaptations must meet the following requirements:

1. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving Vehicle Adaptation Services:

a. The efforts of the Participant’s Support Coordinator to substantiate payer of last resource, including available community, State Plan, or other resources.

b. Verification of Vehicle Adaptation service delivery, including date, location, and specific vehicle adaptations provided.

2. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for individual providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

3102.2 Provider Agencies

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 NOW Program, Vehicle Adaptation Services provider agencies must meet the following requirements:

1. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving Vehicle Adaptation services:

a. The efforts of the Participant’s Support Coordinator to substantiate payer of last resource, including available community, State Plan, or other resources.

b. Verification of Vehicle Adaptation service delivery, including date, location, and specific vehicle adaptations provided.

2. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for individual providers of participant-directed services are specified in Part II Policies and Procedures for NOW, Chapter 1200.

3. DBHDD Contract/LOA and MHDDD Community Service Standards: Providers must adhere to DBHDD Contract Standards, DBHDD Core Requirements for All Providers and all other applicable DBHDD Standards, including accreditation
by a national organization (CARF, JCAHO, The Council, Council on Accreditation) or certification by the DBHDD (see Part II Policies and Procedures for NOW, Chapter 603).

3103 Licensure

Vehicle Adaptations are made by vendors with the applicable Georgia business license as required by the local, city or county government in which the services are provided.

3104 Special Eligibility Conditions

Rev. 10 2009
1. The need for Vehicle Adaptation Services must be related to the individual disability and specified in the Health and Safety Section of the Intake and Evaluation Team approved Individual Service Plan (ISP).

2. When a participant only receives specialized services, a specific goal must be in the ISP for any specialized services, which includes Vehicle Adaptation.
Rev. 10 2009

Rev. 10 2009
3. Medical necessity for Vehicle Adaptation Services must be documented through and order by a Georgia licensed physician.

3105 Prior Approval

1. Vehicle Adaptation Services must relate to specific individual goals and must be required to meet the needs of the participant.

2. Vehicle Adaptation Services must be authorized prior to service delivery by the applicable DBHDD Regional Office at least annually in conjunction with the ISP development and any ISP revisions.

3106 Covered Services

Reimbursable Vehicle Adaptation Services include the following based on the assessed need of the participant and as specified in the approved ISP:

1. Vehicle Adaptations are limited to a participant’s or his or her family’s privately owned vehicle.
2. Vehicle Adaptations include such things as a hydraulic lift, ramps, special seats and other interior modifications to allow for access into and out of the vehicle as well as safety while moving.

3. Vehicle Adaptation to the participant’s primary means of transportation.
4. Repair of a prior existing vehicle adaptation provided the repair is less that replacement.
5. Replacement of a prior existing vehicle adaptation if replacement is less than a repair.
3107 Non-Covered Services

1. Adaptation, repair or replacement costs for adaptations to provider-owned vehicles.

2. Adaptation, repair or replacement costs for adaptations to leased vehicles.

3. Vehicle adaptations will not be replaced in less than three years except in extenuating circumstances and authorized by the Division of Medical Assistance, Department of Community Health.

4. Vehicle backup sensor and alarm systems.

5. Comfort, convenience, or recreational adaptation.

6. Adaptation, replacement or repair that is necessitated by participant’s neglect, wrongful disposition, intentional misuse or abuse. Adaptations will not be replaced due to the participant’s negligence and/or abuse (e.g., before its normal life expectancy has been attained unless supporting medical documentation and change I the physical or developmental condition of the participant).

7. Regularly scheduled upkeep and maintenance of the vehicle or its modifications.

8. Adaptations of general utility that are not of direct medical or remedial benefit to the individual.

9. Purchase or lease of vehicles.

10. Extended warranties and/or maintenance agreements.

11. 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 NOW, Chapter 900.

12. 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.

3108 Basis for Reimbursement

A. Lifetime maximum is $6,240.00 per participant.

B. Reimbursement Rate
Reimbursement rate for Vehicle Adaptation is the lower of three price quotes or the lifetime maximum. The reimbursement rates for all specialized services are found in Appendix A.

3109 Participant-Direction Options

A. Participants may choose the self-direction option with Vehicle Adaptation.

B. For details on participant-direction, see Part II Policies and Procedures for NOW, Chapter1200.

APPENDIX A

REIMBURSEMENT RATES FOR ‘NOW’ SERVICES

The reimbursement rates outlined below are the maximum amount that Medicaid may reimburse providers, unless an exceptional rate has been authorized by the Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD) Regional Office (see Part II, NOW Policies and Procedures Chapter 1000 for information on exceptional rate approval). The Georgia Department of Behavioral Health and Developmental Disabilities, assigns the individual provider rates.
Rev. 01 2011

 

Rev. 01 2011
Note: The reimbursement rates outlined below are the maximum amount that Medicaid will reimburse providers, unless an exceptional rate has been authorized by the DBHDD Regional Office. The Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD) may authorize individual provider rates up to the maximum amount or in extraordinary circumstances related to transition of an individual from an institution or imminent risk of institutionalization of an individual authorize an exceptional rate (see Part II, NOW Policies and Procedures Chapter 1000 for additional information on exceptional rate approval).

A. Adult Occupational Therapy:

Adult OT Evaluation (97003)
Adult OT Evaluation Self-Directed (97003-UC)
Unit = one evaluation
Limit = one evaluation per year
Maximum rate per unit = $52.99

Adult OT Therapeutic Activities (97530-GO)
Adult OT Therapeutic Activities Self-Directed (97530-GO/UC)
Unit = 15 minutes
Limit = 4 units per day
Maximum rate per unit = $19.76

Adult OT Sensory Integrative Techniques (97533-GO)
Adult OT Sensory Integrative Techniques Self-Directed (97533-GO/UC)
Unit = 15 minutes
Limit = 4 units per day
Maximum rate per unit = $24.46

Annual Limit for All Adult Therapies = $1,800.00

B. Adult Physical Therapy:

Adult PT Evaluation (97001)
Adult PT Evaluation Self-Directed (97001-UC)
Unit = one evaluation
Limit = one evaluation per year
Maximum rate per unit = $52.99

Adult PT Therapeutic Procedure (97110)
Adult PT Therapeutic Procedure Self-Directed (97110-UC)
Unit = 15 minutes
Limit = 4 units per day
Maximum rate per unit = $20.07

Annual Limit for All Adult Therapies = $1,800.00

C. Adult Speech and Language Therapy:

Adult Speech Language Evaluation (92523)
Rev. 01 2014
Adult Speech Language Evaluation Self-Directed (92523-UC)
Unit = one evaluation
Limit = one evaluation per year
Maximum rate per unit = $54.93

Adult Speech Language Therapy (92507-GN)
Adult Speech Language Therapy Self-Directed (92507-GN/UC)
One unit = One visit
Maximum rate per unit = $62.53

Adult Speech-Generating Device Therapy (92609)
Adult Speech-Generating Device Therapy Self-Directed (92609-UC)
One unit = One visit
Maximum rate per unit = $54.75

Annual Maximum for All Adult Therapies = $1,800.00

D. Behavioral Supports Consultation Services:

Behavioral Supports Consultation (H2019)
Behavioral Supports Consultation Self-Directed (H2019-UC)
Unit = 15 minutes
Limit = 104 annual units
Maximum rate per unit = $23.56
Annual Maximum = $2,450.24
Rev. 07 2014

Self-Directed
Limit: 1 unit = $1.00
Annual maximum = $2,450

E. Community Access Services:

Community Access Group (T2025-HQ)
Community Access Group Self-Directed (T2025-HQ/UC)
Community Access Group Co-Employer (T2025-HQ/UA)
Unit = 15 minutes
Daily Limit = 24 units
Monthly Limit = 504 units
Annual Limit = 5760 units
Maximum rate per unit = $3.04

Community Access Individual (T2025-UB)
Community Access Individual Self-Directed (T2025-UB/UC)
Community Access Individual Co-Employer (T2025-UB/UA)
Unit = 15 minutes
Daily Limit = 40 units
Annual Limit = 1440 units
Maximum rate per unit = $7.26

Self-Directed
Rev. 07 2014
Community Access Group Limits: 1 unit = $1.00
Annual limit is as authorized in the individual budget
up to an annual maximum of $17,510.

Community Access Individual Limits: 1 unit = $1.00
Annual limit is as authorized in the individual budget
up to an annual maximum of $10,454.

F. Community Guide Services:

Community Guide Self-Directed (H2015-UC)
Community Guide Co-Employer (H2015-UA)
Unit = 15 minutes
Daily Limit = 32 units
Annual Limit = 224 units
Maximum rate per unit = $8.93
Annual Maximum = $2,000.32

Self-Directed
Rev. 07 2014
Limit: 1 unit = $1.00
Annual limit is as authorized in the individual budget up to an annual maximum of $2,000.

G. Community Living Support Services:

Community Living Support – 15 Minutes (T2025-U5)
Community Living Support – 15 Minutes Self-Directed (T2025-U5/UC)
Community Living Support – 15 Minutes Co-Employer (T2025-U5/UA)
Unit = 15 minutes
Maximum annual number of units = 4650
Maximum rate per unit = $4.93
Maximum amount billed per day = $128.52

Community Living Support RN (T1002-U1)
Community Living Support RN Self-Directed (T1002-U1/UC)
Unit = 15 minutes
Maximum rate per unit = $10.00

Community Living Support LPN (T1003-U1)
Community Living Support LPN Self-Directed (T1003-U1/UC)
Unit = 15 minutes
Maximum rate per unit = $8.75

Self-Directed
Rev. 07 2014
Community Living Support: 1 unit = $1.00
Annual limit is as authorized in the individual budget up to an annual maximum of $22,922.00.

Billing for all Community Living Support 15-Minute Units (including nursing) can not exceed annual maximum of $22,924.50
or any annual amount associated with an authorized exceptional rate.

Note: The adjusted rate for a unit of Community Living Support services 15 Minutes and the adjusted units for this services are being phased in effective with April 1, 2010 Individual Service Plans and thereafter.
Rev. 01 2011

H. Environmental Accessibility Adaptation:

Environmental Accessibility Adaptation (S5165)
Environmental Accessibility Adaptation Self-Directed (S5165-UC)
Rev 01 2013
1 unit = $1.00
Lifetime maximum per participant = $10,400.00

The reimbursement rate is the lower of three price quotes or the lifetime maximum.

I. Financial Support Services:

Financial Support Services (T2040-UC)
Monthly maximum unit = 1
Maximum annual number of units = 12
Maximum rate per participant = $75.00 per month

J. Individual Directed Goods and Services:

Individual Directed Goods and Services (T2025 U7/UC)
Maximum annual number of units = 20
Annual maximum = $1,500.00

Rev. 07 2014
Limits: 1 unit = $1.00
$1,500 annual maximum.

K. Natural Support Training Services:

Natural Support Training (T2025-UD)
Natural Support Training Self-Directed (T2025-UD/UC)
Unit = 15 minutes
Maximum annual number of units = 86
Maximum rate per unit = $20.78

Rev. 07 2014
Self-Directed
1 Unit = $1.00
Annual limit is as authorized in the individual budget up to annual maximum of $1,787.

L. Prevocational Services:

Prevocational Services (T2015)
Unit = 15 minutes
Daily Limit = 24 units
Monthly Limit = 504 units
Annual Limit = 5760 units
Maximum rate per unit = $3.04

M. Respite Services:

Respite – 15 Minutes (S5150)
Respite – 15 Minutes Self-Directed (S5150-UC)
Respite – 15 Minutes Co-Employer (S5150-UA)
Unit = 15 minutes
Daily Limit = 24 units
Annual Limit = 889 units
Maximum rate per unit = $4.21

Respite – Overnight (S5151)
Respite – Overnight Self-Directed (S5151-UC)
Respite – Overnight Co-Employer (S5151-UA)
Daily Limit = 1 unit
Annual Limit = 39 units
Maximum rate per unit = $96.00

Annual Maximum for Respite Services = $3,744.00

Self-Directed
Rev. 07 2014
Respite: 1 unit = $1.00
Applies to 15 minutes Respite, not overnight Respite
Annual limit is as authorized in the individual budge up to the annual maximum of $3,744.

N. Specialized Medical Equipment:

Specialized Medical Equipment (T2029)
Specialized Medical Equipment Self-Directed (T2029-UC)
1 unit = $1.00
Annual maximum = $5,200.00

The amount of funds per equipment purchase is the standard Medicaid reimbursement rate for the equipment or, in the absence of a standard Medicaid rate, the lower of three price quotes. The annual maximum number of units is 5,200 unless there is approval to exceed the annual maximum up to the lifetime maximum due to assessed exceptional needs of the participant.
Rev 01 2013
Lifetime maximum per participant = $13,474.76

O. Specialized Medical Supplies:

Specialized Medical Supplies (T2028)
Specialized Medical Supplies Self-Directed (T2028-UC)
1 unit = $1.00
Annual maximum = $1,734.48

Rev 01 2013
The annual maximum number of units is 1,734 unless there is approval to exceed annual maximum units due to assessed exceptional needs of the participant.

P. Support Coordination:

Support Coordination (T2022)
Monthly maximum unit = 1
Maximum annual number of units = 12
Maximum rate per participant = $149.88 per month

Q. Supported Employment Services:
Supported Employment Group (T2019-HQ)
Rev. 01 2009
Supported Employment Group Self-Directed (T2019-HQ/UC)
Supported Employment Group Co-Employer (T2019-HQ/UA)
Unit = 15 minutes
Monthly Limit = 320 units
Annual Limit = 3840 units
Maximum rate per unit = $1.80

Support Employment Individual (T2019-UB)
Rev. 01 2009
Support Employment Individual Self-Directed (T2019-UB/UC)
Support Employment Individual Co-Employer (T2019-UB/UA)
Unit = 15 minutes
Daily Limit = 40 units
Annual Limit = 1440 units
Maximum rate per unit = $7.26

Self-Directed
Rev. 07 2014
Supported Employment Group Limits: 1 unit = $1.00
Annual limit is as authorized in the individual budget up to an annual maximum of $6,912.

Supported Employment Individual Limits: 1 unit = $1.00
Annual limit is authorized in the individual budget up to an annual maximum of $10,454.

R. Transportation Services:

Transportation Encounter/Trip (T2003)
Transportation Encounter/Trip Self-Directed (T2003-UC)
Transportation Encounter/Trip Co-Employer (T2003-UA)
Unit = one-way trip
Annual Limit = 203
Maximum rate per unit = $13.78

Transportation Commercial Carrier, Multi-Pass (T2004)
Transportation Commercial Carrier, Multi-Pass Self-Directed (T2004-UC)
Annual Limit = 203
Participant specific rate for local commercial carrier, multi-pass

Annual Maximum for Transportation Services = $2,797.34

Self-Directed
Rev. 07 2014
Scheduled Encounter/Trip
Limit = $1.00
Annual limit is authorized in the individual budget up to annual maximum for all self-directed Transportation services of $2,797.

Commercial Carrier/Multipass/Intermittent Trip
1 unit = $1.00
Annual limit is as authorized in the individual budget up to annual maximum for all self-directed Transportation Services of $2,797.

S. Vehicle Adaptation Services:

Vehicle Adaptation (T2039)
Vehicle Adaptation Self-Directed (T2039-UC)
1 unit = $1.00
Lifetime maximum per participant = $6,240.00
The reimbursement rate is the lower of three price quotes or the lifetime maximum.

APPENDIX B
GUIDELINES FOR SUPPORTING ADULTS WITH CHALLENGING BEHAVIORS IN COMMUNITY SETTINGS
A Resource Manual for Georgia’s Community Programs
Serving Persons with Serious and Persistent Mental Health Issues And Persons with Mental Retardation or Developmental Disabilities
TABLE OF CONTENTS

I. Preface
Page 6

II. Purpose
Page 7

III. Values of the Division of DBHDD
Page 8

A. Consumer Choice

B. Inclusion

C. Appropriate Environment

D. Quality of Services

E. Individualized Services

IV. Person-Centered Planning
Page 9

V. Understanding Behavior
Page 12

A. What is behavior?

B. What influences behavior?

C. What are challenging behaviors?

D. How do we figure out what the challenging behavior is communicating or what is “causing” the challenging behavior?

E. Focus first on possible medical or psychiatric issues.

VI. Supporting People In Positive Ways
Page 20

A. What can I do on a day-to-day basis that might be helpful to the person?

B. Using positive behavior supports.

C. Combining person-centered planning with positive behavior supports.

D. In closing…

VII. What Do I Do First? Identify and Remove the Cause of
Challenging Behaviors

Page 24

A. Show me some real examples of what you are talking about.

B. The Wellness Recovery Action Plan (WRAP) is an effective way to identify and remove the cause of challenging behaviors.

VIII. APPROACH I: Gather Information About The Challenging Behavior
Page 28

A. We have not been able to figure out the behavior! Now what do we do?

B. What is a functional assessment?

 

C. Looking for the A-B-C’s.

D. How much information needs to be collected and for how long?

E. How do I collect information about the A-B-C’s?

IX. APPROACH II: Call In a Professional To Develop a Positive Behavior Support Plan (PBSP)

Page 32

A. What is a Positive Behavior Support Plan (PBSP)?

B. Thirteen outcomes you should expect to find in a completed PBSP.

C. What kind of professional can write a positive behavior support plan (PBSP)?

D. How do I know that the plan is written using positive behavior approaches?

E. Checks and balances to be sure staff know what to do.

F. Review and oversight of the PBSP.

X. What Can We Do If The Behavior Support Plan Is Not Working?
Page 40

A. Seek additional review and consultation.

B. What if the challenging behavior is affecting the individual’s personal health and safety, or the health and safety of others?

XI. APPROACH IIIA: Develop A Crisis Plan
Page 42

A. What is a crisis plan?

B. What are the essential components of a crisis plan?

APPROACH IIIB: Develop A Safety Plan
Page 44

A. When should a safety plan be written?

B. Where does the PBSP leave off and the safety plan begin?

C. Are there any particular processes that must occur when a safety plan is used?

D. Can medication be used in a safety plan?

E. Should a safety plan be written when the health and safety of the individual or the health and safety of others is NOT affected?

XII. Using Medications For Challenging Behaviors
Page 49

A. Is it ok to give medication for challenging behaviors?

B. Are medications EVER appropriate to give to someone with challenging behaviors?

C. Are PRN medications ever OK to use for individuals living in the community?

D. When we take an individual to the doctor, what does the doctor need to know?

E. How should we prepare for a visit to the doctor?

F. What information needs to GO BACK to best support the individual?

G. In summary…

XIII. Emergency Safety Interventions of Last Resort
Page 56

XIV. Affording Respect To The Individual, Observing Client Rights, Federal and State Laws and Departmental Rules
Page 57

A. Afford respect to persons served.

B. Know the story of the person you serve.

C. Informed Consent.

D. Laws and Regulations.

XV. Strategies That Maintain Resilience in Caregivers
Page 59

XVI. We Hope The Manual Is Helpful
Page 60

XVII. Those Who Gave of Their Time, Energy and Expertise to
Make This Manual Possible
Page 61

APPENDICES

Appendix A: Learning to Listen
Page 1

Appendix B: Physiological Issues to Consider
Page 2

B.1 Pain

B.2 Medical Considerations In the Approach to Problematic Behavior
A. General Considerations

1. Pain

2. Medication Effects, Medication Side Effects and Medication Toxicity
B. Neurologic Effects

1. Headaches

2. Meningitis/Encephalitis

3. Dementia
C. Eyes

D. Ears, Nose, and Throat

E. Pulmonary or Cardiovascular

F. Gastrointestinal

1. Constipation/Fecal Impaction

2. Diarrhea

3. Inflammatory Bowel Disease

4. Gastroesophageal Reflux/Hiatal Hernia

5. Ulcer Disease

6. Intestinal Parasites/Pinworms
G. Genitourinary

1. Dysmenorrhea and Urinary Tract Infection

2. Premenstrual Syndrome and Premenstrual Dysphoric Disorder

3. Vaginitis and Vaginal Candidiasis
H. Integumentary

I. Musculoskeletal

J. Endocrine

K. Menopause

L. Hematologic
Appendix C: Quality of Life Satisfaction Interview For Persons With
Challenging Behaviors

Appendix D: Glossary of Non-Restrictive Techniques
Page 12

D.1 Brief Overview of Non-Restrictive Methods for Use in
Positive Behavior Support Plans

D.2 Definition and Characteristics of Non-Restrictive Methods That
May Be Used in PBSPs

1. Positive Reinforcement

2. Negative Reinforcement

3. Extinction of Maladaptive Behavior that is not Dangerous

4. Differential Reinforcement of Incompatible Behavior (DRI)

5. Differential Reinforcement of Other Behavior (DRO)

6. Differential Reinforcement of Alternative Behavior (DRA)

7. Behavioral Contracting with Positive Consequences (Earning Extra Privileges)

8. Reinforced Practice

9. Contingent Observation

10. Response Blocking or Interruption

11. Restoration of Environment

12. Non-Contingent Dietary Management

13. Withdrawal to a quiet area

14. Brief Manual Hold

Appendix E: The Emergency Safety Intervention of Last Resort That
May Be Used in a Safety Plan or as Part of a Crisis Plan
Within The Community
Page 25

1. Personal (Manual) Restraint

2. Processes for documentation and debriefing after the use of an emergency safety intervention

Appendix F: Emergency Safety Interventions of Last Resort That
May Be Used Within the Community ONLY Within
Residential Crisis Stabilization Programs

Page 27

F.1 Specific Techniques
1. Seclusion of an Individual

2. Physical (Mechanical) Restraint

F.2 Chemical Restraint May Never Be Used
1. Chemical Restraints

I. PREFACE
This resource manual is intended to provide parameters for addressing behavioral concerns of persons with serious and persistent mental health issues and for addressing
behavioral concerns of persons with mental retardation and other developmental disabilities who are served in community programs supported by funding, in whole or in part, that is authorized by the Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD). Additionally the manual is a resource for the development of individual local program policies for behavioral support planning and programming.
The manual sets forth both guidelines and requirements to be followed when behavioral supports are utilized in the care of persons served. Policies developed within community programs regarding behavioral supports are expected to comply with the guidelines and requirements set forth in this manual, including current regulatory standards, individual rights, core values and philosophy of treatment of the Division of DBHDD, and to be consistent with empirical knowledge related to behavior analysis.
This manual was developed in compliance with the Division’s Provider Manual for Community Mental Health, Developmental Disabilities and Addictive Diseases Providers Under Contract with the Georgia Department of Behavioral Health and Developmental Disabilities as well as federal and state law, rules and regulations.
Readers will note that disability groups use different language to describe similar things. For example, within MR/DD the Individualized Service Plan is referred to as the ISP. Within MH it is referred to as the Individual Recovery Plan, or IRP. And you will find similarities when discussing positive behavior supports and WRAP Plans. If the differences and similarities do not become clear as you read, feel free to contact staff in the respective disability sections of the Division of DBHDD.
Appreciation and recognition are expressed to those individuals who served on the task force to develop the manual and to the staff who offered their suggestions on its content. This manual is provided to be a useful resource to facilitate the best services possible within the Division of DBHDD.

II. PURPOSE
The manual has several purposes:
. To provide person-centered guidance for supporting adults with challenging behaviors, regardless of their disability
. To promote consistent and effective services and supports in different settings and circumstances (e.g., families, supported living, etc.).
. To protect the rights of individuals served (client rights), especially the right to participate in and determine the development of their services and supports.
. To provide strategies that promote the highest quality of life possible as determined by the individual.
. To provide tools to enhance skills of persons supporting individuals (staff, family, etc.).
. To provide strategies that maintain resilience in caregivers

III. VALUES OF THE DIVISION OF DBHDD
The Georgia Department of Behavioral Health and Developmental Disabilities hold these values with regard to persons served through the Division.
A. Consumer choice
Consumers and families have choices about DBHDD services through:
. Participation in designing the DBHDD service system;
. Full participation in development of their service plan;
. Selection of service providers, location of services and other factors related to implementation of the service plan; and
. Opportunity for and development of the capacity to make choices in every day life.
B. Inclusion
Consumers are supported to participate in the everyday life of their community, with their family, friends and natural/community support system. Children and adolescents are supported to remain in their own homes with their families.

C. Appropriate environment
Consumers are served in the least restrictive, least intrusive environment possible that meets the needs of the individual served.
D. Quality of services
Consumers have the highest quality services provided by a competent staff, utilizing flexibility and incentives that reinforce quality and efficiency.
E. Individualized services
Individuals are provided services at the appropriate level of intensity based on their individual strengths, needs and choices with sensitivity to cultural differences, age appropriateness and gender specific needs.

IV. PERSON-CENTERED PLANNING
Person-centered planning is a way to get to know a person and their “story” so that you know what they want in life, where they want to live and what makes them happy. It is a planning process used within all disabilities that addresses all areas of a person’s life, including health, community involvement, relationships with friends and family, and work. It is a collaborative process to help individuals get the supports and services they need to live a quality life, based on their own preferences and values. The individual served and those who know the person best are the most important participants in the planning process.
The person-centered planning process starts with listening to the person and honoring his/her vision. A person-centered approach asks us to remember people as whole human beings with hearts, souls, and desires like everyone. To realize their wishes and potential, support and encouragement is required. Person-centered planning focuses on identifying and maximizing the strengths and preferences rather than creating lists of what the individual can’t do.
A person-centered approach for developing a behavior support plan is similar in that it requires listening to the person to gain an understanding of who the person is, the person’s wishes and hopes for his or her life, honoring his/her vision, understanding his or her strengths and challenges, and giving consideration to the context of his or her social and environmental setting, including any relevant medical or psychiatric conditions. It requires listening to the individual through their words and actions so that the significance of the behavior(s) can be understood.
When using a person-centered approach, it is most important to identify the gaps
between the person’s life and how he or she wants his or her life to be. The person-centered planning process may include strategies for minimizing situations that cause stress for the person and maximizing the person’s control over his or her life.
Listening is a critical component of person-centered planning. What follows in Example 4.1 are some really good tips to use when communicating with people.

EXAMPLE 4.1
PERSONAL CONDUCT THAT SAYS YOU ARE LISTENING
And that will
MINIMIZE NEGATIVE RESPONSES FROM OTHERS

Following these suggestions in your daily interactions with others will assist you in minimizing and de-escalating negative responses from others. If at any time another person’s behavior starts to escalate beyond your own comfort zone, disengage from the situation.

DO THIS
DO NOT DO THIS

Focus your full attention on the other person to let them know you are listening and interested in what they are saying.

Encourage the other person to talk. Listen patiently and with empathy.

Maintain a pleasant, open and accepting attitude.
Know the person before you use humor… it can be misinterpreted as making fun of someone.

Stay calm. Move and speak slowly, quietly and project confidence. Watch your own body language, voice pattern, facial expressions and rate of speech.
Do not use a style of communication that suggests apathy, “the brush-off”, coldness, sarcasm, condescension, minimizing concerns, or giving the run-around.

Maintain a relaxed posture, positioning yourself at a right angle.
Don’t stand directly fact-to-face, hands on hips, crossing arms, finger pointing, or hard stare eye contact. These are very challenging behavioral messages.

Make sure there are 3 to 6 feet between you and person with whom you are speaking.
Don’t invade another person’s personal space. Don’t lean into or over the person.

Don’t touch the person if the person is not harming himself or herself or someone else. Touching escalates behaviors at the moment.

Make sure you are at a level of eye contact with the person. Adjust your position so that you are communicating with the person literally at the level of their physical height so that their eyes can look at your eyes without difficulty.
Don’t tower over a short person or a person in a bed, chair or wheelchair.

Be direct and to the point.
Don’t speak with a lot of technical terms, use large vocabulary words, or use complicated information especially when emotions are high.

Listen objectively.
Don’t take sides with what the person is saying. Don’t agree with distortions.

Acknowledge the other person’s feeling even if you
Don’t challenge, threaten or dare the other person.

disagree. Let them know that it is clear that what they are saying is important to them.
Never belittle or make fun.

When acknowledging a person’s feelings, use words like “frustrated,” “upset” or other words that describe a softer version of the emotion displayed.
Don’t use words that are emotionally charged, like “angry” or “pissed off.” If the emotion that you named is NOT on target, allow the individual the control of naming the emotion!

Don’t try to make it all seem less serious than it is. Do NOT minimize the person’s feelings!

Even if you disagree, you can still listen to someone. You might say something like “I hear what you are saying, but I don’t share that same view…”or “I hear what you are saying… but have you considered XXX?”
Don’t argue back to or over the person. Don’t try to change their mind about something.

Accept criticism in a positive way. If a complaint is valid, use statement like “you are probably right”. If the criticism is invalid, ask clarifying questions.
Don’t criticize or act impatiently toward an agitated individual.

Break big problems into smaller, more manageable problems.

Ask for small, specific responses from them such as moving to a quieter area or lowering their voice. Focus on small requests.

Be reassuring and point out the choices available to the person. Allow them to have control of the choice made to the extent possible given the circumstance.

Be truthful.
Don’t make false statements or promises you know you cannot keep. If you are unsure, say that you are unsure.

Establish ground rules or set boundaries if unreasonable behavior continues. Calmly describe the consequences of any inappropriate behavior.
Don’t attempt to bargain or bribe a threatening person.

Ask for their opinions or recommendations. Paraphrase back to the individual what they said.
Don’t immediately reject demands made without listening and communicating to the individual that you are hearing the words and/or the message that is not directly in the words.

Use delaying tactics that will give the person time to calm down. For example, offer a drink of water in a paper cup.

Position yourself to have access to an exit if need be. Be aware of surroundings and people walking in and out, but try to maintain a soft eye contact.

Refer to Appendix A for a real example of the impact of NOT listening.

V. UNDERSTANDING BEHAVIOR
A. What is behavior?
Behavior is what all people do. It includes our observable actions such as smiling,
talking, eating and dressing. Everybody “behaves” almost all the time.
Different situations or environments have different rules or expectations about how to behave. For example, we are expected to behave differently in a library than we do at a ball game. Also, beliefs about what is expected may differ with each person. When someone does not understand these expectations or fails to conform to them, his/her behavior may limit the opportunity for success, participation, status, and friendship.
B. What influences behavior?
Behavior is related to many things. Usually it has a purpose and has a function. Examples of purpose and function are getting something, avoiding something undesirable or enjoying something.
Some behaviors, like unexplained movements or sounds, are neurologically based and cannot be changed with behavioral interventions. These behaviors often “just seem to happen.” While the individual has no control over these behaviors, sometimes the individual or staff is able to figure out that certain stimuli in the environment are helping to trigger their occurrence.
Behavior is a result of or response to something the person is experiencing or has
experienced. The stimulus for a particular behavior can come from any of these sources:
. Physiological (from within the physical part of us);
. Social (from any situation involving all people we have ever encountered);
. Psychological (from emotions, feelings or thought processes); or
. Environmental (from any part of our surroundings).
Some examples of internal and external sources just listed are:
1. Physiological – such as feeling full or satisfied, feeling pain, having skips in your heart [that can mean you have less oxygen to the brain], low blood sugar so you feel really hungry and can’t think, needing to go to the bathroom, etc.;
2. Social – such as seeing a face that reminds you of someone you don’t like, going to a party, seeing the same faces day after day, sitting in church, going to a movie, being at a dance, etc.
3. Psychological – such as an angry response to a particular word, hearing someone laugh when we don’t understand why, being called a name, being given a
compliment, feeling frustrated because things are not as you want them to be, thinking about something nice that happened, etc.; and
4. Environmental – such as a dark corner, a rainstorm, a beautiful garden, a hot sultry day, a car horn blowing, coffee brewing, etc.
While what is going on inside our bodies is hard to see, behavior can be observed and described. But remember to consider what might be going on inside! Most people would find it difficult to concentrate if they had to go to the bathroom, had a toothache, were incredibly thirsty, were hearing voices telling us what to do or had a fight with a family member before coming to work.
BEHAVIORAL “CAUSES” OR INFLUENCES
PHYSIOLOGICAL
ENVIRONMENTAL
PSYCHOLOGICAL
SOCIAL

Allergies
Arthritis
Attention deficit
Constipation
Delusions
Dementia
Ear aches
Energy – too much
Energy – too little
Fractures
Headaches
Hallucinations
Hunger
Hyperactivity
Itching
Medication reactions
Medication side effects
Pain
Premenstrual syndrome
Seizures
Sex drive
Thirst
Tobacco craving

And many more possibilities!
Air quality
Close proximity to others
Humidity
Lighting
Limited physical space
Noise
Smells
Temperature
Uncomfortable furniture

And many more possibilities!
Anxiety
Assertiveness
Attitudes
Beliefs
Boredom
Dominance
Fear
How thoughts are processed
Loneliness
Phobias
Personality traits
Sex drive
Shyness
Submissiveness
Suspiciousness
Vengeance
Worry

And many more possibilities!
Being stared at
Change in staff
Criticism
Danger
Demands
Disapproval
Disruption
Frequent change
Lack of social attention
Not having choices Presence of specific person(s)
Relocation
Sexual provocation
Teasing by others
Tone of voice
Too little to do
Too much to do

And many more
possibilities!

C. What are challenging behaviors?
Challenging behaviors are behaviors that are defined as problematic or maladaptive by others noticing the behavior or by the person displaying the behavior.
Challenging behaviors are those actions that come into conflict with what is
accepted by the individual’s community. Challenging behaviors are behaviors that often isolate the person from their community or are behaviors that can be barriers to the person living or remaining in a specific community. Challenging behaviors vary in seriousness and intensity.
What is determined to be a challenging behavior can vary depending on what is accepted by the individual, a community or by society.
D. How do we figure out what the challenging behavior is communicating or what is “causing” the challenging behavior?
First, medical and psychiatric conditions have been found to play a direct
role in “causing” challenging behaviors. This is especially true for persons who communicate in ways we are not used to hearing. Is the person constipated? [This is a very common side effect of certain medications or not having enough fluids, fruits or vegetables]. Is the person taking their medication for the voices they hear? [Often people will say that the side effects of the medication are worse than hearing the voices tell them what to do]. Does the person have an infection? [How would you know when this is true?].
A second and similarly important consideration is that challenging behaviors result from being lonely, being on the outside looking in. Again, this is especially true for persons who communicate in ways we are not used to hearing. Is the quality of the person’s life acceptable (in their opinion)? Do relationships exist in the person’s life that support choice and maximize social and personal skills? Are the relationships between staff and the individual appropriate from a professional perspective? Does the person have opportunity for involvement in the community that would support personal social relationships?
There is a HUGE difference between developing an appropriate relationship with an individual and simply being with that person because it is your job. If the interventions used do not lead to a meaningful life and relationships for an individual, what have we accomplished?2

E. Focus first on possible medical or psychiatric issues.
We do not usually look at medical or psychiatric issues or personal satisfaction as reasons for challenging behaviors. Instead we get frustrated and say, “they are just being a pain”
or “she’s just ‘that way.’” And sometimes caregivers get frustrated to the point of acting or reacting in ways that make things worse. The challenging behaviors of the individual coupled with our reaction can become a downward spiral!
However, looking at medical or psychiatric issues is imperative! One expert in the MR/DD field who works with persons with challenging behaviors said, “Until proven wrong, my first assumption is that part of the body hurts. Until we help the person feel better, the behavior will not stop. If the person is in pain they have two choices: 1) the pain controls me; or 2) I control the pain. The behavior is a form of intentional communication.”1
1 Pitonyak, David, Ph.D., “Supporting Persons with Difficult Behaviors”, a workshop held September 27, 2004
As further illustration, in the state of Massachusetts a hospital psychiatric unit was set up to work with MR/DD individuals who had very difficult challenging behaviors. They were taken to the psychiatric unit when the “cause” of the challenging behavior could not be figured out in the community. In that psychiatric unit, it was documented that better than 75% of issues determined to be “causing” challenging behaviors were medical in origin, such as chronic infection, enlarged prostate, etc.
For persons with MH issues, challenging behaviors often result from internal physiological or psychological stimuli that cannot be tolerated, or from misperception of social or environmental situations.
We owe it to the person served and to ourselves to try to figure out what the challenging behavior is communicating! Here are some questions to keep in mind while analyzing what is “causing” complex, challenging behaviors:
1. Is the challenging behavior a symptom of a medical disorder? For example, a person with a neurological disorder may strike out when becoming excited due to involuntary movements or poor muscular control.
2. Is the quality of the person’s life acceptable (in their opinion) in terms of personal relationships, personal choices or living situation, etc?
3. Is the challenging behavior a side effect of a medication they are getting?
4. Is the challenging behavior part of a cluster or chain of related behaviors? For example, if a person does not want to go to a workshop, the person may use several behaviors to keep from going, such as refusing to get up, pretending to be sick, running away or attacking others. If so, one intervention may solve many challenges. If not, priorities will have to be set because trying to change many different behaviors at the same time is likely to cause confusion and reduce the chance for success.
5. Is the challenging behavior the result of a lack of a skill or skills? Often challenging behaviors occur because of a missing skill. If a person is asked to do
something that he or she does not understand or is unable to do, the person may become frustrated and strike out or hurt him or her self to make the demand go away.
In summary, be certain to ask these questions:
1. What does the behavior get for the person? What is experienced as positive is entirely in the eyes of the beholder! For example, some people enjoy attention of any kind! Some people prefer to be quiet and alone. Behavior that results in a change that the person perceives as positive in some way is likely to be repeated. Therefore it is important to give people choice as a form of personal control.
2. What does the behavior help the person escape? For example, hitting others who are making too much noise may result in getting sent away from the noise, which is what the person wants!
3. What does the behavior help the person avoid? For example, playing sick may result in getting to stay home from school, which may be a very stressful place.
Example 5.2 is a very extensive list of common “problem” behaviors and what their causes might be. Take a look.
EXAMPLE 5.2

COMMON “PROBLEM” BEHAVIORS AND
SPECULATIONS ABOUT THEIR CAUSES

BEHAVIOR
SUSPECTED CAUSE

Biting side of hand/whole mouth
. Sinus problems

. Ears/Eustachian tubes

. Eruption of wisdom teeth

. Dental problems

. Paresthesias/painful sensations (e.g., pins & Needles) in the hand

Biting thumbs/objects with front teeth
. Sinus problems

. Ears/Eustachian tubes

Biting with back teeth
. Dental

. Otitis (ear)

Fist jammed in mouth/down throat
. Gastroesophageal reflux

. Eruption of teeth

. Asthma

. Rumination

. Nausea

General Scratching
. Eczema

. Drug effects

. Liver/renal disorders

. Scabies

Head Banging
. Pain

. Depression

. Migraine

. Dental

. Seizure

. Otitis (ear ache)

. Mastoiditis (inflammation of bone behind the ear)

. Sinus problems

. Tinea capitis (fungal infection in the head)

“High pain tolerance”
. A lot of experience with pain.

. Fear of expressing opinion.

. Delirium

. Neuropathy (disease of the nerves/many causes)

Intense rocking/preoccupied look

. Visceral pain

. Headaches

. Depression

Odd un-pleasant masturbation
. Prostatitis

. Urinary tract infection

. Candida vagina

. Pinworms

. Repetition phenomena, PTSD

Pica
. General: OCD, hypothalamic problems, history of under-stimulating environments

. Cigarette butts: nicotine addiction, generalized anxiety disorder

. Glass: suicidality

. Paint chips: lead intoxication

. Sticks, rocks, other jagged objects: endogenous opiate addiction

. Dirt: iron or other deficiency state

. Feces: PTSD, psychosis

Scratching/hugging chest
. Asthma

. Pneumonia

. Gastroesophageal reflux

. Costochondritis/”slipped rib syndrome”

. Angina

Scratching stomach
. Gastritis

. Ulcer

. Pancreatitis (also pulling at back)

. Porphyria (bile pigment that causes, among other things, skin disorders)

. Gall bladder disease

Self-restraint/binding
. Pain

. Tic or other movement disorder

. Seizures

. Severe sensory integration deficits

. PTSD

. Paresthesias

Stretched forward
. Gastroesophageal reflux

. Hip/back pain

. Back pain

Sudden sitting down
. Altlantoaxial dislocation (dislocation

. Between the vertebrae in the neck)

. Cardiac problems

. Seizures

. Syncope/orthostasis (fainting or light-headedness caused by medications or other physical conditions)

. Vertigo

. Otitis (thrown off balance by problems in the ear)

Uneven seat
. Hip pain

. Genital discomfort

. Rectal discomfort

Walking on toes
. Arthritis in ankles, feet, hips or

. Knees

. Tight heel cords

Waving fingers in front of the eyes
. Migraine

. Cataract

. Seizure

. Rubbing caused by blepharitis (inflammation of the eyelid) or corneal abrasion

Waving head side to side
. Declining peripheral vision or

. Reliance on peripheral vision

Whipping head forward
. Atlantoaxial dislocation (dislocation between the vertebrae in the neck)

. Pain in hands/arthritis

Won’t sit
. Akasthisia (inner feeling of restlessness)

. Back pain

. Rectal problem

. Anxiety disorder

2Ruth Ryan, M.D. James Salbenblatt, M.D., Melodie Blackridge, M.D.
2 Ruth Ryan, MD, The Community Circle; 1556 Williams Street, Denver, Colorado 80218; Handbook of Mental Health Care for Persons with Developmental Disabilities. (1999)

Pain is often a very real cause of challenging behaviors. Look at Appendix B.1 for excellent ideas to consider about pain being the source of the challenging behavior. And in Appendix B.2 you will find an extensive list of medical issues that should be considered. Be sure to look at both of these for additional ideas.

VI. SUPPORTING PEOPLE IN POSITIVE WAYS
No matter who the person is that we work with (friend, co-worker, person that we support), we can ALL support people in positive ways. You probably already use these approaches and don’t know that they are also called “positive behavior supports”.
A. What can I do on a day-to-day basis that might be helpful to the person?
Consistency is important in working with others. Keep your word! Follow through on what you promise. This is very important in cultivating the trust of persons we serve. Being genuine goes hand-in-glove with consistency.
Treat people in ways that you would want to be treated. Remember that you hope to get MORE support, not less, when you need help. When was the last time you said, “I was non-compliant today, so I don’t believe I’ll smoke that cigarette.” Instead, if
you’re having a really hard time and someone knows you are a smoker, they will likely offer you a cigarette!
Have you noticed that we often ask those who have the least adaptive skills, or persons struggling to deal with their internal world and the world around them, to make the most accommodation within their lives? Would you want to live your life in the same way you are asking of them?
All of us working with other persons can be sensitive to the comfort needs of an individual. For example:
1. If the person is hungry, provide a snack, if permitted.
2. If the person is thirsty, provide water or other suitable drink, if permitted.
3. If the person is hot or cold, alter the environment or assist them into more comfortable clothing.
4. If the person is sad, talk with them about what is making them sad.
5. If the person is bored, talk with them about what they want to do; help them with getting the resources necessary to feel occupied and productive.
6. If a person is uncooperative, provide incentives or offer choices.
7. If a person is being annoying to you, try ignoring the behavior or see if you can figure out what is behind the behavior that is annoying to you.
8. If the person needs to get away from stimulation, support them in finding a quiet place.
9. If the person cannot concentrate during an activity or event, see what you can do to structure the activity or event to be more manageable for them.
10. If the person is not feeling well and does not want to attend what is “required”, permit a “sick day” or figure out how to help them feel better.

B. Using positive behavior supports.
All of us can use positive approaches when working with persons we serve and support. These approaches are called “positive behavior supports.” The purpose of positive behavior supports is to support individual growth, enhance the person’s quality of life, and make the use of more intrusive measures unnecessary. Positive behavior supports work best when we understand what works from the point of view of
the individual.
Positive behavior supports include ways to minimize situations or issues that are stressful for the individual and ways to help the individual have maximum control over their life. Positive behavior supports don’t emphasize rewards and punishments. Positive behavior support strategies include:
. Understanding how and what the individual is communicating;
. Understanding the impact of other’s presence, voice, tone, words, actions, and gestures, and modifying these as necessary;
. Supporting the individual in communicating choices and wishes;
. Supporting staff to change their behavior when it has a detrimental impact;
. Temporarily avoiding situations that are too difficult or too uncomfortable for the individual;
. Allowing the individual to exercise as much control and decision-making as possible over day-to-day routines;
. Assisting the individual to increase control over life activities and environment;
. Teaching the person coping, communication and emotional self-regulation skills;
. Anticipating situations that will be challenging and assisting the individual to cope or to respond in a calm way;
. Filling up the person’s life with opportunities such as valued work, enjoyable physical exercise and preferred recreational activities; and
. Modifying the environment to remove stressors (such as irritating noise, light or cold air).
C. Combining person-centered planning with positive behavior supports
All of us have dreams or goals we want to achieve. And every environment has certain rules and regulations that we must follow in order to achieve those goals or dreams. When working with someone who has identified a goal or dream, you must find out what the person already understands AND what skills the person already has before you teach new rules or skills that will help them achieve the goal or dream.
The steps to take to help the person reach a goal or dream may not be immediately clear. Sometimes you have to figure out how you can help someone reach a goal of “I want to get a part-time job in housekeeping” or “I want to live with my sister.” What
follows is one example of how staff helped an individual increase control over his environment so that he could reach a desired goal.
Emmanuel wanted to continue to live with his sister, Beatrice. Beatrice said he could not live with her because Emmanuel leaves smoldering cigarettes in the ashtrays. So the “rule” was that Emmanuel must put out his cigarettes completely in order to continue living there.
Emmanuel DID know how to get his cigarettes into an ashtray, but he DID NOT extinguish the cigarette. Staff had to teach Emmanuel how to completely extinguish his cigarettes. Staff also had to figure out what he needed that would help him get the cigarette all the way out.

By figuring out what the person already knows how to do, what they don’t know how to do, and what they might need to achieve a goal, we can come to understand how we need to support the person in reaching that goal. Below is an example of how this information might be captured.
EXAMPLE 6.1

BEHAVIOR
WHAT THE PERSON KNOWS
REQUIRED SKILL OR BEHAVIOR
SKILL TO BE TAUGHT
RESOURCE REQUIRED

Leaves cigarette butts smoldering in ashtray
Puts cigarettes in an ash tray
Put the cigarette completely out
Extinguish cigarettes completely
Ashtray with sand
If you look at Appendix C you will find examples of questions that could be used to help you determine an individual’s level of satisfaction with their life and circumstances that surround it.
D. In closing…
As we close this chapter on positive behavior supports, remember that it is important that people have choice in decisions that must be made, that people have supports necessary to help them reach their goal or dream, and that there are things to look forward to. It is important that we understand the strengths, skills and preferences of the individual as well as their needs or limitations. And it is important that we help people develop enduring, positive relationships.
The use of positive behavior supports toward helping people live purposeful and
satisfying lives should be a natural part of how we support and care for individuals.

VII. WHAT DO I DO FIRST? Identify and Remove the Cause of Challenging Behaviors
We’ve got to understand what the person is communicating through the challenging
behavior or what is “causing” the challenging behavior. Have you answered these questions found in Section V.D.?
1. Is the challenging behavior a symptom of a medical disorder?
2. Is the quality of the person’s life acceptable (in their opinion) in terms of personal relationships, personal choices or living situation, etc?
3. Is the challenging behavior a side effect of a medication they are getting?
4. Is the challenging behavior part of a cluster or chain of related behaviors?
5. Is the challenging behavior the result of a lack of a skill or skills?
6. What does the behavior get for the person?
7. What does the behavior help the person escape?
8. What does the behavior help the person avoid?
Remember to consider the details that are part of these questions. Consider the examples of physiological, social, psychological or environmental issues that may be “causing” a person’s behavior that are listed in Section V.B., Example 5.1. Look at the list of common “problem” behaviors and speculations about their causes in Section V.D, Example 5.2. And refer Appendix B for examples of how pain might be communicated and for an extensive list of medical issues and how they may be communicated through behavior.
A. Show me some real examples of what you are talking about.
What follows are three examples of how situations could have been avoided if providers had looked at some common sense causes before assuming that the challenging behavior was due to some “out-of-control” mental illness or developmental disability.
EXAMPLE 7.1
Mr. Jones has severe cognitive challenges and he cannot speak. He has no history of being violent or destructive. One evening, he displayed rage and began throwing the furniture in his home. He was taken to the
local emergency room to be seen by a psychiatric crisis intervention specialist. He was admitted to a psychiatric hospital with a diagnosis of psychosis.
However, the physician at the hospital determined that Mr. Jones was suffering from a severe bowel impaction. Mr. Jones was promptly treated and his outburst did not reappear. His diet and fluid intake were adjusted and his home provider was trained to look for signs of constipation and irregularity. By dealing with these causes, Mr. Jones did not require further psychiatric admission nor did he need a behavior support plan.

EXAMPLE 7.2
Ms. Smith is a person who had never been known to act up. She began to show considerable withdrawal at her work-training program and would not participate in the program. In fact, over a period of days, her withdrawal turned to anger and she would refuse to attend the program. She began complaining of illness and making excuses to avoid going to work. She was taken to the outpatient mental health clinic for psychiatric evaluation. She was prescribed medication for both depression and psychosis.
Days later, a counselor who had worked closely with Ms. Smith in another agency came to work at Ms. Smith’s work-training program. This counselor knew Ms. Smith very well and recalled that Ms. Smith had been a victim of rape years earlier. The rapist was a tall man with tattooed forearms. The work-training staff recognized that about the
time Ms. Smith’s challenging behavior began to surface, she had been assigned to a new work group. In this group was a man whose forearms were tattooed. Although this man was not the rapist, his appearance had triggered a post-traumatic stress reaction in Ms. Smith. Armed with this knowledge, the work-program staff reassigned Ms. Smith to work with others and away from the man with the tattoos. Ms. Smith’s withdrawal, anger, and refusal to cooperate with the work-program vanished immediately. Ms. Smith did not require further medication or a behavior support plan, although she did resume therapy at the local mental health center to help her develop coping strategies for when she encountered men with tattoos.

EXAMPLE 7.3
Ms. Stacy is a woman in her thirties who has autism. She does not communicate with words, but has strong opinions about what she likes and dislikes. Ms. Stacy lives in her own home, with 24-hour support. For many years, Ms. Stacy attended the local day habilitation center. The center had strict rules about “appropriate conduct,” but Ms. Stacy never followed them. While she liked individual staff at the center, she refused to participate in many of the organized group activities. During these group activities, she
would regularly scream, throw things and occasionally strip down to her underwear. On community outings she would often wreak havoc while on the center’s van by yelling, stripping or lying on the van floor, or by refusing to get up.

The center’s staff was incredibly stressed and frustrated by Ms. Stacy’s behavior. Ms. Stacy was only calm when she was allowed to look at her magazines without others around her, often with the support of one staff. However, the center could not guarantee individual staffing all of the time, because it took attention away from other clients. Ms. Stacy, her family, and her providers had numerous meetings about Ms. Stacy’s infractions of the center’s rules and tried a number of behavior modification techniques to address the unacceptable behavior. Nothing worked.

The center discharged Ms. Stacy for repeatedly failing to follow the center’s rules. Ms. Stacy’s personal support provider began supporting Ms. Stacy during her day. Ms. Stacy was no longer required to participate in group activities, could plan her own activities and was accompanied by a companion she adored. Her stripping stopped almost immediately and her other challenging behaviors greatly decreased. Ms. Stacy now smiles more and is much calmer. While she still yells and throws things occasionally, this behavior is typically a result of menstrual cramps or anger about a specific event. Her “behaviors” are more isolated, making them easier to address. Because of individualized supports in an environment that is comfortable for her, Ms. Stacy is able to experience her community on her terms and is enjoying her life more.

B. The Wellness Recovery Action Plan3 (WRAP Plan) is an effective way to identify and remove the cause of challenging behaviors
3 Wellness Recovery Action Plan: A System for Monitoring, Reducing and Eliminating Uncomfortable or Dangerous Physical Symptoms and Emotional Feelings, Mary Ellen Copeland, MS, MA, Peach Press, Revised 2002
In Georgia, many consumers and staff have been introduced to the process of developing a Wellness Recovery Action Plan. The Wellness Recovery Action Program is a structured system for monitoring uncomfortable and distressing symptoms and, through planned responses, reducing, modifying or eliminating those symptoms. It also includes plans for responses from others when an individual’s symptoms have made it impossible for the individual to continue to make decisions, take care of him or her self and keep him or her safe. When the WRAP Plan is used, the person is able to MINIMIZE or AVOID challenging behaviors that can result when symptoms are not
properly addressed.
While this approach is being taught and used in mental health care, persons in MR/DD care who have the cognitive and verbal or expressive skills to describe how they feel and what helps them feel better or worse could also use it.
Anecdotal reporting from persons who are using this system indicates that by helping them feel prepared, they feel more in control of their lives resulting in a better quality of life, even when symptoms of the illness are troublesome.
What follows is the basic outline of a WRAP Plan. Refer to the publication noted in the footnote for full detail. Crisis plans will be discussed in greater detail in Section XI of this manual.
EXAMPLE 7.4

BASIC OUTLINE OF A WRAP PLAN

Section 1 Daily Maintenance Plan
Part 1: Description of how you feel when you feel well
Part 2: List everything you need to do every day to maintain wellness

Section 2 Triggers
Part 1: Events or situations that might cause symptoms to begin
Part 2: A plan of what to do if the triggers occur

Section 3 Early Warning Signs
Part 1: Identification of subtle signs that indicate a worsening situation
Part 2: A plan of what to do if these early warning signs occur

Section 4 Symptoms That Indicate Worsening
Part 1: What to do if these symptoms occur

Section 5 The Crisis Plan
Part 1: What I’m like when I’m feeling well
Part 2: Symptoms that say I’m not doing well
Part 3: Who are my supporters?
Part 4: Medication that works; medication that does not work
Part 5: Treatments that work; treatments that do not work
Part 6: Where can I go in the community?
Home/Community Care/Respite Center
Part 7: Treatment facilities that are options for me
Part 8: What help do I need from my supporters?
Part 9: How do my supporters know I am better?

Section 6 Post Crisis Planning
Descriptive behaviors, feelings and activities that will indicate healing is
under way.

VIII. APPROACH I: GATHER INFORMATION ABOUT THE CHALLENGING BEHAVIOR

A. We have not been able to figure out the behavior! Now what do we do?
Not all cases are like the above examples. And not all persons have the cognitive and verbal or expressive skills to develop a WRAP Plan.

When a WRAP Plan is NOT appropriate and when the less obvious causes of a challenging behavior cannot be determined, it is time to figure out the source of challenging behavior by doing a functional assessment.
B. What is a functional assessment?
A functional assessment is a systematic way to look at information. Functional assessment is based on the understanding that ALL behavior is influenced by the person’s internal AND external environment.

Functional assessment involves looking at what is happening before and after a behavior occurs in order to understand how the behavior is influenced by those events. Such events can take place within the person’s external environment or internal environment. In this sense, a challenging behavior might be influenced by external events like a noisy, over-crowded social situation, but might also be influenced by internal events such as a headache or a feeling of frustration.

Events that take place before a behavior occurs are called antecedents. Events that take place after a behavior occurs are called consequences. By collecting information about events that occur BEFORE a behavior takes place (antecedents), we will begin to see that when the particular event occurs, the behavior of concern will likely occur. Conversely, when these events do not occur, or when the events are modified or interrupted in some way, the behavior of concern is less likely to occur.

By collecting information about events that occur AFTER a behavior takes place (consequences), we will begin to see that if a behavior results in a DESIRABLE consequence for the person, he or she is more likely to repeat that behavior in similar situations. Conversely, if the behavior results in an undesirable consequence for the person, he or she is less likely to repeat that behavior in the future in similar situations.
C. Looking for the A-B-C’s
The analysis of antecedents and consequences is often referred to as the A-B-C Model of functional assessment:
. A stands for the influential events that take place before a behavior occurs (antecedents)

. B stands for the behavior (appropriate or challenging); and

. C stands for the influential events that take place after a behavior occurs (consequences).
Conducting a systematic, organized assessment helps to identify those events that are likely to have the greatest influence on the behavior of concern.
D. How much information needs to be collected and for how long?
It is important to look for the A-B-C’s over time and to gather information each time the behavior is repeated. Some functional assessments can be completed after only a few recorded observations of the behavior. Others may require numerous observations or may even continue after some treatment interventions have been implemented.

Sometimes a functional assessment can be conducted informally by looking at what happened before a challenging behavior occurred. For challenging behaviors that occur with some degree of regularity, it is helpful to write down your observations, to help take a “fresh look” at the situation.

E. How do I collect information about the A-B-C’s?
Examples of ways to document this information are available in books and on the
Internet, but basically the process looks something like the following.

EXAMPLE 8.1
COLLECTING THE A-B-C’S
A = Events that occur before the behavior, or antecedents
B = The behavior
C = Events that occur after the behavior, or consequences

. Physiological

. Social

. Psychological

. Environmental
The behavior should be described in measurable and observable terms that everyone understands
. Did the behavior result in a reward for the person?

. Did the behavior result in escape from a particular situation?

. Did the behavior allow the person to avoid something?

To further illustrate the use of this form, read the case below, and then refer to the grid that follows.
James, a nonverbal individual with severe mental retardation, had a habit of plopping down in front of the refrigerator when he wanted something to eat. He was in the way when staff tried to cook, and because he would not move, they could not open the refrigerator. He also occasionally hurt himself when he plopped himself down on the floor.

EXAMPLE 8.2
COLLECTING THE A-B-C’S – AN EXAMPLE
A = Events that occur before the behavior, or antecedents
B = The behavior
C = Events that occur after the behavior, or consequences

. James smacks his lips

. James sits on the floor only when people are cooking
James “plops” himself down in front of the refrigerator, often with enough force that he bruises himself. He then refuses to move, sitting in a place that blocks the refrigerator door.
. Staff give James bits of food while they cook

. James makes happy-sounding noises after getting something to eat
As a result of collecting the data, staff decided that giving James food in front of the refrigerator was encouraging him to repeat the behavior. They also decided that James should be offered food ONLY at the table. Staff decided to teach James to use sign language for “eat” and for “drink”. When he used the sign, staff rapidly responded to the sign with a snack or drink, which was given to him at the dining table.

It took a while to replace the behavior of sitting in front of the refrigerator because James would exhibit both behaviors – plopping down in front of the refrigerator and signing – at the same time. Since the food was offered at the table and not while he was in the floor in front of the refrigerator, he gradually began going to the table and signing for what he wanted.

The analysis of the event showed staff that James’ internal response (hunger) was being rewarded by an external action or response by the staff (the socialization with staff as they cook AND getting to eat bits of food).

And there can be negative responses to social situations. For example, Johnny loves to watch TV alone. But when others who live in the home come into the room during his TV time, Johnny begins to bang his head. If the others are asked to leave the room, Johnny quits banging his head.

Sometimes you can figure out the “why” of a behavior based on watching the events that occur right before and right after the behavior. But if it is not obvious or you cannot figure it out after trying to collect data on your own, then it is time to call in a professional!

X. APPROACH II: CALL IN A PROFESSIONAL TO DEVELOP A POSITIVE BEHAVIOR SUPPORT PLAN (PBSP)
When a WRAP Plan is NOT appropriate AND when collecting the A-B-C’s described in Approach I DOES NOT result in identifying the “cause” of the
challenging behavior, the provider should call in a professional who is qualified to develop a positive behavior support plan.
A. What is a Positive Behavior Support Plan ((PBSP)?
A positive behavior support plan (PBSP) is a formal plan to help everyone do the same thing on a consistent basis. The plan is based on an assessment of the challenging behavior that includes understanding the strengths, preferences and interests of the individual, the goal that is to be achieved, and the A-B-C’s related to the behavior that is of concern,

The plan consists of using the fewest interventions or support strategies possible coupled with reinforcement for appropriate alternative behaviors that will modify, decrease, re-direct or eliminate the challenging behavior. Success is measured by reductions in challenging behaviors, performance of alternative skills, and improvements in quality of life.

1. Understanding the person’s “story,” including their strengths, skills and limitations;
2. Having respect for the person’s desire to follow his or her dreams to live life as normally as possible while being supported to overcome the challenging behavior;
3. Respect of his or her dignity, the right to make choices, and the right to live as independently as possible.

Positive behavior support plans involve all of the components of Approach I “and then some.” It is the “and then some” that makes it a new approach.

B. Thirteen outcomes you should expect to find in a completed PBSP

The development of a PBSP includes a written plan for ALL involved persons to follow. The following thirteen outcomes are critical in achieving a consistently positive approach in all aspects of the person’s life. This is the “and then some” mentioned above.
1. Ensure that a person-centered approach is used in developing the plan. This may seem obvious, but plans can quickly become “controlling,” in the name of safety when addressing severely challenging behaviors.

2. Establish clear operational definitions of behaviors to be decreased as well as those to be increased. This means using descriptive terms that everyone understands so that there is consistency in identifying the challenging behavior:

a. There must be agreement between the professional and staff as to the behavior that is occurring.

i. Behaviors must be described in observable terms

ii. Behaviors must be described in measurable terms
3. Ensure that the plan is practical… that it can be done. A plan that is not practical, that is cumbersome, that does not consider practical, day-to-day issues WILL FAIL.

4. Identify the antecedents and consequences that influence the occurrence of the behaviors of concern. It is critical to a PBSP to know what events, both before and after a behavior, increase the likelihood of that behavior’s occurrence.

5. Ensure that functional skills are taught as part of the active treatment routine. Learning efforts should focus on meaningful and purposeful skills that:

a. Support the individual’s choices and goals;

b. Are essential to personal independence;

c. Are needed often;

d. Afford opportunity to participate in meaningful, purposeful and age-appropriate activities;

e. Enable the individual to do and attain the things they desire as well as to avoid those things they dislike.
6. Ensure the person’s environment is a positive, healthy, educational, supportive, nurturing, safe and therapeutic environment that:

a. Encourages and honors choices by the individual;

b. Promotes normalcy;

c. Is suited to the individual’s needs; and

d. Includes the individual’s preferred items and events.
7. Identify and reduce or eliminate conflicts regarding individual choice making. Ensure that choice is built into the plan and that everyone involved knows how to help the individual express choices (especially if the person is unable to talk).

a. Not having choice means not having control;

b. Not having control means anger;

c. Anger will be expressed by challenging behaviors
8. Ensure that positive and meaningful social interactions are available both with peers and staff. Identify and reduce or eliminate social interactions that contribute to the occurrence of challenging behavior. Ensure that everyone
involved knows how to interact with the individual in a group setting, how to interact in a positive way, and how to interact in a manner that is suited to the individual’s capacity as well as chronological age.

9. Ensure that everyone involved knows how to use prompts, error correction, and task analysis to increase the likelihood of desirable appropriate behavior. These methods help increase consistency from setting to setting and from person to person.

10. The plan should identify teaching methods such as “shaping” and “chaining.” These methods make teaching and learning easier by conducting learning activities in smaller segments at a pace suited to the individual’s abilities.

a. If you ever taught someone to throw a ball, you used “shaping”

b. If you ever taught someone to memorize his or her phone number, you used “chaining.”
11. Ensure that the fundamental components of the PBSP are clearly described and understood by everyone involved. Regardless of the format used for a PBSP, the fundamental components should address the following:

a. What are the behaviors to increase?

b. What are the behaviors to decrease?

c. What things should be provided in the individual’s environment on a day-to-day basis to decrease the likelihood of challenging behaviors?

d. What things should be avoided in the individual’s environment on a day-to-day basis to decrease the likelihood of challenging behaviors?

e. What event(s) are likely to occur right before a behavior of concern?

f. What should you do if that event(s) happens, or what can you do to keep it from happening?

g. What should you do if the behavior to increase occurs?

h. What should you do if the behavior to decrease occurs? This should not involve punitive reprisals, unpleasant consequences or any other restrictive interventions.
12. Ensure that staff knows when to ask for help! You have a right and responsibility to ask! The professional should identify, with the help of staff, the
types of problems that may occur when implementing a PBSP, and should be certain that everyone knows who to ask for help if implementation problems occur.

13. Ensure that there is some form of reliable data collection taking place. This should be simple, efficient and manageable for staff. The professional should establish the means for evaluating effectiveness of the PBSP using an efficient, reliable data collection method. This is essential to making sound decisions regarding continuation, revisions, or discontinuation of a PBSP.
C. What kind of professional can write a positive behavior support plan (PBSP)?
A PBSP should ONLY be written, implemented and supervised by a qualified professional. The PBSP is considered to be part of the treatment plan for the person served and must be incorporated into the Individualized Service Plan (ISP) or Individual Recovery Plan (IRP) by reference.
The same professional requirements apply to the development of a PBSP that apply to the development of a treatment plan. Generally people in mental health services will develop their own WRAP Plan with the support of a professional. However, if a PBSP is developed:
1. For an individual in mental health services, it must be developed by someone who is a Qualified Mental Health Professional (QMHP)
2. For an individual in MR/DD services, it must be developed by someone who is a Qualified Developmental Disability Professional (QDDP)
For more information about professional qualifications for QMHP or QDDP, refer to the Provider Manual for Community Mental Health, Developmental Disabilities and Addictive Diseases Providers Under Contract with the Georgia Department of Behavioral Health and Developmental Disabilities, Section III B, “Core Requirements for All Providers,” section C, “Professional Designations.”
In both cases, someone who has experience with positive behavior supports MUST develop the PBSP. When you are researching to find a professional, here are some suggestions to consider:
1. Network in the field to get names of several professionals
2. Get references!
3. Talk to other providers who have had a plan written by that professional
a. Was the plan clear?
i. Refer to the list of thirteen outcomes (above)
b. Did the plan include practical considerations?
i. Could it be implemented in the “real world”?
c. Did the professional train the staff
i. About the plan?
ii. About how it should be implemented?
d. Was the professional available to the staff?
e. How much support did the professional provide?
f. Was the professional willing to figure out an alternative plan when the original plan needed to be modified?
g. Did the professional see the plan through until there was a satisfactory outcome?
D. How do I know that the plan is written using positive behavior approaches?
NOTE: Remember that the plan uses ONLY positive interventions to
replace the challenging behavior with other behavior judged to
be more acceptable. The PBSP does not use any restrictive
or unpleasant techniques to modify challenging behaviors.

In Appendix D, a variety of positive behavioral approaches are identified. If you have a concern, check Appendix D.
E. Checks and balances to be sure staff know what to do
Below are four things that SHOULD BE CHECKED to be certain you understand the plan. If you can answer these questions, the plan is likely a complete and comprehensive plan.
1. Do you understand the behaviors of concern that are targeted by the plan?
a. What are the behaviors to increase?
b. What are the behaviors to decrease?
2. Do you know what environmental supports MUST be in place on a day-to-day basis to reduce the likelihood that problems will occur?
a. What things need to be in place on a daily basis to support the individual?
i. For example, Gina was known to HAVE to have her purse with her at all times! If she forgot her purse, she became inconsolable and absolutely nothing else could be done until she had her purse. This is an example of an environmental support for Gina.
b. What things should be avoided to support the individual?
i. For example, it was well known that loud sudden noises triggered a post-traumatic stress reaction for Joe that would become psychotic in nature. Therefore it was important to try to avoid settings where this might occur.
3. Do you know the antecedents to look for?
a. The plan needs to identify those things that occur prior to the challenging behavior. This is AS IMPORTANT as knowing what the target behavior is.
b. When those events happen, what needs to happen to modify, re-direct, interrupt, remove or prevent the challenging behavior?
NOTE that ALL PBSPs need to identify the antecedents. If you can’t respond before the behavior occurs, that leaves ONLY an option of responding after, which is NOT proactive but is reactive.

4. Do you know what you should do following a challenging behavior?
a. What do we do when appropriate behaviors occur?
b. How do we respond in a non-restrictive way when challenging behaviors occur?
This means doing as little as possible or only what is necessary to stop the challenging behavior or to assure that no one gets hurt.

IF YOU CANNOT ANSWER THESE QUESTIONS, YOU DO NOT KNOW WHAT TO DO! It is a good idea for staff to write their own answers to these questions after the plan is developed. That way the professional can see what staff understands in their own words, and the professional can be certain that everyone has a correct understanding of the plan and how to implement the plan.

F. Review and oversight of the PBSP
As stated, all consumers have a treatment plan that must be developed and approved by
either an interdisciplinary treatment team or a multidisciplinary treatment team. The
PBSP must be incorporated by reference into ISP or the IRP. The rules set within
each agency for the monthly, quarterly, and annual review of ISP’s should be made
applicable also to the PBSP.

Review and approval by all of the above stakeholders should occur when a PBSP is first developed. When the plan is first implemented, it may need tweaking as often as weekly, monthly or quarterly. Additionally, the plan should be reviewed and re-authorized more frequently if the PBSP undergoes a significant revision. The data should be reviewed at least annually thereafter. NOTE that annually is the LEAST frequent interval that the plan should be reviewed.
Remember to obtain appropriate consents and authorizations from:
1. The consumer or his or her representative
2. The interdisciplinary team
3. And to incorporate it into the ISP
Despite your best efforts, there will be occasions when serious and challenging behaviors represent a danger to the individual or to others. If the individual has this sort of history OR if this becomes the case, there should be a safety plan or crisis plan to fall back on. These plans, along with parameters for implementation and management, will be discussed next.

X. WHAT CAN WE DO IF THE BEHAVIOR SUPPORT PLAN IS NOT WORKING?
A. Seek additional review and consultation
The first and most obvious answer is to re-evaluate the PBSP as well as re-evaluate the implementation of the plan. Actions to take and issues to consider in the re-evaluation of any plan include but may not be limited to the following:
1. Call the professional who wrote the PBSP and ask for an evaluation of:
a. The plan
b. The implementation of the plan
2. Talk with the individual to the extent possible regarding:
a. The plan
b. The implementation of the plan
3. Talk with the staff regarding
a. The plan
b. The implementation of the plan
i. Assure that the plan has been implemented in a personal, caring and consistent manner
4. Affirm with staff what they are doing right
5. Tweak the plan as necessary
6. Invite the interdisciplinary or multidisciplinary team to review and discuss the concerns
7. Invite subject experts to sit in, including regional or state DBHDD staff
8. Seek additional consultation as required

REMEMBER: something that works initially will not be effective indefinitely. The plan WILL have to be tweaked and revised on more than one occasion!

B. What if the challenging behavior is affecting the individual’s personal health
and safety, or the health and safety of others?
If the challenging behavior is affecting or is likely to affect the individual’s personal health and safety or the health and safety of others, then a crisis plan or safety plan should be done.
1. A crisis plan should be developed as a part of the WRAP Plan by the individual with the support of a professional.
2. If the person is in MR/DD care and a WRAP Plan is not appropriate for them, a safety plan should be done by a professional.
The same recommendations and requirements about professionals discussed in Section IX. C. applies here.
Both the safety plan and the crisis plan (as part of the WRAP Plan) should be incorporated by reference into the ISP or IRP.

XI. APPROACH III A: DEVELOP A CRISIS PLAN
A. What is a crisis plan?
Crisis plans are used largely in the MH side of care. However, any individual who has the cognitive and verbal or expressive skills to describe how they feel and what helps them feel better or worse can develop a crisis plan. This can be accomplished independently or with the help and support of a professional.
Crisis plans are part of the Wellness Recovery Action Plan3 (WRAP Plan) that is developed by the individual. A professional may give guidance to assure the plan is well thought through, but the crisis plan should represent the individual’s work and their wishes.
3 Wellness Recovery Action Plan: A System for Monitoring, Reducing and Eliminating Uncomfortable or Dangerous Physical Symptoms and Emotional Feelings, Mary Ellen Copeland, MS, MA, Peach Press, Revised 2002
Noticing and responding to symptoms BEFORE they are manifest as challenging behaviors reduces the chances that the individual will be in crisis. By writing a clear crisis plan when the individual is well, he or she can instruct others about care when he or she is not well. Thus the individual maintains responsibility for his or her own care.
The crisis plan portion of the WRAP Plan is different from the rest of the WRAP Plan in that other persons will use the crisis plan on behalf of the individual. Once the individual has completed their personal crisis plan, copies of the plan should be given to the people named in the plan as supporters.
B. What are the essential components of a crisis plan?
The essential components of a crisis plan are the following. Since the individual is writing their own plan, the components are described in first person language.
1. Describe what I’m like when I’m feeling well
2. List the symptoms the would indicate to others that they need to take over responsibility for my care and make decisions on my behalf
3. Identify my supporters or those people who I want to take over for me when the symptoms come up
a. There should be at least five people on the list of supporters
4. List all of the information about my medications
a. The name of my physician or physicians and phone numbers
b. My pharmacy and the number
c. My allergies
d. The medications I am currently on
i. Why I take these medications
e. The medications I prefer to take if medication becomes necessary
i. Additional medication I prefer to take if required
ii. Why I choose these medications
f. The medications that should be avoided
i. Why those medications should be avoided
5. List the treatments I would want in a crisis situation
a. Tell why the treatment is selected
b. Also list treatments that have negative connotations
i. Why those treatments feel bad or don’t work
6. Identify options for community care
a. Would you be able to stay at home?
i. If so, what supports would you need to make that happen
b. Is community care outside of the home an option as an alternative to hospitalization?
i. If so, identify what that is, where it is and how to access it
c. Is respite an option?
7. Specify where you would go if you need a safe facility outside the scope of community care
a. Where do you want to go?
b. Where do you want to avoid?
8. What do I need my supporters to do for me?
a. What could they do that would reduce symptoms?
b. What could they do that would help me relax?
c. What could they say to me that helps?
d. What could they do for me that MUST be done?
i. Get the mail
ii. Feed the pets
iii. Pick up the kids
iv. Pay my bills
e. What do my supporters need to avoid because those things make me worse?
9. How do my supporters know when to back off or that I am feeling better?
The crisis plan should be updated whenever there is new information that needs to be shared or when a different decision is made that needs to be communicated. Remember that the supporters need to have copies when this information is updated.
Be sure that the individual signs the crisis plan in the presence of two witnesses. While crisis plans are not considered a legal document in Georgia in the way Living Wills or Durable Powers of Attorney are, if the plan is witnessed, the seriousness of the plan and its intent for use is emphasized.

APPROACH III B: DEVELOP A SAFETY PLAN
A. When should a safety plan be written?
In instances where challenging behaviors affect the health and safety of the individual or others, a safety plan should be developed.
Safety plans should begin with the use of interventions written in the PBSP, but should further specify additional steps to take in response to challenging behavior that is dangerous to the health and safety of the individual or others.
B. Where does the PBSP leave off and the safety plan begin?
A safety plan should be written when there are indications of challenging behavior(s) that may jeopardize the psychological or physical health and safety of individual or others. The safety plan should be constructed so that the individual AND staff are aware of how such challenging behaviors(s) are to be addressed.
IN ALL CASES, interventions found in ANY safety plan should begin with the least
restrictive intervention that would reduce or eliminate risk. Examples of issues to consider when making a safety plan follow.
1. Identify and document the challenging behavior(s) that represent risk to the psychological or physical health and safety of others.
2. Do contingency planning so that the individual and staff know “what to do if” or “what will happen if.”

a. For each challenging behavior, document the interventions to be used, such as:

i. Specify verbal intervention strategies

ii. Opportunity for quiet music, exercise, or some other form of activity that would re-direct his or her attention and energy

iii. Offer the individual an opportunity to get away from stimulation

3. Determine what technological devices might offer extra supports for staff assistance, such as, but not limited to:

a. Warning devices

b. Staff cell phones
4. Determine whether more intensive supports in the form of staff presence is needed

a. Specify under what conditions the more intensive supports could be accessed

b. Specify how staff should access these supports
5. Specify the challenging behaviors that would trigger the use of a safety intervention of last resort:

a. The challenging behavior MUST be one that threatens the health or safety of the individual or others.

b. Only manual hold (also known as personal restraint) may be used. Refer to Section XIII for a full discussion of this safety intervention of last resort.
6. Specify the challenging behaviors or circumstances that would require the support of law enforcement

7. Specify the challenging behaviors or circumstances that would require professional emergency intervention, such as stabilization at an emergency receiving and evaluating facility
The safety plan must be developed under the direction and
supervision of a QDDP and must be incorporated by
reference into the ISP, or for persons in MH care, the plan
must be developed under the direction and supervision of a
QMHP and must be incorporated by reference into the
IRP. The rules set within each agency for the monthly,
quarterly, and annual review of ISP’s should also be made
applicable to the safety plan.

Review and approval by all of the above stakeholders should occur when a safety plan is first developed. It should be reviewed and reauthorized more frequently if the PBSP undergoes a significant revision or if it is determined that it is not meeting the needs of the individual. Remember to obtain appropriate consents and authorizations from:
1. The individual or his or her representative
2. The interdisciplinary team
And to incorporate it into the ISP or IRP
C. Are there any particular processes that must occur when a safety plan is used?
When an emergency intervention of last resort is used, there are certain specific processes for documentation and debriefing that must be followed. Don’t forget that situations such as elopement or the use of an emergency intervention requires that an incident report be completed. Be sure to refer to your agency policies and procedures on these issues as well as policies and procedures of the Division of DBHDD, which are referenced in the Provider Manual for Community Mental Health, Developmental Disabilities and Addictive Diseases Providers Under Contract with the Georgia Department of Behavioral Health and Developmental Disabilities. Processes for documentation and debriefing after the use of an emergency safety intervention are discussed in Appendix E.2, “Processes for documentation and debriefing after the use of an emergency safety intervention.”
D. Can medication be used in a safety plan?
Did you notice that medication is NOT referenced as part of the equation of the safety plan? A group of physicians, psychiatrists and pediatricians who work with psychiatric and behavioral issues in public and private settings stated that medications should be
used for targeted symptoms. Using this line of thinking, medication should be used within the safety plan ONLY if there are targeted symptoms that are addressed by the medication, such as:
1. Hallucinations
2. Impulsive thoughts, etc.
You will find a full discussion regarding the use of medication for challenging behaviors in Section XII.
E. Should a safety plan be written when the health and safety of the individual or the health and safety of others is NOT affected?
A safety plan could be written when the health and safety of the individual or others is NOT affected. Examples of when this might occur are the following:
1. Verbal threats that do not result in physical harm to the person or to others

2. Destruction of property that does not affect the health and safety of the individual or of others

3. Challenging behaviors such as stealing, arson, vandalism, pulling fire alarms, etc.
You will need to give THOUGHTFUL consideration when you write plans for issues that, when put into action, are actually crimes. Incorporating legal responses to these behaviors needs to be carefully considered.
When writing a safety plan that addresses challenging behaviors that DO NOT affect the health and safety of the individual or of others, the interventions written MAY NOT include using a safety intervention of last resort. A discussion of safety interventions of last resort will follow in Section XIII.
XII. USING MEDICATIONS FOR CHALLENGING BEHAVIORS
Unfortunately it has been noted from time to time that medication is periodically used to “control” challenging and not so challenging behaviors. The worst case discovered in a provider setting was one in which ALL individuals in the care of the provider (20 plus people) were prescribed some form of major tranquilizer such as Haldol, Mellaril or Thorazine; benzodiazepine such as Ativan, Xanex or Valium; AND medication ordinarily given for extra pyramidal symptoms that was given in such amounts that it was causing sedation, such as Benadryl or Cogentin.
This is an extreme example, but variations of this example are periodically found in
the community.
A. Is it ok to give medication for challenging behaviors?
We have talked about the fact that behavior is something you can see. It is something you can count. Behavior is NOT a mood, an attitude, or the fact that someone has an unbounded amount of energy.
So is it ok to give medication for challenging behaviors? No, it is NOT ok to give medication for challenging behaviors. A group of physicians, psychiatrists and pediatricians who work with psychiatric and behavioral issues in public and private settings said, “NO…behaviors are best treated with specific behavioral solutions”. They went on to say that medications should be used to treat ILLNESSES and their symptoms.
What follows are the points these physicians made about behavior and how to intervene with challenging behaviors. If you have read the other chapters that precede this one, these comments sound VERY familiar.
1. The overall goal when caring for individuals is that we support them with a safe and satisfying quality of life.
2. Many times we try to modify a behavior that is not really that big of a deal. Maybe it is OK for them to do something that we see as inappropriate. The behavior may be obnoxious but it is not hurting anyone.
a. An example is that of an individual who sits down in the floor and will not move. How important is it that they move at that time?
3. BEWARE OF POWER STRUGGLES! Many times the only winning move is not to play!
4. There is not a behavior that does not have an antecedent. We may not understand what that is, but there is definitely an antecedent behind that behavior.
5. Staff needs to be trained in how to look at a challenging behavior and figure out what might be happening that affects that behavior or the meaning of the behavior. All staff working with individuals needs to be more aware of antecedents.
6. Not every behavioral intervention will successfully address the challenging behavior. Sometimes you must go through series of changes in the plan in order to figure out how best to address the behavior.
7. It is very important to prioritize which challenging behavior to address and to work on one behavior at a time.
8. Think of behavior plans in terms of baby steps, not huge giant steps.
9. People have to see plans as fluid in nature. If the positive reinforcer is not working, it is not a positive reinforcer.
10. Staff’s interventions are only as good as the plan that is developed.
a. A behavior plan is only as good as the trained person developing it
b. A behavior plan is only as good as the consistency with which it is carried out
11. If the recommendations made are not followed, there is no chance that the intervention will work. Recommendations MUST be followed!
12. Decisions about the effectiveness of behavioral interventions need to be DATA DRIVEN.
13. It is very important to know what has been tried in the past.
14. Behavior plans need to be individualized to include choice and preferences of the individual. Homogenized plans (what is good for one is good for another) don’t work!
15. It comes back to identifying the cause of challenging behaviors.
16. Interventions recommended may be more difficult or time consuming to do, but the result is more positively life-changing in the long run.
Additionally, the physicians recommended that staff be trained in non-physical means of intervening with individuals, and that the training should emphasize maintaining the dignity of and respect for the person.
B. Are medications EVER appropriate to give to someone with challenging behaviors?
The answer is “yes,” but ONLY if the medication is used to treat symptoms of an
illness. The group of physicians discussing these issues made the following points.
1. Medications should be used to treat ILLNESSES and their symptoms. Medications should NOT be used for challenging behaviors that are not a product of illnesses and their symptoms.
2. You may see self-hurtful or injurious behaviors with psychiatric disorders; HOWEVER the medication used in these situations is treating psychiatric symptoms.
3. Symptoms should be treated even though it may not be totally clear what the diagnosis is.
4. When you cannot clearly explain that you are giving medication for particular symptoms, the line has been crossed.
5. The line has been crossed when medication effects interfere in daily life.
6. The purpose of medication is to improve the quality of life for the individual. If you are doing anything else with medication, it is not appropriate.
7. Medication should be used for specific symptoms only research supports the use of that medication for those symptoms.
8. It is important to know what medications have been tried in the past.
9. It is important for staff to understand that most psychiatric medications take a while to work. Some take up to a month or so to get a therapeutic level in the body.
10. It is VERY important to add only one medication at a time.
11. Decisions about medications and their effectiveness on targeted symptoms need to be DATA DRIVEN.
12. It is important that staff understand that any of us might have idiosyncratic reactions to medication (reactions that are opposite or different from the intended effect). This is ESPECIALLY true for individuals who have MR/DD disabilities AND with children.
C. Are PRN medications ever OK to use for individuals living in the community?
On this topic, the group of physicians was very clear: PRN medication should be to treat specific symptoms of illness, NOT challenging behaviors. Additionally, PRN medications are very appropriately used for psychiatric symptoms as a part of a WRAP or relapse plan.
PRN medications should be used ONLY in this way:
1. For specific targeted symptoms
2. The frequency of use should be tracked
a. How often is the PRN medication used?
b. What are the circumstances when the PRN medication is used?
3. What symptom was the PRN medication used for?
a. How effective was the medication for that symptom?
Orders for PRN medications should be written in this way:
1. Use X medication
2. Given or taken in X way
3. For X symptom
4. Not to exceed X amount in X times

D. When we take an individual to the doctor, what does the doctor need to know?
It is VERY important to both TAKE and BRING BACK the right information when seeing a physician. The physicians gave VERY SPECIFIC suggestions about what a doctor needs to know in order to make their best determination about how best help the individual.
REMEMBER, physicians see literally hundreds of people a month in their practice,
regardless of whether it is a public or private practice. The more detail you can have available for the doctor at the time of the visit, the better able the doctor will be to properly treat the individual. Here is what the physician group said.
1. Physicians need a good description of the symptoms or challenging behavior. They need to understand as clearly as possible exactly:
a. What is going on
b. When it is occurring, and
c. What is going on within the environment when these symptoms, issues or challenging behaviors occur?
2. They need to understand exactly what supports are in place so that the individual can live in the community
Additionally, they suggested having a more objective person make observations about
the symptoms, challenging behavior or other issues going on…someone who is not as closely involved on a day-to-day basis.
E. How should we prepare for a visit to the doctor?
These are specific points that were made about HOW TO PREPARE FOR A VISIT TO THE DOCTOR.
1. Come to the physician with a brief but succinct and accurate description of the individual’s medical history to include
a. A history of illnesses, surgeries, etc.
b. A list of chronic and ongoing medical issues for the individual
i. Include how each chronic and ongoing medical issue affects the life of the individual
c. A list of allergies and sensitivities
2. Bring a GOOD description of the symptoms or challenging behavior that is the concern, including
a. Exactly what is going on
b. Exactly when it is occurring
c. Exactly what is going on within the environment when these symptoms, issues or behaviors occur
d. Bring any data or tracking sheets that relate to the reason for the visit
3. Bring a complete list of the current medications that the individual is on, including
a. The name, dose, route and frequency of each medication
b. The purpose of each medication
c. Who ordered each medication
d. The original date the medication was ordered
4. Be able to clearly describe the community supports that are in place, which would include the individual’s
a. Living situation
b. Work situation or other daytime activities
c. Who is available to support the individual (who is important to the person)
5. It is VERY important to have someone accompanying the individual who knows the person’s story.
a. It is equally important that the person accompanying the individual be someone who can connect with and relate to the person.
b. Encourage family to come if possible or appropriate
6. Staff accompanying the individual need to make it clear that the purpose of the visit is to seek help for the individual, and to be specific about
a. The description of the behavior, issue or symptom
b. Exactly what we have attempted to do
c. And that we are willing to come back for additional visits if necessary to resolve the illness, issues or symptoms
F. What information needs to GO BACK to best support the individual?
It is important that good and accurate information GO BACK WITH the individual and staff so that care given to the individual is EXACTLY what the physician orders. The physician’s suggested this list of questions that the PROVIDER staff should ask.
1. Exactly what is being treated?
2. Ask for explicit instructions about the interventions or care that is ordered by the physician
a. Staff might consider using a tape recorder to help remember what gets said
3. If medications are ordered, be sure the individual AND staff understands
a. What are risks, benefits and alternatives to medication?
i. Say “the team wants to know”
4. Ask for explicit instructions about use of medications (this information could also come from a pharmacist)
a. How does the medication interact with food?
b. Are there any issues about taking this medication with other medications?
c. Are there any issues about the time of day the medication is ordered for?
d. What should be done if a dose is missed?
e. Are there any symptoms that would indicate that the medication is causing a problem?
f. Are there any lab requirements with the use of this medication?
NOTE: Use same pharmacy to fill ALL prescriptions so that the pharmacist is
WELL AWARE of ALL medications used by the individual and so adverse interactions between medications can be prevented
5. How long will medication take to effect a change in the symptom or illness?
6. If the medication is stopped, how long will it take to wear out of the person’s system
7. Be certain that staff understand the instructions given. If the use of a tape recorder was not an option
a. Ask for copy of physician’s note for the person’s record
b. If you have an agency form, the physician might be willing to make these notes on your form
8. Ask the physician if it is possible to e-mail questions to him or her (or some other form of written communication) if questions arise.
b. In regard to communication, the physician group also said that it is INCUMBENT upon the service provider, advocates, etc. to be a link for person served. It is CRITICAL that each person in our system of care have someone who can support him or her in his or her story being heard.
G. In Summary
The physician group summarized the work of the day with these thoughts. When individuals have challenging behaviors:
1. First, look for medical issues that might be going on.
a. Refer to Appendix B.2, B.3 and B.4 for many ideas of things to look for
2. Second, determine if the environment or persons in that environment is having an impact on the individual’s behavior.
a. Refer to Appendix B.1 for ideas.
3. Last, medication used for the purpose of behavior modification or chemical restraint is NEVER an option.

XIII. EMERGENCY SAFETY INTERVENTIONS OF LAST RESORT
There is only ONE emergency safety intervention of last resort that may be used within community settings, and that is personal (manual) restraint.
The definition of personal (manual) restraint is: The application of physical force, without the use of any device, for the purpose of restricting the free movement of a person’s body.
Personal restraint does not include briefly holding a person without undue force in order to calm or comfort the person or holding the person’s hand to safely escort the person from one place to another.
Personal or manual restraint IS permitted within all community settings associated with the Division of DBHDD EXCEPT in homes operated under a Personal Care Home license. Personal Care Home rules DO NOT permit the use of any safety intervention of last resort.
The use of personal or manual restraint as an emergency safety intervention of last resort MUST be incorporated into a crisis plan or a safety plan.
Training of staff in the use of personal or manual restraint must be done using procedures and techniques taught by nationally benchmarked emergency safety intervention training programs.
There are other emergency safety interventions of last resort that you may have heard about, HOWEVER NONE are permitted under any circumstance in community outpatient, day habilitation or residential settings. Of course there is one exception. Crisis Stabilization Programs, which are residential Emergency Receiving and Evaluation Facilities whose mission it is to provide psychiatric stabilization or detoxification, may use the other emergency safety interventions of last resort which are listed in Appendix F.
Finally, the use of medication to modify behavior or for the purpose of chemical restraint is NEVER permitted. Refer also to Appendix F for additional information.

XIV. AFFORDING RESPECT TO THE INDIVIDUAL, OBSERVING CLIENTS RIGHTS, FEDERAL AND STATE LAWS AND DEPARTMENTAL RULES
A. Afford respect to persons served
As you think about how you will work with person(s) with challenging behaviors, special care must be given to the protection of the dignity of the individual and to each person’s unique needs. Remember to afford the person with the same respect you would want for yourself. Always remember that the most effective teaching tool you have is how you behave.
B. Know the story of the person you serve
Spending time with people and getting to know their stories will tell you most of what you want or need to know. Also remember that you may be the only voice for the person that you serve. Being known is strategic to the individual over their lifetime. Vulnerability and isolation can lead to serious trouble.
C. Informed consent
Every person has a right to consent to or deny services, unless a court has taken that right from the person or a licensed psychologist, physician, licensed clinical social worker or clinical nurse specialist believes that he or she is an imminent danger to self or others and signs an emergency document indicating the same.
In order for an individual to give his or her consent, he or she must be informed both of the potential risk and benefit associated with the proposed treatment. It can be a difficult process to explain potential risk and benefit to someone who has difficulty understanding words or to someone who has trouble verbally communicating. However the risk and benefit MUST be explained to each person using means that they can best understand.
While full family participation should always be encouraged, do not automatically conclude that the person wishes family or friends to participate or that a parent is authorized to give consent. In Georgia, persons who are adults must consent BEFORE any other person who is NOT a professional can be given any information about the individual, their treatment or care. Unless the person has a guardian, or has in some other way been adjudicated incompetent, an adult person is the only one who can legally give consent for his or her treatment. However, it would be advisable to have a client
representative participate in this process when the individual has difficulty understanding or communicating.
D. Laws and regulations
Special care must be taken to ensure that all services, treatment and care take place in full compliance with applicable laws and regulations. The Official Code of Georgia Annotated (O.C.G.A.) makes it very clear in Chapters 33, 34 and 37 that persons will be served in the least restrictive environment [least restrictive way] that meets the needs of the person served. This is further emphasized in the Rules and Regulations for Clients’ Rights Chapter 290-4-9.
The Division’s “Core Requirements for All Providers” found in the Provider Manual for Community Mental Health, Developmental Disabilities and Addictive Diseases Providers Under Contract with the Georgia Department of Behavioral Health and Developmental Disabilities provide additional detail about how these ideas must be implemented. For additional information, refer to the source documents mentioned.
XV. STRATEGIES THAT MAINTAIN RESILIENCE IN CAREGIVERS
Someone who takes care of him or her self takes better care of another person’s needs. If we don’t take the time to take care of ourselves, we behave in ways much like the challenging behaviors of the person that we serve. In other words, our thoughts and feelings about what is not tended to in our lives will often easily manifest in ways we do not want or plan.
Having the tools to do the work required is imperative! In the business of working with people, some of the tools required are likely to be: 1) knowing our personal story including our strengths and limitations; 2) knowing the story of the person; 3) knowing something about characteristics of the issues the person struggles with; 4) knowing what is expected in the work setting; and 5) knowing how to access support and clarification when needed.
There are two metaphors that can apply to those of us who take care of others:
1.The first is to remember that before taking off in a plane, you are taught to put the oxygen mask on yourself before helping anyone else. If you pass out from lack of oxygen while trying to help someone else, you have done neither of you any good.
2.The second is for you to imagine that your job is to jump into the water to rescue someone who is drowning. You may know that if you swim directly toward a drowning person, that person will grab on to you and try to keep from going under the water by holding on to your neck or literally trying to climb on top of you.
In both of these examples, you must first know what to do. And you must have the skills through training to do the job! It simply won’t work any other way.
APPENDIX C
Procedures for Billing and Documenting Personal Assistance Retainer

Rev 01 2012
A personal assistance retainer is a component of Community Living Support Services. The personal assistance allows continued payment for Community Living Support services while a participant is hospitalized or otherwise away from the home in order to ensure stability and continuity of care. This retainer allows continued payment to personal caregivers under the waiver for up to thirty (30) days per calendar year for absences of participant from his or her home.

Personal Assistance Retainer Documentation: Providers, except for providers of participant-directed services, must 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.

4. Scheduled staff was not deployed to work at any other provider location.

The Co-Employer agency of any participant/representative who opts for participant-direction through a Co-Employer Agency must document the personal assistance retainer as above. The participant/representative who opts for participant-direction through a Financial Support Services Provider must maintain copies of CLS Personal Assistance Retainer Timesheet for any claims of this retainer for Community Living Support Services.

Personal Assistance Retainer Allowances and Exclusions:

A. Personal Assistance Retainer Allowances

The personal assistance retainer allows continued payment to personal caregivers under the waiver for up to thirty (30) days per year for absences of the participant from his or her home, per calendar year.

1) Only for the scheduled days and amounts of Community Living Support services as indicated in the ISP (e.g., if a participant receives CLS services only on Tuesday, Wednesday, and Thursday for a total of 16 units per day, the personal assistance retainer may only be claimed for Tuesday, Wednesday, and Thursday for 16 units per day for any week for which the retainer provides continued payment). The provider must document specific days and units billed under the personal assistance retainer.

B. Personal Assistance Retainer Exclusions

The following exclusions apply to the personal assistance retainer:

1) Payment is not made for Personal Assistance Retainer outside of scheduled days and units per day for Community Living Support Services as specified in the Individual Service Plan.

2) Payment of Personal Assistance retainer is not allowable for absences due to services that are reimbursable as other waiver and Medicaid State Plan services except for admissions to a general hospital or nursing facility as indicated below.

3) Payment of Personal Assistance retainer beyond allowable days indicated below.

Personal Assistance Retainer Billing:

Providers must submit claims as follows for the personal assistance retainer:

A. Claims During Hospital Stays

1) Providers submit claims for each admission to a general hospital or nursing facility, including ICF/ID and skilled nursing facilities;

Rev 01 2013

2) Providers submit claims for only scheduled days and units as specified in the participant’s Individual Service Plan;
3) Providers bill a separate line for each day claimed during the hospital stay;
4) Providers list place of service on the claim as follows:
. 31 for Skilled Nursing Facility

. 32 for Nursing Facility

. 54 for Intermediate Care Facility/MR

. 21 for Inpatient Hospital

Rev 01 2013
Note: For personal assistance retainer claims during hospital stays, the provider must bill a separate line for each day claimed during the hospital stay up to the allowable (30) days per calendar year for all absences of the participant from his or her home.

B. Claims for Other Absences

1) Providers submit claims up to the allowable thirty (30) days per calendar year for all absences of the participant from his or her home, including hospital stays as in Section A. above and other absences of the participant from his or her home, such as vacations and family/relative visit, per calendar year;

Rev 01 2013

2) Providers submit claims for only scheduled days and units as specified in the participant’s Individual Service Plan;
3) Providers may submit claims for other absences as standard (that is, in weekly, bi-weekly, or monthly spans)

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