907 KAR 3:210 - [Effective 1/30/2030] Acquired brain injury long-term care waiver services and reimbursement
RELATES TO: KRS 17.165, 202A.011, 205.5605, 205.5607, 205.8451, 205.8477, 314.011, 319.010(8), 319A.010, 319.056, 327.010, 334A.020, 335.300(2), 335.500(3), 620.030, 42 C.F. R. 441 Subpart G, 455 Subpart B, 42 U. S. C. 1396a, 1396b, 1396d, 1396n
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and Family Services, Department for Medicaid Services, has responsibility to administer the Medicaid Program. KRS 205.520(3) authorizes the cabinet, by administrative regulation, to comply with a requirement that may be imposed, or opportunity presented, by federal law to qualify for federal Medicaid funds. KRS 205.5606(1) requires the cabinet to promulgate administrative regulations to establish a participant-directed services program to provide an option for the home and community-based services waivers. This administrative regulation establishes the coverage provisions relating to home- and community- based waiver services provided to an individual with an acquired brain injury as an alternative to nursing facility services and including a participant-directed services program pursuant to KRS 205.5606. The purpose of acquired brain injury long term care waiver services is to provide an alternative to institutional care to individuals with an acquired brain injury who require maintenance services.
Section 1.
Definitions.
(1) "1915(c) home and community
based services waiver program" means a Kentucky Medicaid program established
pursuant to and in accordance with
42 U. S. C.
1396n(c).
(2) "ABI" means an acquired brain
injury.
(3) "ABI provider" means an
entity that meets the criteria established in Section 2 of this administrative
regulation.
(4) "ABIB" means the
Acquired Brain Injury Branch in the Division of Community Alternatives, in the
Cabinet for Health and Family Services.
(5) "Acquired brain injury long term care
waiver service" means a home and community based waiver service for an
individual who requires long term maintenance and has acquired a brain injury
involving the central nervous system that resulted from:
(a) An injury from a physical
trauma;
(b) Anoxia or a hypoxic
episode; or
(c) Allergic condition,
toxic substance, or another acute medical incident.
(6) "ADHC services" means adult day health
care services provided on a regularly scheduled basis that ensure optimal
functioning of a participant who does not require twenty-four (24) hour care in
an institutional setting.
(7)
"Assessment" or "reassessment" means a comprehensive evaluation of abilities,
needs, and services that:
(a) Serves as the
basis for a level of care determination;
(b) Is completed on a MAP 351, Medicaid
Waiver Assessment that is uploaded into the MWMA; and
(c) Occurs at least once every twelve (12)
months thereafter.
(8)
"Axis I diagnosis" means a clinical disorder or other condition which may be a
focus of clinical attention.
(9)
"Behavior intervention committee" or "BIC" means a group of individuals
established to evaluate the technical adequacy of a proposed behavior
intervention for a participant.
(10) "Blended services" means a
nonduplicative combination of ABI waiver services identified in Section 6 of
this administrative regulation and participant-directed services identified in
Section 10 of this administrative regulation provided in accordance with the
participant's approved person-centered service plan.
(11) "Board certified behavior analyst" means
an independent practitioner who is certified by the Behavior Analyst
Certification Board, Inc.
(12)
"Case manager" means an individual who manages the overall development and
monitoring of a participant's person-centered service plan.
(13) "Covered services and supports" is
defined by KRS 205.5605(3).
(14) "Crisis prevention and response plan"
means a plan developed to identify any potential risk to a participant and to
detail a strategy to minimize the risk.
(15) "DCBS" means the Department for
Community Based Services.
(16)
"Department" means the Department for Medicaid Services or its
designee.
(17) "Family training"
means providing to the family or other responsible person:
(a) Interpretation or explanation of medical
examinations and procedures;
(b)
Treatment regimens;
(c) Use of
equipment specified in the person-centered service plan; or
(d) Advising the family how to assist the
participant.
(18) "Good
cause" means a circumstance beyond the control of an individual which affects
the individual's ability to access funding or services, including:
(a) Illness or hospitalization of the
individual which is expected to last sixty (60) days or less;
(b) Death or incapacitation of the primary
caregiver;
(c) Required paperwork
and documentation for processing in accordance with Section 3 of this
administrative regulation that has not been completed but is expected to be
completed in two (2) weeks or less; or
(d) The individual not having been accepted
for services or placement by a potential provider despite the individual or
individual's legal representative having made diligent contact with the
potential provider to secure placement or access services within sixty (60)
days.
(19) "Human rights
committee" means a group of individuals established to protect the rights and
welfare of a participant.
(20)
"Human rights restriction" means the denial of a basic right or freedom to
which all humans are entitled, including the right to life and physical safety,
civil and political rights, freedom of expression, equality before the law,
social and cultural justice, the right to participate in culture, the right to
food and water, the right to work, and the right to education.
(21) "Licensed marriage and family therapist"
or "LMFT" is defined by
KRS 335.300(2).
(22) "Licensed medical professional" means:
(a) A physician;
(b) An advanced practice registered
nurse;
(c) A physician
assistant;
(d) A registered
nurse;
(e) A licensed practical
nurse; or
(f) A
pharmacist.
(23)
"Licensed practical nurse" or "LPN" means a person who:
(a) Meets the definition of
KRS 314.011(9); and
(b) Works under the supervision of a
registered nurse.
(24)
"Licensed professional clinical counselor" or "LPCC" is defined by
KRS 335.500(3).
(25) "Medically necessary" or "medical
necessity" means that a covered benefit is determined to be needed in
accordance with
907 KAR 3:130.
(26) "MWMA" means the Kentucky Medicaid
Waiver Management Application internet portal located at http://chfs.
Ky.gov/dms/mwma. Htm.
(27) "Nursing
supports" means training and monitoring of services by a registered nurse or a
licensed practical nurse.
(28)
"Occupational therapist" is defined by
KRS 319A.010(3).
(29) "Occupational therapy assistant" is
defined by KRS 319A.010(4).
(30) "Participant" means an individual who
meets the criteria established in Section 3 of this administrative
regulation.
(31)
"Participant-directed services" or "PDS" means an option established by
KRS 205.5606 within the 1915(c) home and
community based service waiver programs which allows participants to receive
non-medical services in which the individual:
(a) Assists with the design of the
program;
(b) Chooses the providers
of services; and
(c) Directs the
delivery of services to meet their needs.
(32) "Person-centered service plan" means a
written individualized plan of services for a participant that meets the
requirements established in Section 4 of this administrative
regulation.
(33) "Person-centered
team" means the participant, the participant's guardian or representative, and
other individuals who are natural or paid supports, and who:
(a) Recognize that evidenced based decisions
are determined within the basic framework of what is important for the
participant and within the context of what is important to the participant
based on informed choice;
(b) Work
together to identify what roles they will assume to assist the participant in
becoming as independent as possible in meeting the participant's needs;
and
(c) Include providers who
receive payment for services who shall:
1. Be
active contributing members of the person centered team meetings;
2. Base their input upon evidence-based
information; and
3. Not request
reimbursement for person centered team meetings.
(34) "Physical therapist" is
defined by KRS 327.010(2).
(35) "Physical therapist assistant" means a
skilled health care worker who:
(a) Is
certified by the Kentucky Board of Physical Therapy; and
(b) Performs physical therapy and related
duties as assigned by the supervising physical therapist
(36) "Pro re nata" or "PRN" means as
needed.
(37) "Psychologist" is
defined by KRS 319.010(8).
(38) "Psychologist with autonomous
functioning" means an individual who is licensed in accordance with
KRS 319.056.
(39) "Qualified mental health professional"
is defined by KRS 202A.011(12).
(40) "Registered nurse" or "RN" means a
person who:
(a) Meets the definition
established in KRS 314.011(5); and
(b) Has one (1) year or more experience as a
professional nurse.
(41)
"Representative" is defined by
KRS 205.5605(6).
(42) "Speech-language pathologist" is defined
by KRS 334A.020(3).
(43) "Support broker" means an individual
designated by the department to:
(a) Provide
training, technical assistance, and support to a participant; and
(b) Assist a participant in any other aspects
of participant-directed services.
Section 2. Non-PDS Provider Participation
Requirements.
(1) In order to provide an ABI
waiver service in accordance with Section 4 of this administrative regulation,
excluding a participant-directed service, an ABI provider shall:
(a) Be enrolled as a Medicaid provider in
accordance with
907 KAR 1:671;
(b) Be located within an office in the
Commonwealth of Kentucky; and
(c)
1. Be a licensed provider in accordance with:
a.
902 KAR 20:066, if an adult day
health care provider;
b.
902 KAR 20:081, if a home health
service provider; or
c.
902 KAR 20:091, if a community
mental health center; or
2. Be certified by the department in
accordance with
907 KAR 12:010, Section 3, or
907 KAR 3:090, Section 2, if a
provider type is not listed in subparagraph 1. of this paragraph; and
(d) Complete and submit a
MAP-4100a to the department.
(2) An ABI provider shall comply with:
(a)
907 KAR 1:671;
(b)
907 KAR 1:672;
(c)
907 KAR 1:673;
(d)
907 KAR 7:005;
(3) An ABI provider shall have a governing
body that shall be:
(a) A legally-constituted
entity within the Commonwealth of Kentucky; and
(b) Responsible for the overall operation of
the organization including establishing policy that complies with this
administrative regulation concerning the operation of the agency and the
health, safety, and welfare of a participant served by the agency.
(4) An ABI provider shall:
(a) Unless providing participant-directed
services, ensure that an ABI waiver service is not provided to a participant by
a staff member of the ABI provider who has one (1) of the following blood
relationships to the participant:
1.
Child;
2. Parent;
3. Sibling; or
4. Spouse;
(b) Not enroll a participant for whom the ABI
provider cannot meet the service needs; and
(c) Have and follow written criteria in
accordance with this administrative regulation for determining the eligibility
of an individual for admission to services.
(5) An ABI provider shall meet the following
requirements if responsible for the management of a participant's funds:
(a) Separate accounting shall be maintained
for each participant or for the participant's interest in a common trust or
special account;
(b) Account
balance and records of transactions shall be provided to the participant or
legal representative on a quarterly basis; and
(c) The participant or legal representative
shall be notified if a large balance is accrued that may affect Medicaid
eligibility.
(6) An ABI
provider shall have a written statement of its mission and values.
(7) An ABI provider shall have written
policies and procedures for communication and interaction with a family and
legal representative of a participant which shall:
(a) Require a timely response to an
inquiry;
(b) Require the
opportunity for interaction with direct care staff;
(c) Require prompt notification of any
unusual incident;
(d) Permit
visitation with the participant at a reasonable time and with due regard for
the participant's right of privacy;
(e) Require involvement of the legal
representative in decision-making regarding the selection and direction of the
service provided; and
(f) Consider
the cultural, educational, language, and socioeconomic characteristics of the
participant.
(8)
(a) An ABI provider shall have written
policies and procedures for all settings that assure the participant has:
1. Rights of privacy, dignity, respect, and
freedom from coercion and restraint; and
2. Freedom of choice:
a. As defined by the experience of
independence, individual initiative, or autonomy in making life choices, both
in small everyday matters (what to eat or what to wear), and in large,
life-defining matters (where and with whom to live and work); and
b. Including the freedom to choose:
(i) Services;
(ii) Providers;
(iii) Settings from among setting options
including non-disability specific settings; and
(iv) Where to live with as much independence
as possible and in the most community-integrated environment.
(b) The
setting options and choices shall be:
1.
Identified and documented in the person-centered service plan; and
2. Based on the participant's needs and
preferences.
(c) For a
residential setting, the resources available for room and board shall be
documented in the person-centered service plan.
(9) An ABI provider shall have written
policies and procedures for residential settings that assure the participant
has:
(a) Privacy in the sleeping unit and
living unit in a residential setting;
(b) An option for a private unit in a
residential setting;
(c) A unit
with lockable entrance doors and with only the participant and appropriate
staff having keys to those doors;
(d) A choice of roommate or
housemate;
(e) The freedom to
furnish or decorate the sleeping or living units within the lease or other
agreement;
(f) Visitors of the
participant's choosing at any time and access to a private area for visitors;
and
(g) Physical accessibility,
defined as being easy to approach, enter, operate, or participate in a safe
manner and with dignity by a person with or without a disability.
1. Settings considered to be physically
accessible shall also meet the Americans with Disabilities Act standards of
accessibility for all participants served in the setting.
2. All communal areas shall be accessible to
all participants as well as have a means to enter the building (i. E. keys,
security codes, etc.).
3. Bedrooms
shall be accessible to the appropriate persons.
4.
a. Any
modification of an additional residential condition except for the setting
being physically accessible requirement shall be supported by a specific
assessed need and justified in the participant's person-centered service
plan.
b. Regarding a modification,
the following shall be documented in a participant's person-centered service
plan:
(i) That the modification is the result
of an identified specific and individualized assessed need;
(ii) Any positive intervention or support
used prior to the modification;
(iii) Any less intrusive method of meeting
the participant's need that was tried but failed;
(iv) A clear description of the condition
that is directly proportionate to the specific assessed need;
(v) Regular collection and review of data
used to measure the ongoing effectiveness of the modification;
(vi) Time limits established for periodic
reviews to determine if the modification remains necessary or should be
terminated;
(vii) Informed consent
by the participant or participant's representative for the modification;
and
(viii) An assurance that
interventions and supports will cause no harm to the participant.
(10) An ABI provider shall cooperate with
monitoring visits from monitoring agents.
(11) An ABI provider shall maintain a record
for each participant served that shall:
(a) Be
recorded in permanent ink;
(b) Be
free from correction fluid;
(c)
Have a strike through for each error which is initialed and dated;
and
(d) Contain no blank lines
between each entry.
(12)
A record of each participant who is served shall:
(a) Be cumulative;
(b) Be readily available;
(c) Contain a legend that identifies any
symbol or abbreviation used in making a record entry;
(d) Contain the following specific
information:
1. The participant's name and
Medical Assistance Identification Number (MAID);
2. An assessment summary relevant to the
service area;
3. The
person-centered service plan;
4.
The crisis prevention and response plan that shall include:
a. A list containing emergency contact
telephone numbers; and
b. The
participant's history of any allergies with appropriate allergy alerts for
severe allergies;
5. The
training objective for any service which provides skills training to the
participant;
6. The participant's
medication record, including a copy of the prescription or the signed
physician's order and the medication log if medication is administered at the
service site;
7. Legally-adequate
consent for the provision of services or other treatment including consent for
emergency attention which shall be located at each service site;
8. The MAP-350, Long Term Care Facilities and
Home and Community Based Program Certification Form updated at recertification;
and
9. Current level of care
certification;
(e) Be
maintained by the provider in a manner to ensure the confidentiality of the
participant's record and other personal information and to allow the
participant or legal representative to determine when to share the
information;
(f) Be secured against
loss, destruction, or use by an unauthorized person ensured by the provider;
and
(g) Be available to the
participant or legal guardian according to the provider's written policy and
procedures which shall address the availability of the record.
(13) An ABI provider:
(a) Shall ensure that each new staff person
or volunteer performing direct care or a supervisory function has had a
tuberculosis (TB) risk assessment performed by a licensed medical professional
and, if indicated, a TB skin test with a negative result within the past twelve
(12) months as documented on test results received by the provider;
(b) Shall maintain documentation of the
annual TB risk assessment or negative TB test result described in paragraph (a)
of this subsection for:
1. Existing staff;
or
2. A volunteer, if the volunteer
performs direct care or a supervisory function;
(c) Shall ensure that an employee or
volunteer who tests positive for TB, or has a history of a positive TB skin
test, shall be assessed annually by a licensed medical professional for signs
or symptoms of active disease;
(d)
Shall if it is determined that signs and symptoms of active TB are present,
ensure that the employee or volunteer has follow-up testing administered by the
employee's or volunteer's physician and that the follow-up test results
indicate the employee or volunteer does not have active TB disease;
(e) Shall not permit an individual to work
for or volunteer for the provider if the individual has TB or symptoms of
active TB;
(f) Shall maintain
documentation for an employee or volunteer with a positive TB test to ensure
that active disease or symptoms of active disease are not present;
(g)
1.
Shall:
a. Prior to the employee's date of hire
or the volunteer's date of service, obtain the results of:
(i) A criminal record check from the
Administrative Office of the Courts or the equivalent out-of-state agency if
the individual resided, worked, or volunteered outside Kentucky during the year
prior to employment or volunteer service in Kentucky;
(ii) A Nurse Aide Abuse Registry check as
described in
906 KAR 1:100; and
(iii) A Caregiver Misconduct Registry check
as described in
922 KAR 5:120; and
b. Within thirty (30) days of the
date of hire or service as a volunteer, obtain the results of a Central
Registry check as described in
922 KAR 1:470; or
2. May use Kentucky's national
background check program established by
906 KAR 1:190 to satisfy the
background check requirements of subparagraph 1 of this paragraph;
(h) Shall annually, for
twenty-five (25) percent of employees randomly selected, obtain the results of
a criminal record check from:
1. The Kentucky
Administrative Office of the Courts; or
2. The equivalent out-of-state agency, if the
individual resided or worked outside of Kentucky during the year prior to
employment;
(i) Shall
evaluate and document the performance of each employee upon completion of the
agency's designated probationary period, and at a minimum, annually
thereafter;
(j) Conduct and
document periodic and regularly scheduled supervisory visits of all
professional and paraprofessional direct service staff at the service site in
order to ensure that high quality, appropriate services are provided to the
participant;
(k) Not employ or
permit an individual to serve as a volunteer performing direct care or a
supervisory function, if the individual has a prior conviction of an offense
delineated in KRS 17.165(1) through (3) or
prior felony conviction;
(l) Not
permit an employee or volunteer to transport a participant, if the employee or
volunteer has a conviction of Driving under the Influence (DUI) during the past
year;
(m) Not employ or permit an
individual to serve as a volunteer performing direct care or a supervisory
function, if the individual has a conviction of abuse or sale of illegal drugs
during the past five (5) years;
(n)
Not employ or permit an individual to serve as a volunteer performing direct
care or a supervisory function, if the individual has a conviction of abuse,
neglect, or exploitation;
(o) Not
employ or permit an individual to serve as a volunteer performing direct care
or a supervisory function, if the individual has a Cabinet for Health and
Family Services finding of:
1. Child abuse or
neglect pursuant to the Central Registry; or
2. Adult abuse, neglect, or exploitation
pursuant to the Caregiver Misconduct Registry; and
(p) Not employ or permit an individual to
serve as a volunteer performing direct care or a supervisory function, if the
individual is listed on the:
1. Nurse Aide
Abuse Registry pursuant to
906 KAR 1:100; or
2. Kentucky Caregiver Misconduct Registry
pursuant to
922 KAR 5:120.
(14) An ABI provider
shall:
(a) Have an executive director who:
1. Is qualified with a bachelor's degree from
an accredited institution in administration or a human services field;
and
2. Has a minimum of one (1)
year of administrative responsibility in an organization which served an
individual with a disability; and
(b) Have adequate direct contact staff who:
1. Is eighteen (18) years of age or older and
has a high school diploma or GED; and
2. Has a minimum of two (2) years of
experience in providing a service to an individual with a disability or has
successfully completed a formalized training program approved by the
department.
(15) An ABI provider shall establish written
guidelines which:
(a) Ensure the health,
safety, and welfare of the participant;
(b) Address maintenance of sanitary
conditions;
(c) Ensure each site
operated by the provider is equipped with:
1.
Operational smoke detectors placed in strategic locations; and
2. A minimum of two (2) correctly charged
fire extinguishers placed in strategic locations, one (1) of which shall be
capable of extinguishing a grease fire and with a rating of 1A10BC;
(d) Ensure the availability of a
supply of hot and cold running water with the water temperature at a tap, for
water used by the participant, not exceeding 120 degrees Fahrenheit, for a
Supervised Residential Care, Adult Day Training, or Adult Day Health
provider;
(e) Ensure that the
nutritional needs of the participant are met in accordance with the current
recommended dietary allowance of the Food and Nutrition Board of the National
Research Council or as specified by a physician;
(f) Ensure that staff who supervise waiver
participants in medication administration:
1.
Unless the employee is a licensed or registered nurse, have been provided
specific training by a licensed medical professional and competency has been
documented on cause and effect and proper administration and storage of
medication; and
2. Document on a
medication log all medication administered, including:
a. Self-administered and over-the-counter
drugs; and
b. The date, time, and
initials of the person who administered the medication;
(g) Ensure that the medication
shall be:
1. Kept in a locked
container;
2. Kept under double
lock if it is a controlled substance;
3. Carried in a proper container labeled with
medication, dosage, and time of administration, if administered to the
participant or self-administered at a program site other than the participant's
residence;
4. Documented on a
medication administration form; and
5. Properly disposed of if it is
discontinued; and
(h)
Establish policy and procedures for monitoring of medication administration,
which shall be approved by the department before services begin to ensure that
medication administration will be properly monitored under the policies and
procedures as approved by the department.
(16) An ABI provider shall establish and
follow written guidelines for handling an emergency or a disaster which shall:
(a) Be readily accessible on site;
(b) Include an evacuation drill:
1. To be conducted and documented at least
quarterly; and
2. For a residential
setting, scheduled to include a time when a participant is asleep;
(c) Mandate:
1. That the result of an evacuation drill be
evaluated and modified as needed; and
2. That results of the prior years'
evacuation drills be maintained on site.
(17) An ABI provider shall:
(a) Provide orientation for each new employee
which shall include the agency's:
1.
Mission;
2. Goals;
3. Organization; and
4. Policies and procedures;
(b) Require documentation of all
training provided which shall include the:
1.
Type of training;
2. Name and title
of the trainer;
3. Length of the
training;
4. Date of completion;
and
5. Signature of the trainee
verifying completion;
(c) Ensure that each employee completes ABI
training consistent with the curriculum that has been approved by the
department, prior to working independently with a participant, which shall
include:
1. Required orientation in brain
injury;
2. Identifying and
reporting:
a. Abuse;
b. Neglect; and
c. Exploitation;
3. Unless the employee is a licensed or
registered nurse, first aid provided by an individual certified as a trainer
by:
a. The American Red Cross; or
b. Other nationally accredited organization;
and
4. Coronary
pulmonary resuscitation provided by an individual certified as a trainer by:
a. The American Red Cross; or
b. Other nationally accredited
organization;
(d) Ensure that each employee completes six
(6) hours of continuing education in brain injury annually, following the first
year of service;
(e) Not be
required to receive the training specified in paragraph (c)1 of this subsection
if the provider is a professional who has, within the prior five (5) years,
attained 2,000 hours of experience providing services to a person with a
primary diagnosis of a brain injury including:
1. An occupational therapist or occupational
therapy assistant providing occupational therapy;
2. A psychologist or psychologist with
autonomous functioning providing psychological services;
3. A speech-language pathologist providing
speech therapy;
4. A board
certified behavior analyst; or
5. A
physical therapist or physical therapist assistant providing physical therapy;
and
(f) Ensure that
prior to the date of service as a volunteer, an individual receives training
which shall include:
1. Required orientation
in brain injury as specified in paragraph (c)1, 2, 3, and 4 of this
subsection;
2. Orientation to the
agency;
3. A confidentiality
statement; and
4. Individualized
instruction on the needs of the participant to whom the volunteer shall provide
services.
(18) An ABI provider shall provide
information to a case manager necessary for completion of a Mayo-Portland
Adaptability Inventory-4 for each participant served by the provider.
Section 3. Participant
Eligibility, Enrollment, and Termination.
(1)
(a) To be eligible to receive a service in
the ABI long term care waiver program, an individual shall:
1. Be at least eighteen (18) years of
age;
2. Have an ABI which
necessitates:
a. Supervision;
b. Rehabilitative services; and
c. Long term supports;
3. Have an ABI that involves:
a. Cognition;
b. Behavior; or
c. Physical function; and
4. Be screened by the department
for the purpose of making a preliminary determination of whether the individual
might qualify for ABI waiver services.
(b) In addition to the individual meeting the
requirements established in paragraph (a) of this subsection, the individual or
a representative on behalf of the individual shall:
1. Apply for 1915(c) home and community based
waiver services via the MWMA; and
2. Complete and upload into the MWMA a MAP -
115 Application Intake - Participant Authorization.
(2) The department shall utilize a
first come, first serve priority basis to enroll an individual who meets the
eligibility criteria established in this section.
(3) If funding is not available, an
individual shall be placed on the ABI long term care waiver waiting list in
accordance with Section 9 of this administrative regulation.
(4)
(a) A
certification packet shall be entered into the MWMA by a case manager or
support broker on behalf of the applicant.
(b) The packet shall contain:
1. A copy of the allocation letter sent to
the applicant at the time funding was allocated for the applicant's
participation in the ABI Long Term Care Waiver program;
2. A MAP-351, Medicaid Waiver
Assessment;
3. A statement of the
need for ABI long term care waiver services which shall be signed and dated by
a physician on a MAP 10, Waiver Services Physician's Recommendation
form;
4. A MAP-350, Long Term Care
Facilities and Home and Community Based Program Certification Form;
and
5. A person-centered service
plan.
(5) An
individual shall receive notification of potential funding allocated for the
ABI long term care waiver services for the individual in accordance with this
section.
(6) An individual shall
meet the patient status criteria for nursing facility services established in
907 KAR 1:022, including nursing
facility services for a brain injury.
(7) An individual shall:
(a) Have a primary diagnosis that indicates
an ABI with structural, non-degenerative brain injury;
(b) Be medically stable;
(c) Meet Medicaid eligibility requirements
established in
907 KAR 20:010;
(d) Exhibit:
1. Cognitive damage;
2. Behavioral damage;
3. Motor damage; or
4. Sensory damage;
(e) Have a rating of at least four (4) or
above on the Family Guide to the Rancho Levels of Cognitive Functioning;
and
(f) Receive notification of
approval from the department.
(8) The basis of an eligibility determination
for participation in the ABI long term care waiver program shall be the:
(a) Presenting problem;
(b) Person-centered service plan;
(c) Expected benefit of the
admission;
(d) Expected
outcome;
(e) Service required;
and
(f) Cost effectiveness of
service delivery as an alternative to nursing facility and nursing facility
brain injury services.
(9) An ABI long term care waiver service
shall not be furnished to an individual if the individual is:
(a) An inpatient of a hospital, nursing
facility, or an intermediate care facility for individuals with an intellectual
disability; or
(b) Receiving a
service in another 1915(c) home and community based services waiver
program.
(10) The
department shall make:
(a) An initial
evaluation to determine if an individual meets the nursing facility level of
care criteria established in
907 KAR 1:022; and
(b) A determination of whether to admit an
individual into the ABI long term care waiver program.
(11) To maintain eligibility as a
participant:
(a) An individual shall maintain
Medicaid eligibility requirements established in
907 KAR 20:010;
(b) A reevaluation shall be conducted at
least once every twelve (12) months to determine if the individual continues to
meet the patient status criteria for nursing facility services established in
907 KAR 1:022; and
(c) Progress toward outcomes identified in
the approved person-centered service plan shall not be required.
(12) The department shall exclude
an individual from receiving an ABI long term care waiver service for whom the
average cost of ABI waiver service is reasonably expected to exceed the cost of
a nursing facility service.
(13)
Involuntary termination and loss of an ABI long term care waiver program
placement shall be in accordance with
907 KAR 1:563 and shall be
initiated if:
(a) An individual fails to
initiate an ABI long term care waiver service within sixty (60) days of
notification of potential funding without good cause shown. The individual or
legal representative shall have the burden of providing documentation of good
cause, including:
1. A statement signed by the
participant or legal representative;
2. Copies of letters to providers;
and
3. Copies of letters from
providers;
(b) A
participant or legal representative fails to access the required service as
outlined in the person-centered service plan for a period greater than sixty
(60) consecutive days without good cause shown.
1. The participant or legal representative
shall have the burden of providing documentation of good cause including:
a. A statement signed by the participant or
legal representative;
b. Copies of
letters to providers; and
c. Copies
of letters from providers.
2. Upon receipt of documentation of good
cause, the department shall grant one (1) extension period, which shall not
exceed sixty (60) days, to the participant during which time period the
participant shall initiate the ABI long term care waiver services or access the
required services as outlined in the person-centered service plan. The
extension shall be in writing;
(c) A participant changes residence outside
the Commonwealth of Kentucky;
(d) A
participant does not meet the patient status criteria for nursing facility
services established in
907 KAR 1:022;
(e) A participant is no longer able to be
safely served in the community; or
(f) A participant is no longer actively
participating in services within the approved person-centered service plan as
determined by the person-centered team.
(14) Involuntary termination of a service to
a participant by an ABI provider shall require:
(a) Simultaneous notice, which shall:
1. Be sent at least thirty (30) days prior to
the effective date of the action, to the:
a.
Department;
b. Participant or legal
representative; and
c. Case
manager; and
2. Include:
a. A statement of the intended
action;
b. The basis for the
intended action;
c. The authority
by which the action is taken; and
d. The participant's right to appeal the
intended action through the provider's appeal or grievance process;
and
(b) The
case manager in conjunction with the provider to:
1. Provide the participant with the name,
address, and telephone number of each current ABI provider in the
state;
2. Provide assistance to the
participant in making contact with another ABI provider;
3. Arrange transportation for a requested
visit to an ABI provider site;
4.
Provide a copy of pertinent information to the participant or legal
representative;
5. Ensure the
health, safety, and welfare of the participant until an appropriate placement
is secured;
6. Continue to provide
supports until alternative services or another placement is secured;
and
7. Provide assistance to ensure
a safe and effective service transition.
(15) Voluntary termination and loss of an ABI
long term care waiver program placement shall be initiated if a participant or
legal representative submits a written notice of intent to discontinue services
to the service provider and to the department.
(a) An action to terminate services shall not
be initiated until thirty (30) calendar days from the date of the
notice.
(b) The participant or
legal representative may reconsider and revoke the notice in writing during the
thirty (30) calendar day period.
Section 4. Person-centered Service Plan
Requirements.
(1) A person-centered service
plan shall be established:
(a) For each
participant; and
(b) By the
participant's person-centered service plan team.
(2) A participant's person-centered service
plan shall:
(a) Be developed by:
1. The participant, the participant's
guardian, or the participant's representative;
2. The participant's case manager;
3. The participant's person-centered team;
and
4. Any other individual chosen
by the participant if the participant chooses any other individual to
participate in developing the person-centered service plan;
(b) Use a process that:
1. Provides the necessary information and
support to empower the participant, the participant's guardian, or
participant's legal representative to direct the planning process in a way that
empowers the participant to have the freedom and support to control the
participant's schedules and activities without coercion or restraint;
2. Is timely and occurs at times and
locations convenient for the participant;
3. Reflects cultural considerations of the
participant;
4. Provides
information:
a. Using plain language in
accordance with 42 C.F. R. 435.905(b); and
b. In a way that is accessible to an
individual with a disability or who has limited English proficiency;
5. Offers an informed choice
defined as a choice from options based on accurate and thorough knowledge and
understanding to the participant regarding the services and supports to be
received and from whom;
6. Includes
a method for the participant to request updates to the person-centered service
plan as needed;
7. Enables all
parties to understand how the participant:
a.
Learns;
b. Makes decisions;
and
c. Chooses to live and work in
the participant's community;
8. Discovers the participant's needs, likes,
and dislikes;
9. Empowers the
participant's person-centered team to create a person-centered service plan
that:
a. Is based on the participant's:
(i) Assessed clinical and support
needs;
(ii) Strengths;
(iii) Preferences; and
(iv) Ideas;
b. Encourages and supports the participant's:
(i) Rehabilitative needs;
(ii) Habilitative needs; and
(iii) Long term satisfaction;
c. Is based on reasonable costs
given the participant's support needs;
d. Includes:
(i) The participant's goals;
(ii) The participant's desired outcomes;
and
(iii) Matters important to the
participant;
e. Includes
a range of supports including funded, community, and natural supports that
shall assist the participant in achieving identified goals;
f. Includes:
(i) Information necessary to support the
participant during times of crisis; and
(ii) Risk factors and measures in place to
prevent crises from occurring;
g. Assists the participant in making informed
choices by facilitating knowledge of and access to services and
supports;
h. Records the
alternative home and community-based settings that were considered by the
participant;
i. Reflects that the
setting in which the participant resides was chosen by the
participant;
j. Is understandable
to the participant and to the individuals who are important in supporting the
participant;
k. Identifies the
individual or entity responsible for monitoring the person-centered service
plan;
l. Is finalized and agreed to
with the informed consent of the participant or participant's legal
representative in writing with signatures by each individual who will be
involved in implementing the person-centered service plan;
m. Shall be distributed to the individual and
other people involved in implementing the person-centered service
plan;
n. Includes those services
which the individual elects to self-direct; and
o. Prevents the provision of unnecessary or
inappropriate services and supports; and
(c) Includes in all settings the ability for
the participant to:
1. Have access to make
private phone calls, texts, or emails at the participant's preference or
convenience; and
2.
a. Choose when and what to eat;
b. Have access to food at any time;
c. Choose with whom to eat or whether to eat
alone; and
d. Choose appropriating
clothing according to the:
(i) Participant's
preference;
(ii) Weather;
and
(iii) Activities to be
performed.
(3) If a participant's person-centered
service plan includes ADHC services, the ADHC services plan of treatment shall
be addressed in the person-centered service plan.
(4)
(a) A
participant's person-centered service plan shall be:
1. Entered into the MWMA by the participant's
case manager; and
2. Updated in the
MWMA by the participant's case manager.
(b) A participant or participant's authorized
representative shall complete and upload into the MWMA a MAP - 116 Service Plan
- Participant Authorization prior to or at the time the person-centered service
plan is uploaded into the MWMA.
Section 5. Case Management Requirements.
(1) A case manager shall:
(a)
1. Be a
registered nurse;
2. Be a licensed
practical nurse; or
3. Be an
individual with a bachelor's degree or master's degree in a human services
field who meets all applicable requirements of his or her particular field
including a degree in:
a.
Psychology;
b. Sociology;
c. Social work;
d. Rehabilitation counseling; or
e. Occupational therapy;
(b)
1. Be independent as defined as not being
employed by an agency that is providing ABI waiver services to the participant;
or
2. Be employed by or work under
contract with a free-standing case management agency; and
(c) Have completed case management training
that is consistent with the curriculum that has been approved by the department
prior to providing case management services.
(2) A case manager shall:
(a) Communicate in a way that ensures the
best interest of the participant;
(b) Be able to identify and meet the needs of
the participant;
(c)
1. Be competent in the participant's language
either through personal knowledge of the language or through interpretation;
and
2. Demonstrate a heightened
awareness of the unique way in which the participant interacts with the world
around the participant;
(d) Ensure that:
1. The participant is educated in a way that
addresses the participant's:
a. Need for
knowledge of the case management process;
b. Personal rights; and
c. Risks and responsibilities as well as
awareness of available services; and
2. All individuals involved in implementing
the participant's person-centered service plan are informed of changes in the
scope of work related to the person-centered service plan as
applicable;
(e) Have a
code of ethics to guide the case manager in providing case management which
shall address:
1. Advocating for standards
that promote outcomes of quality;
2. Ensuring that no harm is done;
3. Respecting the rights of others to make
their own decisions;
4. Treating
others fairly; and
5. Being
faithful and following through on promises and commitments;
(f)
1. Lead the person-centered service planning
team; and
2. Take charge of
coordinating services through team meetings with representatives of all
agencies involved in implementing a participant's person-centered service
plan;
(g)
1. Include the participant's participation or
legal representative's participation in the case management process;
and
2. Make the participant's
preferences and participation in decision making a priority;
(h) Document:
1. A participant's interactions and
communications with other agencies involved in implementing the participant's
person-centered service plan; and
2. Personal observations;
(i) Advocate for a participant
with service providers to ensure that services are delivered as established in
the participant's person-centered service plan;
(j) Be accountable to:
1. A participant to whom the case manager
providers case management in ensuring that the participant's needs are
met;
2. A participant's
person-centered service plan team and provide leadership to the team and follow
through on commitments made; and
3.
The case manager's employer by following the employer's policies and
procedures;
(k) Stay
current regarding the practice of case management and case management
research;
(l) Assess the quality of
services, safety of services, and cost effectiveness of services being provided
to a participant in order to ensure that implementation of the participant's
person-centered service plan is successful and done so in a way that is
efficient regarding the participant's financial assets and benefits;
(m) Document services provided to a
participant by entering the following into the MWMA:
1. A monthly department-approved person
centered monitoring tool; and
2. A
monthly entry which shall include:
a. The
month and year for the time period the note covers;
b. An analysis of progress toward the
participant's outcome or outcomes;
c. Identification of barriers to achievement
of outcomes;
d. A projected plan to
achieve the next step in achievement of outcomes;
e. The signature and title of the case
manager completing the note; and
f.
The date the note was generated;
(n) Document via an entry into the MWMA if a
participant is:
1. Admitted to the ABI long
term care waiver program;
2.
Terminated from the ABI long-term care waiver program;
3. Temporarily discharged from the ABI long
term care waiver program;
4.
Admitted to a hospital;
5. Admitted
to a nursing facility;
6. Changing
the primary ABI provider;
7.
Changing the case management agency;
8. Transferred to another Medicaid 1915(c)
home and community based waiver service program; or
9. Relocated to a different address;
and
(o) Provide
information about participant-directed services to the participant or the
participant's guardian:
1. At the time the
initial person-centered service plan is developed; and
2. At least annually thereafter and upon
inquiry from the participant or participant's guardian.
(3) A case management provider
shall:
(a) Establish a human rights committee
which shall:
1. Include an:
a. Individual with a brain injury or a family
member of an individual with a brain injury;
b. Individual not affiliated with the ABI
provider; and
c. Individual who has
knowledge and experience in human rights issues;
2. Review and approve each person-centered
service plan with human rights restrictions at a minimum of every six (6)
months;
3. Review and approve, in
conjunction with the participant's team, behavior intervention plans that
contain human rights restrictions; and
4. Review the use of a psychotropic
medication by a participant without an Axis I diagnosis; and
(b) Establish a behavior
intervention committee which shall:
1. Include
one (1) individual who has expertise in behavior intervention and is not the
behavior specialist who wrote the behavior intervention plan;
2. Be separate from the human rights
committee; and
3. Review and
approve, prior to implementation and at a minimum of every six (6) months in
conjunction with the participant's team, an intervention plan that includes
highly restrictive procedures or contain human rights restrictions;
and
(c) Complete and
submit a Mayo-Portland Adaptability Inventory-4 to the department for each
participant:
1. Within thirty (30) days of the
participant's admission into the ABI program;
2. Annually thereafter; and
3. Upon discharge from the ABI waiver
program.
(4)
(a) Case management for any participant who
begins receiving ABI waiver services after the effective date of this
administrative regulation shall be conflict free.
(b)
1.
Conflict free case management shall be a scenario in which a provider including
any subsidiary, partnership, not-for-profit, or for-profit business entity that
has a business interest in the provider who renders case management to a
participant shall not also provide another 1915(c) home and community based
waiver service to that same participant unless the provider is the only willing
and qualified ABI waiver services provider within thirty (30) miles of the
participant's residence.
2. An
exemption to the conflict free case management requirement shall be granted if:
a. A participant requests the
exemption;
b. The participant's
case manager provides documentation of evidence to the department, that there
is a lack of a qualified case manager within thirty (30) miles of the
participant's residence;
c. The
participant or participant's representative and case manager signs a completed
MAP - 531 Conflict-Free Case Management Exemption; and
d. The participant, participant's
representative, or case manager uploads the completed MAP - 531 Conflict-Free
Case Management Exemption into the MWMA.
3. If a case management service is approved
to be provided despite not being conflict free, the case management provider
shall document conflict of interest protections, separating case management and
service provision functions within the provider entity and demonstrate that the
participant is provided with a clear and accessible alternative dispute
resolution process.
4. An exemption
to the conflict free case management requirement shall be requested upon
reassessment or at least annually.
(c) A participant who receives ABI waiver
services prior to the effective date of this administrative regulation shall
transition to conflict free case management when the participant's next level
of care determination occurs.
(d)
During the transition to conflict free case management, any case manager
providing case management to a participant shall educate the participant and
members of the participant's person-centered team of the conflict free case
management requirement in order to prepare the participant to decide, if
necessary, to change the participant's:
1.
Case manager; or
2. Provider of
non-case management ABI waiver services.
(5) Case management shall:
(a) Include initiation, coordination,
implementation, and monitoring of the assessment or reassessment, evaluation,
intake, and eligibility process;
(b) Assist a participant in the
identification, coordination, and facilitation of the person centered team and
person centered team meetings;
(c)
Assist a participant and the person centered team to develop an individualized
person-centered service plan and update it as necessary based on changes in the
participant's medical condition and supports;
(d) Include monitoring of the delivery of
services and the effectiveness of the person-centered service plan, which
shall:
1. Be initially developed with the
participant and legal representative if appointed prior to the level of care
determination;
2. Be updated within
the first thirty (30) days of service and as changes or recertification occurs;
and
3. Include the person-centered
service plan being sent to the department or its designee prior to the
implementation of the effective date the change occurs with the
participant;
(e) Include
a transition plan that shall:
1. Be:
a. Developed within the first thirty (30)
days of service;
b. Updated as
changes or recertification occurs; and
c. Updated thirty (30) days prior to
discharge; and
2.
Include:
a. The skills or service obtained
from the ABI waiver program upon transition into the community; and
b. A listing of the community supports
available upon the transition;
(f) Assist a participant in obtaining a
needed service outside those available by the ABI waiver;
(g) Be provided by a case manager who:
1. Meets the requirements of subsection (1)
of this section;
2. Shall provide a
participant and legal representative with a listing of each available ABI
provider in the service area;
3.
Shall maintain documentation signed by a participant or legal representative of
informed choice of an ABI provider and of any change to the selection of an ABI
provider and the reason for the change;
4. Shall provide a distribution of the crisis
prevention and response plan, transition plan, person-centered service plan,
and other documents within the first thirty (30) days of the service to the
chosen ABI service provider and as information is updated;
5. Shall provide twenty-four (24) hour
telephone access to a participant and chosen ABI provider;
6. Shall work in conjunction with an ABI
provider selected by a participant to develop a crisis prevention and response
plan which shall be:
a. Individual-specific;
and
b. Updated as a change occurs
and at each recertification;
7. Shall assist a participant in planning
resource use and assuring protection of resources;
8. Shall conduct one (1) face-to-face meeting
with a participant within a calendar month occurring at a covered service site
with one (1) visit quarterly at the participant's residence;
9. Shall ensure twenty-four (24) hour
availability of services; and
10.
Shall ensure that the participant's health, welfare, and safety needs are met;
and
(h) Be documented by
a detailed staff note in the MWMA which shall include:
1. The participant's health, safety and
welfare;
2. Progress toward
outcomes identified in the approved person-centered service plan;
3. The date of the service;
4. Beginning and ending time;
5. The signature and title of the individual
providing the service; and
6. A
quarterly summary which shall include:
a.
Documentation of monthly contact with each chosen ABI provider; and
b. Evidence of monitoring of the delivery of
services approved in the participant's person-centered service plan and of the
effectiveness of the person-centered service plan.
(6) Case management
shall involve:
(a) A constant recognition of
what is and is not working regarding a participant; and
(b) Changing what is not working.
Section 6. Covered
Services.
(1) An ABI waiver service shall:
(a) Not be covered unless it has been
prior-authorized by the department; and
(b) Be provided pursuant to the participant's
person-centered service plan.
(2) An ABI waiver provider shall provide the
following services to a participant:
(a) Case
management services in accordance with Section 4 of this administrative
regulation;
(b) Behavioral
services, which shall:
1. Be a systematic
application of techniques and methods to influence or change a behavior in a
desired way;
2. Include a
functional analysis of the participant's behavior including:
a. An evaluation of the impact of an ABI on:
(i) Cognition; and
(ii) Behavior;
b. An analysis of potential communicative
intent of the behavior;
c. The
history of reinforcement for the behavior;
d. Critical variables that precede the
behavior;
e. Effects of different
situations on the behavior; and
f.
A hypothesis regarding the:
(i) Motivation
behind the behavior;
(ii) Purpose
of the behavior; and
(iii) Factors
that maintain the behavior;
3. Include the development of a behavioral
support plan, which shall:
a. Be developed by
the behavioral specialist;
b. Not
be implemented by the behavior specialist who wrote the plan;
c. Be revised as necessary;
d. Define the techniques and procedures
used;
e. Include the hierarchy of
behavior interventions ranging from the least to the most
restrictive;
f. Reflect the use of
positive approaches; and
g.
Prohibit the use of:
(i) Prone or supine
restraint;
(ii) Corporal
punishment;
(iii)
Seclusion;
(iv) Verbal abuse;
and
(v) Any procedure which denies
private communication, requisite sleep, shelter, bedding, food, drink, or use
of a bathroom facility;
4. Include the provision of training to other
ABI providers concerning implementation of the behavioral intervention
plan;
5. Include the monitoring of
a participant's progress, which shall be accomplished through:
a. The analysis of data concerning the
behavior's:
(i) Frequency;
(ii) Intensity; and
(iii) Duration; and
b. Reports involved in implementing the
behavioral service plan;
6. Be provided by a behavior specialist who
shall:
a. Be:
(i) A psychologist;
(ii) A psychologist with autonomous
functioning;
(iii) A licensed
psychological associate;
(iv) A
psychiatrist;
(v) A licensed
clinical social worker;
(vi) A
clinical nurse specialist with a master's degree in psychiatric nursing or
rehabilitation nursing;
(vii) An
advanced practice registered nurse;
(viii) A board certified behavior analyst;
or
(ix) A licensed professional
clinical counselor; and
b. Have at least one (1) year of behavior
specialist experience or provide documentation of completed coursework
regarding learning and behavior principles and techniques; and
7. Be documented by a detailed
staff note in the MWMA which shall include:
a.
The date of the service;
b. The
beginning and ending time;
c. The
signature and title of the behavioral specialist; and
d. A summary of data analysis and progress of
the individual related to the approved person-centered service plan;
(c) Community living
supports, which shall:
1. Be provided in
accordance with the participant's person-centered service plan, including:
a. A nonmedical service;
b. Supervision; or
c. Socialization;
2. Include assistance, prompting, observing,
or training in activities of daily living;
3. Include activities of daily living which
shall include:
a. Bathing;
b. Eating;
c. Dressing;
d. Personal hygiene;
e. Shopping; and
f. Money management;
4. Include prompting, observing, and
monitoring of medications and nonmedical care not requiring a nurse or
physician intervention;
5. Include
socialization, relationship building, and participation in community activities
according to the approved person-centered service plan which are therapeutic
and not diversional in nature;
6.
Accompany and assist a participant while utilizing transportation
services;
7. Include documentation
in a detailed staff note in the MWMA which shall include the:
a. Progress toward goals and objectives
identified in the approved person-centered service plan;
b. Date of the service;
c. Beginning and ending time; and
d. Signature and title of the individual
providing the service;
8. Not be provided to a participant who
receives community residential services; and
9. Be provided by a:
a. Home health agency licensed and operating
in accordance with
902 KAR 20:081;
b. Community mental health center licensed
and operating in accordance with
902 KAR 20:091;
c. Community habilitation program certified
at least annually by the department; or
d. Supervised residential care setting
certified at least annually by the department;
(d) Supervised residential care level I,
which:
1. Shall be provided by:
a. A community mental health center licensed
and operating in accordance with
902 KAR 20:091 and certified at
least annually by the department; or
b. An approved waiver provider certified at
least annually by the department;
2. Shall not be provided to a participant
unless the participant has been authorized to receive residential care by the
department's residential review committee which shall:
a. Consider applications for residential care
in the order in which the applications are received;
b. Base residential care decisions on the
following factors:
(i) Whether the applicant
resides with a caregiver or not;
(ii) Whether the applicant resides with a
caregiver but demonstrates maladaptive behavior which places the applicant at
significant risk of injury or jeopardy if the caregiver is unable to
effectively manage the applicant's behavior or the risk it poses, resulting in
the need for removal from the home to a more structured setting; or
(iii) Whether the applicant demonstrates
behavior which may result in potential legal problems if not
ameliorated;
c. Be
comprised of three (3) Cabinet for Health and Family Services employees:
(i) With professional or personal experience
with brain injury or other cognitive disabilities; and
(ii) Two (2) of whom shall not be supervised
by the manager of the acquired brain injury branch; and
d. Only consider applications for a monthly
committee meeting which were received no later than the close of business the
day before the committee convenes;
3. Shall not have more than three (3)
participants simultaneously in a home rented or owned by the ABI
provider;
4. Shall provide
twenty-four (24) hours of supervision daily unless the provider implements,
pursuant to subparagraph 5. of this paragraph, an individualized plan allowing
for up to five (5) unsupervised hours per day;
5. May include the provision of up to five
(5) unsupervised hours per day per participant if the provider develops an
individualized plan for the participant to promote increased independence which
shall:
a. Contain provisions necessary to
ensure the participant's health, safety, and welfare;
b. Be approved by the participant's treatment
team, with the approval documented by the provider; and
c. Contain periodic reviews and updates based
on changes, if any, in the participant's status;
6. Shall include assistance and training with
daily living skills including:
a.
Ambulating;
b. Dressing;
c. Grooming;
d. Eating;
e. Toileting;
f. Bathing;
g. Meal planning;
h. Grocery shopping;
i. Meal preparation;
j. Laundry;
k. Budgeting and financial matters;
l. Home care and cleaning;
m. Leisure skill instruction; or
n. Self-medication instruction;
7. Shall include social skills
training including the reduction or elimination of maladaptive behaviors in
accordance with the individual's person-centered service plan;
8. Shall include provision or arrangement of
transportation to services, activities, or medical appointments as
needed;
9. Shall include
accompanying or assisting a participant while the participant utilizes
transportation services as specified in the participant's person-centered
service plan;
10. Shall include
participation in medical appointments or follow-up care as directed by the
medical staff;
11. Shall be
documented by a detailed staff note in the MWMA which shall document:
a. Progress toward goals and objectives
identified in the approved person-centered service plan;
b. The date of the service;
c. The beginning and ending time of the
service; and
d. The signature and
title of the individual providing the service;
12. Shall not include the cost of room and
board;
13. Shall be provided to a
participant who:
a. Does not reside with a
caregiver;
b. Is residing with a
caregiver but demonstrates maladaptive behavior that places him or her at
significant risk of injury or jeopardy if the caregiver is unable to
effectively manage the behavior or the risk it presents, resulting in the need
for removal from the home to a more structured setting; or
c. Demonstrates behavior that may result in
potential legal problems if not ameliorated;
14. May utilize a modular home only if the:
a. Wheels are removed;
b. Home is anchored to a permanent
foundation; and
c. Windows are of
adequate size for an adult to use as an exit in an emergency;
15. Shall not utilize a motor
home;
16. Shall provide a sleeping
room which ensures that a participant:
a. Does
not share a room with an individual of the opposite gender who is not the
participant's spouse;
b. Does not
share a room with an individual who presents a potential threat; and
c. Has a separate bed equipped with
substantial springs, a clean and comfortable mattress, and clean bed linens as
required for the participant's health and comfort; and
17. Shall provide service and training to
obtain the outcomes for the participant as identified in the approved
person-centered service plan;
(e) Supervised residential care level II,
which shall:
1. Meet the requirements
established in paragraph (d) of this subsection except for the requirements
established in paragraph (d)4 and 5;
2. Provide twelve (12) to eighteen (18) hours
of daily supervision, the amount of which shall:
a. Be based on the participant's
needs;
b. Be approved by the
participant's treatment team; and
c. Be documented in the participant's
person-centered service plan which shall also contain periodic reviews and
updates based on changes, if any, in the participant's status; and
3. Include provision of
twenty-four (24) hour on-call support;
(f) Supervised residential care level III,
which shall:
1. Meet the requirements
established in paragraph (d) of this subsection except for the requirements
established in paragraph (d)4 and 5;
2. Be provided in a single family home,
duplex, or apartment building to a participant who lives alone or with an
unrelated roommate;
3. Not be
provided to more than two (2) participants simultaneously in one (1) apartment
or home;
4. Not be provided in more
than two (2) apartments in one (1) building;
5. If provided in an apartment building, have
staff:
a. Available twenty-four (24) hours per
day and seven (7) days per week; and
b. Who do not reside in a dwelling occupied
by a participant; and
6.
Provide less than twelve (12) hours of supervision or support in the home based
on an individualized plan developed by the provider to promote increased
independence which shall:
a. Contain
provisions necessary to ensure the participant's health, safety, and
welfare;
b. Be approved by the
participant's treatment team, with the approval documented by the provider;
and
c. Contain periodic reviews and
updates based on changes, if any, in the participant's status;
(g) Counseling
services, which:
1. Shall be designed to help
a participant resolve personal issues or interpersonal problems resulting from
the participant's ABI;
2. Shall
assist a family member in implementing a participant's approved person-centered
service plan;
3. In a severe case,
shall be provided as an adjunct to behavioral programming;
4. Shall include substance use or chemical
dependency treatment, if needed;
5.
Shall include building and maintaining healthy relationships;
6. Shall develop social skills or the skills
to cope with and adjust to the brain injury;
7. Shall increase knowledge and awareness of
the effects of an ABI;
8. May
include group counseling if the service is:
a.
Provided to a maximum of twelve (12) participants; and
b. Included in the participant's approved
person-centered service plan for:
(i)
Substance use or chemical dependency treatment;
(ii) Building and maintaining healthy
relationships;
(iii) Developing
social skills;
(iv) Developing
skills to cope with and adjust to a brain injury, including the use of
cognitive remediation strategies consisting of the development of compensatory
memory and problem solving strategies, and the management of impulsivity;
and
(v) Increasing knowledge and
awareness of the effects of the acquired brain injury upon the participant's
functioning and social interactions;
9. Shall be provided by:
a. A psychiatrist;
b. A psychologist;
c. A psychologist with autonomous
functioning;
d. A licensed
psychological associate;
e. A
licensed clinical social worker;
f.
A clinical nurse specialist with a master's degree in psychiatric
nursing;
g. An advanced practice
registered nurse;
h. A certified
alcohol and drug counselor;
i. A
licensed marriage and family therapist;
j. A licensed professional clinical
counselor;
k. A licensed clinical
alcohol and drug counselor associate effective and contingent upon approval by
the Centers for Medicare and Medicaid Services; or
l. A licensed clinical alcohol and drug
counselor effective and contingent upon approval by the Centers for Medicare
and Medicaid Services; and
10. Shall be documented by a detailed staff
note in the MWMA which shall include:
a.
Progress toward the goals and objectives established in the person-centered
service plan;
b. The date of the
service;
c. The beginning and
ending time; and
d. The signature
and title of the individual providing the service;
(h) Family training, which shall:
1. Provide training and counseling services
for the families of individuals served in the ABI long term care waiver.
Training to family or other responsible persons shall include:
a. Interpretation or explanation of medical
examinations and procedures;
b.
Treatment regimens;
c. Use of
equipment specified in the person-centered service plan; or
d. Advising how to assist the
participant;
2. Include
updates as needed to safely maintain the participant at home;
3. Include specified goals in the
participant's person-centered service plan;
4. Be training provided to family that may
include a person who:
a. Lives with, or
provides care to, a participant; and
b. Is a:
(i)
Parent;
(ii) Spouse;
(iii) Child;
(iv) Relative;
(v) Foster family; or
(vi) In-law;
5. Not include an individual who is employed
to care for the participant;
6. Be
provided by an approved ABI waiver provider that is certified at least annually
and which may include:
a. An occupational
therapist;
b. A certified
occupational therapy assistant;
c.
A licensed practical nurse;
d. A
physical therapist;
e. A physical
therapist assistant;
f. A
registered nurse;
g. A
speech-language pathologist;
h. A
psychiatrist;
i. A
psychologist;
j. A psychologist
with autonomous functioning;
k. A
licensed psychological associate;
l. A clinical nurse specialist with a
master's degree in:
(i) Psychiatric nursing;
or
(ii) Rehabilitative
nursing;
m. An advanced
practice registered nurse;
n. A
certified alcohol and drug counselor;
o. A licensed professional clinical
counselor;
p. A board certified
behavior analyst;
q. A licensed
clinical social worker;
r. A
licensed marriage and family therapist;
s. A licensed clinical alcohol and drug
counselor associate effective and contingent upon approval by the Centers for
Medicare and Medicaid Services; or
t. A licensed clinical alcohol and drug
counselor effective and contingent upon approval by the Centers for Medicare
and Medicaid Services; and
7. Be documented by a detailed staff note in
the MWMA which shall include:
a. Progress
toward the goals and objectives established in the person-centered service
plan;
b. The date of the
service;
c. The beginning and
ending time; and
d. The signature
and title of the individual providing the service;
(i) Nursing supports, which shall
include:
1.
a. A physician order to monitor medical
conditions; or
b. A physician order
for training and oversight of medical procedures;
2. The monitoring of specific medical
conditions;
3. Services that shall
be provided by:
a. A registered nurse who
meets the definition established in
KRS 314.011(5); or
b. A licensed practical nurse as defined by
KRS 314.011(9) who works under
the supervision of a registered nurse; and
4. Documentation by a detailed staff note in
the MWMA which shall include:
a. Progress
toward the goals and objectives established in the person-centered service
plan;
b. The date of the
service;
c. The beginning and
ending time; and
d. The signature
and title of the individual providing the service;
(j) Occupational therapy, which
shall be:
1. A physician-ordered evaluation
of a participant's level of functioning by applying diagnostic and prognostic
tests;
2. Physician-ordered
services in a specified amount and duration to guide a participant in the use
of therapeutic, creative, and self-care activities to assist the participant in
obtaining the highest possible level of functioning;
3. Provided by an occupational therapist or
an occupational therapy assistant if supervised by an occupational therapist in
accordance with
201 KAR 28:130; and
4. Documented by a detailed staff note in the
MWMA which shall include:
a. Progress toward
goals and objectives identified in the approved person-centered service
plan;
b. The date of the
service;
c. The beginning and
ending time; and
d. The signature
and title of the individual providing the service;
(k) A physical therapy service,
which shall be:
1. A physician-ordered
evaluation of a participant by applying muscle, joint, and functional ability
tests;
2. Physician-ordered
treatment in a specified amount and duration to assist a participant in
obtaining the highest possible level of functioning;
3. Training of another ABI provider to
improve the level of functioning of the participant in that provider's service
setting;
4. Provided by a physical
therapist or a physical therapist assistant supervised by a physical therapist
in accordance with
201 KAR 22:001 and
201 KAR 22:020; and
5. Documented by a detailed staff note in the
MWMA, which shall include:
a. Progress made
toward outcomes identified in the person-centered service plan;
b. The date of the service;
c. The beginning and ending time of the
service; and
d. The signature and
title of the individual providing the service;
(l) A respite service, which shall:
1. Be provided only to a participant unable
to administer self-care;
2. Be
provided by a:
a. Nursing facility;
b. Community mental health center;
c. Home health agency;
d. Supervised residential care
provider;
e. Adult day training
provider; or
f. Adult day health
care provider;
3. Be
provided on a short-term basis due to the absence or need for relief of a
non-paid primary caregiver;
4. Be
limited to 5,760 fifteen (15) minute units per one (1) year authorized
person-centered service plan period unless an individual's non-paid primary
caregiver is unable to provide care due to a:
a. Death in the family;
b. Serious illness; or
c. Hospitalization;
5. Not be provided to a participant who
receives supervised residential care;
6. Not include the cost of room and board if
provided in a nursing facility; and
7. Be documented by a detailed staff note in
the MWMA, which shall include:
a. Progress
toward goals and objectives identified in the approved person-centered service
plan;
b. The date of the
service;
c. The beginning and
ending time; and
d. The signature
and title of the individual providing the service;
(m) Speech-language pathology
services, which shall be:
1. A
physician-ordered evaluation of a participant with a speech, hearing, or
language disorder;
2. A
physician-ordered habilitative service in a specified amount and duration to
assist a participant with a speech and language disability in obtaining the
highest possible level of functioning;
3. Provided by a speech-language pathologist;
and
4. Documented by a detailed
staff note in the MWMA, which shall include:
a. Progress toward goals and objectives
identified in the approved person-centered service plan;
b. The date of the service;
c. The beginning and ending time;
and
d. The signature and title of
the individual providing the service;
(n) Adult day training services, which shall:
1. Be provided by:
a. An adult day training center that is
certified at least annually by the department;
b. An outpatient rehabilitation facility that
is licensed and operating in accordance with 902 KAR 20:190; or
c. A community mental health center licensed
and operating in accordance with
902 KAR 20:091;
2. Focus on enabling the
participant to attain or maintain the participant's maximum functional level
and reintegrate the participant into the community;
3. Not exceed a staffing ratio of five (5)
participants per one (1) staff person;
4. Include the following services:
a. Social skills training related to
problematic behaviors identified in the participant's person-centered service
plan;
b. Sensory or motor
development;
c. Reduction or
elimination of a maladaptive behavior;
d. Prevocational; or
e. Teaching concepts and skills to promote
independence including:
(i) Following
instructions;
(ii) Attendance and
punctuality;
(iii) Task
completion;
(iv) Budgeting and
money management;
(v) Problem
solving; or
(vi) Safety;
5. Be provided in a
nonresidential setting;
6. Be
developed in accordance with a participant's overall approved person-centered
service plan;
7. Reflect the
recommendations of a participant's person-centered team;
8. Be appropriate:
a. Given a participant's:
(i) Age;
(ii) Level of cognitive and behavioral
function; and
(iii)
Interest;
b. Given a
participant's ability prior to and after the participant's injury;
and
c. According to the approved
person-centered service plan and be therapeutic in nature and not
diversional;
9. Be
coordinated with the occupational, speech, or other rehabilitation therapy
included in a participant's person-centered service plan;
10. Provide a participant with an organized
framework within which to function in the participant's daily
activities;
11. Entail frequent
assessments of a participant's progress and be appropriately revised as
necessary; and
12. Be documented by
a detailed staff note in the MWMA, which shall include:
a. Progress toward goals and objectives
identified in the approved person-centered service plan;
b. The date of the service;
c. The beginning and ending time;
and
d. The signature and title of
the individual providing the service;
(o) Adult day health care services, which
shall:
1. Be provided by an adult day health
care center that is licensed and operating in accordance with
902 KAR 20:066; and
2. Include the following basic services and
necessities provided to a participant during the posted hours of operation:
a. Skilled nursing services provided by a
registered nurse or licensed practical nurse, including:
(i) Ostomy care;
(ii) Urinary catheter care;
(iii) Decubitus care;
(iv) Tube feeding;
(v) Venipuncture;
(vi) Insulin injections;
(vii) Tracheotomy care; or
(viii) Medical monitoring;
b. Meal service corresponding with
hours of operation with a minimum of one (1) meal per day and therapeutic diets
as required;
c. Snacks;
d. Supervision by a registered
nurse;
e. Daily activities that are
appropriate, given a participant's:
(i)
Age;
(ii) Level of cognitive and
behavioral function; and
(iii)
Interest; and
f. Routine
services that meet the daily personal and health care needs of a participant,
including:
(i) Monitoring of vital
signs;
(ii) Assistance with
activities of daily living; and
(iii) Monitoring and supervision of
self-administered medications, therapeutic programs, and incidental supplies
and equipment needed for use by a participant;
3. Include developing, implementing, and
maintaining nursing policies for nursing or medical procedures performed in the
adult day health care center;
4.
Focus on enabling the participant to attain or maintain the participant's
maximum functional level and reintegrate a participant into the community by
providing the following training:
a. Social
skills training related to problematic behaviors identified in the
participant's person-centered service plan;
b. Sensory or motor development;
c. Reduction or elimination of a maladaptive
behavior per the participant's person-centered service plan;
d. Prevocational services; or
e. Teaching concepts and skills to promote
independence including:
(i) Following
instructions;
(ii) Attendance and
punctuality;
(iii) Task
completion;
(iv) Budgeting and
money management;
(v) Problem
solving; or
(vi) Safety;
5. Be provided in a
nonresidential setting;
6. Be
developed in accordance with a participant's overall approved person-centered
service plan, therapeutic in nature, and not diversional;
7. Reflect the recommendations of a
participant's person-centered team;
8. Include ancillary services in accordance
with 907 KAR 1:023 if ordered by a
physician, physician assistant, or advanced practice registered nurse in a
participant's adult day health care plan of treatment. Ancillary services
shall:
a. Consist of evaluations or
reevaluations for the purpose of developing a plan that shall be carried out by
the participant or adult day health care center staff;
b. Be reasonable and necessary for the
participant's condition;
c. Be
rehabilitative in nature;
d.
Include:
(i) Physical therapy provided by a
physical therapist or physical therapist assistant;
(ii) Occupational therapy provided by an
occupational therapist or occupational therapy assistant; or
(iii) Speech-language pathology services
provided by a speech-language pathologist; and
e. Comply with the physical, occupational,
and speech-language pathology service requirements established in
907 KAR 1:030, Section
3;
9. Be provided to a
participant by the health team in an adult day health care center, which may
include:
a. A physician;
b. A physician assistant;
c. An advanced practice registered
nurse;
d. A registered
nurse;
e. A licensed practical
nurse;
f. An activities
director;
g. A physical
therapist;
h. A physical therapist
assistant;
i. An occupational
therapist;
j. An occupational
therapy assistant;
k. A
speech-language pathologist;
l. A
social worker;
m. A
nutritionist;
n. A health
aide;
o. An LPCC;
p. A licensed marriage and family
therapist;
q. A certified
psychologist with autonomous functioning; or
r. A licensed psychological
associate;
10. Be
provided pursuant to a plan of treatment and developed annually in accordance
with 902 KAR 20:066 and from
information in the MAP 351, Medicaid Waiver Assessment and revised as needed;
and
11. Be documented by a detailed
staff note in the MWMA, which shall include:
a. Progress toward goals and objectives
identified in the approved person-centered service plan;
b. The date of the service;
c. The beginning and ending time;
d. The signature and title of the individual
providing the service; and
e. A
monthly summary that assesses the participant's status related to the approved
person-centered service plan;
(p) Supported employment, which shall be:
1. Intensive, ongoing services for a
participant to maintain paid employment in an environment in which an
individual without a disability is employed;
2. Provided by a:
a. Supported employment provider;
b. Sheltered employment provider;
or
c. Structured day program
provider;
3. Provided
one-on-one;
4. Unavailable under a
program funded by either the Rehabilitation Act of 1973 (29 U. S. C. Chapter
16) or Pub.L.
99-457 (34 C.F. R. Parts 300 to 399), proof of
which shall be documented in the participant's file;
5. Limited to forty (40) hours per week alone
or in combination with adult day training or adult day health
services;
6. An activity needed to
sustain paid work by a participant receiving waiver services, including:
a. Supervision; and
b. Training;
7. Exclusive of work performed directly for
the supported employment provider; and
8. Documented by a time and attendance
record, which shall include:
a. Progress
toward the goals and objectives identified in the person-centered service
plan;
b. The date of
service;
c. The beginning and
ending time; and
d. The signature
and title of the individual providing the service;
(q) Specialized medical equipment
and supplies, which shall:
1. Include durable
and nondurable medical equipment, devices, controls, appliances, or ancillary
supplies;
2. Enable a participant
to increase his or her ability to perform daily living activities or to
perceive, control, or communicate with the environment;
3. Be ordered by a physician, documented in a
participant's person-centered service plan, entered into the MWMA by the
participant's case manager or support broker, and include three (3) estimates
if the equipment is needed for vision or hearing;
4. Include equipment necessary for the proper
functioning of specialized items;
5. Not be available through the department's
durable medical equipment, vision, or hearing programs;
6. Not be necessary for life
support;
7. Meet applicable
standards of manufacture, design, and installation; and
8. Exclude those items which are not of
direct medical or remedial benefit to a participant;
(r) Environmental and minor home adaptations,
which shall:
1. Be provided in accordance with
applicable state and local building codes;
2. Be provided to a participant if:
a. Ordered by a physician;
b. Prior-authorized by the ABIB;
c. Specified in the participant's approved
person-centered service plan and entered into the MWMA, by the participant's
case manager or support broker;
d.
Necessary to enable the participant to function with greater independence
within the participant's home; and
e. Without the modification, the participant
requires institutionalization;
3. Not include a vehicle
modification;
4. Be limited to no
more than $2,000 for a participant in a twelve (12) month period; and
5. If entailing:
a. Electrical work, be provided by a licensed
electrician; or
b. Plumbing work,
be provided by a licensed plumber;
(s) Assessment services, which shall:
1. Be a comprehensive assessment that shall
identify a participant's needs and the services that the participant's family
cannot manage or arrange for the participant;
2. Evaluate a participant's physical health,
mental health, social supports, and environment;
3. Be requested by an individual requesting
ABI services or a family or legal representative of the individual;
4. Be conducted by an ABI case manager or
support broker;
5. Be conducted
within seven (7) calendar days of receipt of the request for
assessment;
6. Include at least one
(1) face-to-face contact with the participant and, if appropriate, the
participant's family by the assessor in the participant's home; and
7. Not be reimbursable if the individual does
not receive a level of care certification; or
(t) Reassessment services, which shall:
1. Be performed at least every twelve (12)
months;
2. Be conducted using the
same procedures as for an assessment service;
3. Be conducted by an ABI case manager or
support broker and submitted to the department no more than three (3) weeks
prior to the expiration of the current level of care certification to ensure
that certification is consecutive;
4. Not be reimbursable if conducted during a
period that the participant is not covered by a valid level of care
certification; and
5. Not be
retroactive.
Section 7. Exclusions of the Acquired Brain
Injury Waiver Program. A condition included in the following list shall not be
considered an acquired brain injury requiring specialized rehabilitation:
(1) A stroke treatable in a nursing facility
providing routine rehabilitation services;
(2) A spinal cord injury for which there is
no known or obvious injury to the intracranial central nervous
system;
(3) Progressive dementia or
another condition related to mental impairment that is of a chronic
degenerative nature, including:
(a) Senile
dementia;
(b) Organic brain
disorder;
(c) Alzheimer's
disease;
(d) Alcoholism;
or
(e) Another addiction;
(4) A depression or a psychiatric
disorder in which there is no known or obvious central nervous system
damage;
(5) A birth
defect;
(6) An intellectual
disability without an etiology to an acquired brain injury; or
(7) A condition which causes an individual to
pose a level of danger or an aggression that is unable to be managed and
treated in a community.
Section
8. Incident Reporting Process.
(1)
(a)
There shall be two (2) classes of incidents.
(b) The following shall be the two (2)
classes of incidents:
1. An incident;
or
2. A critical
incident.
(2)
An incident shall be any occurrence that impacts the health, safety, welfare,
or lifestyle choice of a participant and includes:
(a) A minor injury;
(b) A medication error without a serious
outcome; or
(c) A behavior or
situation that is not a critical incident.
(3) A critical incident shall be an alleged,
suspected, or actual occurrence of an incident that:
(a) Can reasonably be expected to result in
harm to a participant; and
(b)
Shall include:
1. Abuse, neglect, or
exploitation;
2. A serious
medication error;
3.
Death;
4. A homicidal or suicidal
ideation;
5. A missing person;
or
6. Other action or event that
the provider determines may result in harm to the participant.
(4)
(a) If an incident occurs, the ABI provider
shall:
1. Report the incident by making an
entry into the MWMA that includes details regarding the incident; and
2. Be immediately assessed for potential
abuse, neglect, or exploitation.
(b) If an assessment of an incident indicates
that the potential for abuse, neglect, or exploitation exists:
1. The incident shall immediately be
considered a critical incident;
2.
The critical incident procedures established in subsection (5) of this section
shall be followed; and
3. The ABI
provider shall report the incident to the participant's case manager and
participant's guardian, if the participant has a guardian, within twenty-four
(24) hours of discovery of the incident.
(5)
(a) If
a critical incident occurs, the individual who witnessed the critical incident
or discovered the critical incident shall immediately act to ensure the health,
safety, and welfare of the at-risk participant.
(b) If the critical incident:
1. Requires reporting of abuse, neglect, or
exploitation, the critical incident shall be immediately reported via the MWMA
by the individual who witnessed or discovered the critical incident;
or
2. Does not require reporting of
abuse, neglect, or exploitation, the critical incident shall be reported via
the MWMA by the individual who witnessed or discovered the critical incident
within eight (8) hours of discovery.
(c) The ABI provider shall:
1. Conduct an immediate investigation and
involve the participant's case manager in the investigation; and
2. Prepare a report of the investigation,
which shall be recorded in the MWMA and shall include:
a. Identifying information of the participant
involved in the critical incident and the person reporting the critical
incident;
b. Details of the
critical incident; and
c. Relevant
participant information including:
(i) Axis I
diagnosis or diagnoses;
(ii) Axis
II diagnosis or diagnoses;
(iii)
Axis III diagnosis or diagnoses;
(iv) A listing of recent medical
concerns;
(v) An analysis of causal
factors; and
(vi) Recommendations
for preventing future occurrences.
(6)
(a) Following a death of a participant
receiving ABI services from an ABI provider, the ABI provider shall enter
mortality data documentation into the MWMA within fourteen (14) days of the
death.
(b) Mortality data
documentation shall include:
1. The
participant's person-centered service plan at the time of death;
2. Any current assessment forms regarding the
participant;
3. The participant's
medication administration records from all service sites for the past three (3)
months along with a copy of each prescription;
4. Progress notes regarding the participant
from all service elements for the past thirty (30) days;
5. The results of the participant's most
recent physical exam;
6. All
incident reports, if any exist, regarding the participant for the past six (6)
months;
7. Any medication error
report, if any exists, related to the participant for the past six (6)
months;
8. The most recent
psychological evaluation of the participant;
9. A full life history of the participant
including any update from the last version of the life history;
10. Names and contact information for all
staff members who provided direct care to the participant during the last
thirty (30) days of the participant's life;
11. Emergency medical services notes
regarding the participant if available;
12. The police report if available;
13. A copy of:
a. The participant's advance directive,
medical order for scope of treatment, living will, or health care directive if
applicable;
b. Any functional
assessment of behavior or positive behavior support plan regarding the
participant that has been in place over any part of the past twelve (12)
months; and
c. The cardiopulmonary
resuscitation and first aid card for any ABI provider's staff member who was
present at the time of the incident that resulted in the participant's
death;
14. A record of
all medical appointments or emergency room visits by the participant within the
past twelve (12) months; and
15. A
record of any crisis training for any staff member present at the time of the
incident which resulted in the participant's death.
(7)
(a) An ABI provider shall report a medication
error to the MWMA.
(b) An ABI
provider shall document all medication error details on a medication error log
retained on file at the ABI provider site.
Section 9. ABI Long Term Care Waiver Waiting
List.
(1) An individual eighteen (18) years of
age or older applying for an ABI long term care waiver service shall be placed
on a statewide ABI long term care waiver waiting list that shall be maintained
by the department.
(2) In order to
be placed on the ABI long term care waiver waiting list, an individual or the
individual's representative shall:
(a) Apply
for 1915(c) home and community based waiver services via the MWMA;
(b) Complete and upload into the MWMA a MAP -
115 Application Intake - Participant Authorization; and
(c) Upload into the MWMA a completed MAP 10,
Waiver Services Physician's Recommendation form that has been signed by a
physician.
(3) The order
of placement on the ABI long term care waiver waiting list shall be determined
by the:
(a) Chronological date of complete
application information regarding the individual being entered into the
MWMA;
(b) Category of need of the
individual as follows:
1. Emergency. An
emergency shall exist if an immediate service is indicated as determined by:
a. The individual currently is demonstrating
behavior related to the individual's acquired brain injury that places the
participant, caregiver, or others at risk of significant harm; or
b. The individual is demonstrating behavior
related to the individual's acquired brain injury which has resulted in the
individual's arrest; or
2. Nonemergency; and
(c) Emergency Committee, which shall consider
applications for the Acquired Brain Injury long term care waiver program for
emergency placement.
1. The Emergency
Committee meetings shall regularly occur during the fourth week of each month.
To be considered at the monthly committee meeting, an application shall be
received by the department no later than three (3) business days before the
scheduled committee meeting.
2. The
Emergency Review Committee shall be comprised of three (3) program staff of the
cabinet.
a. Each member shall have
professional or personal experience with brain injuries or other cognitive
disabilities.
b. At least two (2)
members shall not be supervised by the branch manager of the Acquired Brain
Injury Branch.
(4) In determining chronological status, the
original date of the individual's complete application information being
entered into the MWMA shall:
(a) Be
maintained; and
(b) Not change if
an individual is moved from one (1) category of need to another.
(5) A written statement by a
physician or other qualified mental health professional shall be required to
support the validation of risk of significant harm to an individual or
caregiver, or the nature of the individual's medical need.
(6) Written documentation by law enforcement
or court personnel shall be required to support the validation of a history of
arrest.
(7) A written notification
of placement on the waiting list shall be mailed to the individual or the
individual's legal representative and case management provider if
identified.
(8) Maintenance of the
ABI long term care waiver waiting list shall occur as follows:
(a) The department shall, at a minimum,
update the waiting list annually; and
(b) If an individual is removed from the ABI
long term care waiver waiting list, written notification shall be mailed by the
department to the:
1. Individual;
2. Individual's legal representative;
and
3. ABI case manager.
(9) Reassignment of
category of need shall be completed based on the updated information and
validation process.
(10) An
individual or legal representative may submit a request for consideration of
movement from one (1) category of need to another at any time an individual's
status changes.
(11) An individual
shall be removed from the ABI long term care waiver waiting list if:
(a) After a documented attempt, the
department is unable to locate the individual or the individual's legal
representative;
(b) The individual
is deceased;
(c) The individual or
individual's legal representative refuses the offer of ABI long term care
waiver services and does not request to be maintained on the ABI long term care
waiver waiting list; or
(d) The
individual does not access services without demonstration of good cause within
sixty (60) days of the placement allocation date.
1. The individual or individual's legal
representative shall have the burden of providing documentation of good cause
including:
a. A signed statement by the
individual or the legal representative;
b. Copies of letters to providers;
and
c. Copies of letters from
providers.
2. Upon
receipt of documentation of good cause, the department shall grant one (1)
sixty (60) day extension in writing.
(12) The removal of an individual from the
ABI long term care waiver waiting list shall not prevent the submittal of a new
application at a later date.
(13)
Potential funding allocated for services for an individual shall be based upon:
(a) The individual's category of need;
and
(b) The individual's
chronological date of placement on the ABI long term care waiver waiting
list.
Section
10. Participant-Directed Services.
(1) Covered services and supports provided to
a participant receiving PDS shall include:
(a)
A home and community support service, which shall:
1. Be available only as a
participant-directed service;
2. Be
provided in the participant's home or in the community;
3. Be based upon therapeutic goals and not be
diversional in nature;
4. Not be
provided to an individual if the same or similar service is being provided to
the individual by a non-PDS acquired brain injury service; and
5.
a. Be
respite for the primary caregiver; or
b. Be supports and assistance related to
chosen outcomes to facilitate independence and promote integration into the
community for an individual residing in the individual's own home or the home
of a family member and may include:
(i)
Routine household tasks and maintenance;
(ii) Activities of daily living;
(iii) Personal hygiene;
(iv) Shopping;
(v) Money management;
(vi) Medication management;
(vii) Socialization;
(viii) Relationship building;
(ix) Meal planning;
(x) Meal preparation;
(xi) Grocery shopping; or
(xii) Participation in community
activities;
(b) Goods and services, which shall:
1. Be individualized;
2. Be utilized to reduce the need for
personal care or to enhance independence within the home or community of the
participant;
3. Not include
experimental goods or services; and
4. Not include chemical or physical
restraints; and
(c) A
community day support service, which shall:
1.
Be available only as a participant-directed service;
2. Be provided in a community
setting;
3. Be tailored to the
participant's specific personal outcomes related to the acquisition,
improvement, and retention of skills and abilities to prepare and support the
participant for:
a. Work or community
activities;
b. Socialization;
and
c. Leisure or retirement
activities;
4. Be based
upon therapeutic goals and not be diversional in nature; and
5. Not be provided to an individual if the
same or similar service is being provided to the individual by a non-PDS
acquired brain injury service.
(2) To be covered, a PDS shall be specified
in a participant's person-centered service plan.
(3) Reimbursement for a PDS shall not exceed
the department's allowed reimbursement for the same or a similar service
provided in a non-PDS ABI setting.
(4) A participant, including a married
participant, shall choose a provider and the choice of PDS provider shall be
documented in the participant's person-centered service plan.
(5)
(a) A
participant may designate a representative to act on the participant's
behalf.
(b) The PDS representative
shall:
1. Be twenty-one (21) years of age or
older;
2. Not be monetarily
compensated for acting as the PDS representative or providing a PDS;
and
3. Be appointed by the
participant on a MAP-2000, Initiation/Termination of Participant-Directed
Services.
(6)
A participant may voluntarily terminate PDS by completing a MAP-2000,
Initiation/Termination of Participant-Directed Services and submitting it to
the support broker.
(7) The
department shall immediately terminate a participant from receiving PDS if:
(a) Imminent danger to the participant's
health, safety, or welfare exists;
(b) The participant fails to pay patient
liability;
(c) The participant's
person-centered service plan indicates the participant requires more hours of
service than the program can provide, jeopardizing the participant's safety and
welfare due to being left alone without a caregiver present; or
(d) The participant, caregiver, family, or
guardian threatens or intimidates a support broker or other PDS
staff.
(8) The
department may terminate a participant from receiving PDS if the department
determines that the participant's PDS provider has not adhered to the
person-centered service plan.
(9)
Except as provided in subsection (7) of this section, prior to a participant's
termination from receiving PDS, the support broker shall:
(a) Notify the assessment or reassessment
service provider of potential termination;
(b) Assist the participant in developing a
resolution and prevention plan;
(c)
Allow at least thirty (30), but no more than ninety (90), days for the
participant to resolve the issue, develop and implement a prevention plan, or
designate a PDS representative;
(d)
Complete and submit to the department a MAP-2000, Initiation/Termination of
Participant-Directed Services terminating the participant from receiving PDS if
the participant fails to meet the requirements in paragraph (c) of this
subsection; and
(e) Assist the
participant in transitioning back to traditional ABI services.
(10) Upon an involuntary
termination of PDS, the department shall:
(a)
Notify a participant in writing of its decision to terminate the participant's
PDS participation; and
(b) Except
if the participant failed to pay patient liability, inform the participant of
the right to appeal the department's decision in accordance with Section 13 of
this administrative regulation.
(11) A PDS provider shall:
(a) Be selected by the participant;
(b) Submit a completed Kentucky
Participant-Directed Services Employee Provider Contract to the support
broker;
(c) Be eighteen (18) years
of age or older;
(d) Be a citizen
of the United States with a valid Social Security number or possess a valid
work permit if not a U. S. citizen;
(e) Be able to communicate effectively with
the participant, participant representative, or family;
(f) Be able to understand and carry out
instructions;
(g) Be able to keep
records as required by the participant;
(h) Submit to a criminal background check
conducted by:
1. The Administrative Office of
the Courts if the individual is a Kentucky resident; or
2. An equivalent out-of-state agency if the
individual resided or worked outside Kentucky during the year prior to
selection as a provider of PDS;
(i) Submit to a check of the Central Registry
maintained in accordance with
922 KAR 1:470 and not be found on
the registry.
1. A participant may employ a
provider prior to a Central Registry check result being obtained for up to
thirty (30) days.
2. If a
participant does not obtain a Central Registry check result within thirty (30)
days of employing a provider, the participant shall cease employment of the
provider until a favorable result is obtained;
(j) Submit to a check of the:
1. Nurse Aide Abuse Registry maintained in
accordance with
906 KAR 1:100 and not be found on
the registry; and
2. Caregiver
Misconduct Registry in accordance with
922 KAR 5:120 and not be found on
the registry;
(k) Not
have pled guilty or been convicted of committing a sex crime or violent crime
as defined in KRS 17.165(1) through (3);
(l) Complete training on the reporting of
abuse, neglect, or exploitation in accordance with
KRS 209.030 or
620.030 and on the needs of the
participant;
(m) Be approved by the
department;
(n) Maintain and submit
timesheets documenting hours worked; and
(o) Be a friend, spouse, parent, family
member, other relative, employee of a provider agency, or other person hired by
the participant.
(12) A
parent, parents combined, or a spouse shall not provide more than forty (40)
hours of services in a calendar week (Sunday through Saturday) regardless of
the number of family members who receive waiver services.
(13)
(a)
The department shall establish a budget for a participant based on the
individual's historical costs in any Medicaid waiver program minus five (5)
percent to cover costs associated with administering participant-directed
services.
(b) If no historical cost
exists for the participant, the participant's budget shall equal the average
per capita historical costs of a participant participating in the ABI waiver
program established by
907 KAR 3:090 minus five (5)
percent.
(c) Cost of services
authorized by the department for the participant's prior year person-centered
service plan but not utilized may be added to the budget if necessary to meet
the individual's needs.
(d) The
department may adjust a participant's budget based on the participant's needs
and in accordance with paragraphs (e) and (f) of this subsection.
(e) A participant's budget shall not be
adjusted to a level higher than established in paragraph (a) of this subsection
unless:
1. The participant's support broker
requests an adjustment to a level higher than established in paragraph (a) of
this subsection; and
2. The
department approves the adjustment.
(f) The department shall consider the
following factors in determining whether to allow for a budget adjustment:
1. If the proposed services are necessary to
prevent imminent institutionalization;
2. The cost effectiveness of the proposed
services;
3. Protection of the
participant's health, safety, and welfare; or
4. If a significant change has occurred in
the participant's:
a. Physical condition
resulting in additional loss of function or limitations to activities of daily
living and instrumental activities of daily living;
b. Natural support system; or
c. Environmental living arrangement resulting
in the participant's relocation.
(g) A participant's budget shall not exceed
the average per capita cost of services provided to individuals with a brain
injury in a nursing facility.
(14) Unless approved by the department
pursuant to subsection (13)(c) through (f) of this section, if a PDS is
expanded to a point in which expansion necessitates a budget allowance
increase, the entire service shall only be covered via a traditional (non-PDS)
waiver service provider.
(15) A
support broker shall:
(a) Provide needed
assistance to a participant with any aspect of PDS or blended
services;
(b) Be available by phone
or in person to a participant twenty-four (24) hours per day, seven (7) days
per week to assist the participant in obtaining community resources as
needed;
(c) Comply with applicable
federal and state laws and requirements;
(d) Continually monitor a participant's
health, safety, and welfare; and
(e) Complete or revise a person-centered
service plan using person-centered planning principles.
(16) For a participant receiving PDS, a
support broker may conduct an assessment or reassessment.
(17) Services provided by a support broker
shall meet the conflict free requirements established for case management in
Section 5(4) of this administrative regulation.
(18) Financial management services shall:
(a) Include managing, directing, or
dispersing a participant's funds identified in the participant's approved PDS
budget;
(b) Include payroll
processing associated with an individual hired by a participant or the
participant's representative;
(c)
Include withholding local, state, and federal taxes and making payments to
appropriate tax authorities on behalf of a participant;
(d) Be performed by an entity:
1. Enrolled as a Medicaid provider in
accordance with
907 KAR 1:672; and
2. With at least two (2) years of experience
working with acquired brain injury; and
(e) Include preparing fiscal accounting and
expenditure reports for:
1. A participant or
participant's representative; and
2. The department.
Section 11.
Reimbursement and Coverage.
(1) The department
shall reimburse a participating provider for a service provided to a Medicaid
eligible person who meets the ABI long term care waiver program requirements as
established in this administrative regulation.
(2) The department shall reimburse an ABI
participating long term waiver provider for a prior-authorized ABI long term
waiver service if the service is:
(a) Included
in the person-centered service plan;
(b) Medically necessary; and
(c) Essential to provide an alternative to
institutional care to an individual with an acquired brain injury who requires
maintenance services.
(3) Under the ABI long term care waiver
program, the department shall not reimburse a provider for a service provided:
(a) To an individual who does not meet the
criteria established in Section 3 of this administrative regulation;
or
(b) Which has not been prior
authorized as a part of the person-centered service plan.
(4)
(a) A
participating ABI long term care waiver service provider shall be reimbursed a
fixed rate for reasonable and medically necessary services for a
prior-authorized unit of service provided to a participant.
(b) A participating ABI long term care waiver
service provider certified in accordance with this administrative regulation
shall be reimbursed at the lesser of:
1. The
provider's usual and customary charge; or
2. The Medicaid fixed upper payment limit per
unit of service as established in subsection (5) of this section.
(5)
(a) The unit amounts, fixed upper payment
limits, and other limits established in the following table shall apply:
|
Service |
Unit of Service |
Upper Payment Limit |
|
Case Management |
1 month |
$375.00 - limited to one (1) unit per member per month |
|
Community Living Supports |
15 minutes |
$5.56 - limited to 160 units per member, per calendar week. |
|
Respite Care |
5 minutes |
$4.00 - limited to 5,760 units, equal to 1440 hours, per member, per calendar year, except as provided in paragraph (c) of this subsection |
|
Adult Day Health Care |
15 minutes |
$3.19 - limited to 160 units per member, per calendar week. |
|
Adult Day Training |
15 minutes |
$4.03 - limited to 160 units per member, per calendar week alone or in combination with supported employment services. |
|
Supported Employment |
15 minutes |
$7.98 - limited to 160 units per member, per calendar week alone or in combination with adult day training. |
|
Behavior Programming |
15 minutes |
$33.61 - limited to 80 units per member, per calendar month for the first three (3) months; after initial three (3) months limited to forty-eight (48) units per member, per month. |
|
Counseling. Individual Counseling. Group |
15 minutes 15 minutes |
$23.84 - limited to 52 units per member, per month. $5.75 - limited to 48 units per member, per calendar month. |
|
Occupational Therapy |
15 minutes |
$25.90 - limited to 52 units per member, per calendar month. |
|
Speech Therapy |
15 minutes |
$28.41 - limited to 52 units per member, per calendar month |
|
Specialized Medical Equipment and Supplies (see paragraph (b) of this subsection) |
Per Item |
As negotiated by the department |
|
Environmental Modification |
Per Modification |
Actual cost not to exceed $2,000 per member, per calendar year. |
|
Supervised Residential Care Level I |
(1) calendar day |
$200.00 - Limited to one (1) unit per member, per calendar day |
|
Supervised Residential Care Level II |
(1) calendar day |
$150.00 - Limited to one (1) unit per member, per calendar day |
|
Supervised Residential Care Level III |
(1) calendar day |
$75.00 - Limited to one (1) unit per member, per calendar day |
|
Nursing Supports |
15 minutes |
$25.00 - Limited to 28 units per member, per calendar week |
|
Family Training |
15 minutes |
$25.00 - Limited to 8 units per member, per calendar week |
|
Physical Therapy |
15 minutes |
$25.00 - Limited to 52 units per member, per calendar month. |
|
Assessment |
One (1) unit equals entire process |
$100.00 |
|
Assessment or Reassessment |
One (1) unit equals entire process |
$100.00 |
|
Participant-Directed Services: |
||
|
Home and Community Supports |
Service limited by dollar amount prior authorized by QIO based on DMS approved participant budget |
|
|
Community Day Supports |
Service limited by dollar amount prior authorized by QIO based on DMS approved participant budget |
|
|
Goods and Services |
Service limited by dollar amount prior authorized by DMS based on DMS approved participant budget |
|
|
Support Broker |
One (1) unit equal to one (1) calendar month |
$375.00 - Limited to one (1) unit per member, per calendar month |
|
Financial Management Services |
Fifteen (15) minutes |
$12.50 Limited to eight (8) units per member, per calendar month |
(b)
Specialized medical equipment and supplies shall be reimbursed on a per item
basis based on a reasonable cost as negotiated by the department if they meet
the following criteria:
1. They are not
covered through the Medicaid durable medical equipment program established in
907 KAR 1:479; and
2. They are provided to an individual
participating in the ABI waiver program.
(c) Respite care may exceed 1,440 hours in a
twelve (12) month period if an individual's usual caregiver is unable to
provide care due to a:
1. Death in the
family;
2. Serious illness;
or
3. Hospitalization.
(d) If supported employment
services are provided at a work site in which persons without disabilities are
employed, payment shall be made only for the supervision and training required
as the result of the participant's disabilities and shall not include payment
for supervisory activities normally rendered.
(e)
1. The
department shall only pay for supported employment services for an individual
if supported employment services are unavailable under a program funded by
either the Rehabilitation Act of 1973 (29 U. S. C. Chapter 16) or
Pub.L.
94-142 (34 C.F. R. Subtitle B, Chapter
III).
2. For an individual
receiving supported employment services, documentation shall be maintained in
the individual's record demonstrating that the services are not currently
available under a program funded by either the Rehabilitation Act of 1973 (29
U. S. C. Chapter 16) or Pub.L. 94-142 (34 C.F. R.
Subtitle B, Chapter III).
(6) Payment shall not include:
(a) The cost of room and board unless
provided as part of respite care in a Medicaid certified nursing facility. If a
participant is placed in a nursing facility to receive respite care, the
department shall pay the nursing facility its per diem rate for that
individual;
(b) The cost of
maintenance, upkeep, an improvement, or an environmental modification to a
group home or other licensed facility;
(c) The cost of a service that is not listed
in the approved person-centered service plan; or
(d) A service provided by a family member
unless provided as an approved participant-directed service.
(7) A participating provider
shall:
(a) Maintain fiscal and service records
for a period of at least six (6) years. If the Secretary of the United States
Department of Health and Human Services requires a longer document retention
period, pursuant to 42 C.F. R. 431.17, the period established by the secretary
shall be the required period;
(b)
Provide, as requested by the department, a copy of, and access to, each record
of the ABI Waiver Program retained by the provider pursuant to paragraph (a) of
this subsection or
907 KAR 1:672; and
(c) Upon request, make available service and
financial records to a representative or designee of the:
1. Commonwealth of Kentucky, Cabinet for
Health and Family Services;
2.
United States Department for Health and Human Services, Comptroller
General;
3. United States
Department for Health and Human Services, Centers for Medicare and Medicaid
Services (CMS);
4. General
Accounting Office;
5. Commonwealth
of Kentucky, Office of the Auditor of Public Accounts; or
6. Commonwealth of Kentucky, Office of the
Attorney General.
Section 12. Electronic Signature Usage. The
creation, transmission, storage, and other use of electronic signatures and
documents shall comply with the requirements established in
KRS 369.101 to
369.120.
Section 13. Appeal Rights.
(1) An appeal of a department decision
regarding a Medicaid beneficiary based upon an application of this
administrative regulation shall be in accordance with
907 KAR 1:563.
(2) An appeal of a department decision
regarding Medicaid eligibility of an individual based upon an application of
this administrative regulation shall be in accordance with
907 KAR 1:560.
(3) An appeal of a department decision
regarding a provider based upon an application of this administrative
regulation:
(a) Regarding a provider's
reimbursement shall be in accordance with
907 KAR 1:671, Sections 8 and 9;
or
(b) Not regarding a provider's
reimbursement shall be in accordance with
907 KAR 1:671.
Section 14.
Incorporation by Reference.
(1) The following
material is incorporated by reference:
(a)
"MAP 10, Waiver Services Physician's Recommendation", June 2015;
(b) "MAP - 115 Application Intake -
Participant Authorization", May 2015;
(c) "MAP - 116 Service Plan - Participant
Authorization", May 2015;
(d) "MAP
- 531 Conflict-Free Case Management Exemption", October 2015;
(e) "MAP-350, Long Term Care Facilities and
Home and Community Based Program Certification Form", June 2015;
(f) "MAP 351, Medicaid Waiver Assessment",
July 2015;
(g) "MAP-2000,
Initiation/Termination of Participant-Directed Services (CDO) ", June
2015;
(h) "Mayo-Portland
Adaptability Inventory-4", March 2003;
(i) "Family Guide to the Rancho Levels of
Cognitive Functioning", August 2006;
(j) "Kentucky Participant-Directed Services
Employee Provider Contract", June 2015; and
(k) "MAP 4100a Acquired Brain Injury Waiver
Program Provider Information and Services", September 2009.
(2) This material may be
inspected, copied, or obtained, subject to applicable copyright law:
(a) At the Department for Medicaid Services,
275 East Main Street, Frankfort, Kentucky 40621, Monday through Friday, 8 a. M.
to 4:30 p. M.; or
(b) Online at the
department's Web site at
http://www.chfs.ky.gov/dms/incorporated.htm.
Notes
STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), 205.5606(1).
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.