Appendix F: Participant Rights, Appendix F-1: Opportunity to Request a Fair Hearing, Procedures for Offering Opportunity to Request a Fair Hearing; narrative, page 241
DBHDS sometimes will communicate with case managers/support coordinators and waiver service providers before making a final service authorization decision. During this communication through WaMS, by email and telephone, DBHDS will stipulate that they will re-consider the request if the case manager/support coordinator or provider will adjust the authorization request and/or plan (Part V) to reduce the items or units/hours being requested. This is often done without knowledge of the individual until the final authorization is provided. If the individual requests a specific item or number of units/hours of service and this need is documented in the plan, appeal notice and rights are not provided if the service is reduced at the direction of DBHDS.
RECOMMENDATION: Clarify that in situations in which DBHDS requests, recommends, or otherwise reduces the items or units/hours on the signed plan, including the Part V, written notice with appeal rights must be provided to the individual.
Appendix F: Participant Rights, Appendix F-3: State Grievance/Complaint System, a. Operation of Grievance/Appeal System, page 242, b. Operational Responsibility, narrative, page 243
On page 242 of the draft Application, DMAS selects the statement indicating that there is a state grievance/complaint system. On page 243, DMAS states there is “not a formal complaint system”, but “concerns are taken seriously”. There does not appear to be a tracking, standard, or other uniform process for an individual to file a complaint.
RECOMMENDATION: Include a formal complaint system.
Appendix F: Participant Rights, Appendix F-3: State Grievance/Complaint System, c. Description of System, narrative, page 243
Individuals are not informed about how to file a grievance or complaint, separate from or in addition to a fair hearing request. Additionally, the first sentence in this narrative lists only one FIS Waiver service provider, services facilitator, who informs the individual they may file a grievance or make a complaint. It is unclear what information is provided to individuals about how to take these actions. This process could identify and track common complaints and provide remediation to providers.
RECOMMENDATION: Include a formal complaint system, including how and where to register a complaint, including timelines and methods used to resolve the complaint.
Appendix G: Participant Safeguards, Appendix G-2: Safeguards Concerning Restraints and Restrictive Interventions (1 of 3), a. Use of Restraints, narrative, page 250
The draft Application states that mechanical and physical restraints can be used “when the behavior places him or others at imminent risk”. Nonetheless, the narrative includes details about the provider’s duties that call for the removal of the restraint when the “criteria for removal are met”. The criteria is unclear. It appears, the restraint may continue beyond its purpose of preventing imminent risk. The restraint should end immediately when the individual or others are no longer at imminent risk of serious bodily injury. The narrative includes a timeline for limiting the restraint to a certain number of hours depending on the age of the individual. There is minimal notice required to the individual about the use restraint. There are no notice requirements to the primary paid or unpaid caregivers, family of any aged person or guardians.
RECOMMENDATION: Clarify that restraints can only be used when the individual’s behavior places him or other at imminent risk of serious bodily injury and that the restraint must be removed immediately upon cessation of imminent risk.
RECOMMENDATION: Add requirements for notification in writing within a short specific timeline to the individual’s parents, if the individual is a minor, other unpaid caregivers known to the CSB, all service providers identified on the individual’s plan, guardian, or others the CSB has authorization to exchange the individual’s information.
RECOMMENDATION: Clarify that restraints may only be used by nonlicensed providers when the individual’s behavior places him or others at imminent risk of serious bodily injury.
RECOMMENDATION: Include expectations regarding restraints for providers of FIS Waiver services that are not licensed by DBHDS.
Appendix G: Participant Safeguards, Appendix G-2: Safeguards Concerning Restraints and Restrictive Interventions (2 of 3), b. Use of Restrictive Interventions, i. Safeguards Concerning the Use of Restrictive Interventions, narrative, page 256
The draft Application appears to address the use of restrictive interventions used in DBHDS licensed settings. Yet there are FIS Waivers service providers who are not licensed by DBHDS.
RECOMMENDATION: Include expectations regarding restrictive interventions for providers of FIS Waiver services that are not licensed by DBHDS.
Appendix G: Participant Safeguards, Appendix G-2: Safeguards Concerning Restraints and Restrictive Interventions (1 of 3), b. Use of Restrictive Interventions, ii. State Oversight Responsibility, narrative, item B, page 259
The draft Application states that individual has the right to complain. There are no details about how the complaint should be presented, who to send the complaint to, or any other details about the process of complaining.
RECOMMENDATION: Include details about the complaint process to be used for complaints related to the use of restrictive interventions.
Appendix G: Participant Safeguards, Appendix G-3: Medication Management and Administration, (2 of 2), c. Medication Administration by Waiver Providers, ii. State Policy, narrative, 4th paragraph, 3rd paragraph, page 263
The draft Application states that the services facilitator “be a registered nurse or establish a relationship with the individual’s primary care provider in order to review medical concerns, including medication”.
Current regulations, 12VAC30-122-500 D.2.a., require the following: “If the services facilitator is not an RN then, within 30 days from the start of such service, the services facilitator shall inform the primary health care provider for the individual enrolled in the waiver that consumer-directed service is being provided and request skilled nursing or other consultation as needed by the individual.”
RECOMMENDATION: Clarify the intent is for the services facilitator to inform the primary health care provider that the individual is using consumer-direction and request skilled nursing or consultation as needed by the individual.
RECOMMENDATION: Clarify the role of the case manager/support coordinator when the individual does not select services facilitation and the case manager/support coordinator is not a nurse.
Appendix G: Participant Safeguards, Quality Improvement: Health and Welfare, a. Methods for Discovery: Health and Welfare, page 266
The Agreement lacks Health and Welfare Performance Measures representing input from individual.
RECOMMENDATION: Add a Performance Measure that will capture information from the individual about the availability to receive the supports they need due to lack of waiver service providers or other factors.
RECOMMENDATION: Add a Performance Measure that indicates the length of time to complete a request for DD Waivers screening from the time the individual requests screening.
Appendix G: Participant Safeguards, Quality Improvement: Health and Welfare, b. Methods for Remediation/Fixing Individual Problems, page 281
The Agreement lacks remediation of issues identified when reviewing Performance Measures related to the satisfaction of participants about their own health and welfare. The remediation methods described in the draft Application are applicable to providers.
RECOMMENDATION: Add remediation methods that relate to the Performance Measures indicative of consumer input about their own health and welfare.
Appendix H: Quality Improvement Strategy (3 of 3), H-2: Use of Patient Experience of Care/Quality of Life Survey, page 287
DMAS has selected not to conduct a survey.
RECOMMENDATION: Include a statement that DMAS intends to develop and use a survey in the second year of the Application approval period.
Appendix I: Financial Accountability, I-2: Rates, Billing and Claims (1 of 3), narrative, 2nd paragraph, last sentence, page 297
Individuals report that they are unable to access FIS Waiver providers in numerous geographical locations. It is difficult to determine if this is due to the lack of available providers or the lack of information from case managers/support coordinators about providers.
RECOMMENDATION: Replace draft Application language regarding sufficiency of provider availability with a statement about how provider information will be more readily available.
RECOMMENDATION: Include language about how Performance Measures indicative of the experiences of individuals will help DMAS to gauge the adequacy of provider availability and adjust rates, if needed, to improve provider availability.
Appendix I: Financial Accountability, I-3: Payment (2 of 7), a. Direct payment, narrative, 4th paragraph, 3rd sentence, page 304
This paragraph describes why and how some CSBs are providers of or a conduit to environmental modification and assistive technology services. The draft Application includes the following sentence: “It is not advantageous to building contractors to become Medicaid waiver providers in general.” DMAS establishes the provider requirements. CSBs can and do refuse to be providers or conduits for these services. The result is that individuals are unable to access needed environmental modifications and assistive technology.
RECOMMENDATION: Knowing that “It is not advantageous to building contractors to become Medicaid waiver providers in general,” establish a process for individuals to access needed environmental modifications and assistive technology that is not reliant on CSBs. CSBs willing to serve as providers of these services should continue to do so.