The Board offers the following comments and recommendations to improve the renewal application for the CL waiver.
Community Living Waiver:
Brief Waiver Description
1. The statement of goals and objectives should be revised to better reflect the purposes of the CL waiver. The Board recommends that the goal and objectives of the Community Living Waiver be revised to reflect better the tenets of the HCBS settings rule and national best practice.
For example, the stated goal is to facilitate the transition of individuals currently residing in institutions to life in the community and to engage those community residents in need of supports to retain their community resident status through receiving those supports. Consider a goal more consistent with the purpose of HCBS, for example, “To provide support and assistance that enables individuals with developmental disabilities to live as independently as possible within their communities.”
The objectives should be focused on achieving this goal, for example:
Appendix A: Waiver Administration and Operation
2. Quality Improvement: Administrative Authority of the Single State Medicaid Agency: The Board recommends a performance measure to strengthen oversight and facilitate transparency regarding the performance of contracted entities. For example,
Number and percent of deficiencies identified during the state monitoring activities that were appropriately and timely remediated by the contracted entity. N: Number of deficiencies identified during the state monitoring activities that were appropriately and timely remediated by the contracted entity D: Total number of deficiencies identified during the state monitoring activities
The Quality Improvement strategy for administrative authority includes three performance measures. These performance measures cover all contracted entities, including DBHDS and the Fiscal/Employer Agent for fiscal management services for consumer-directed services and local/regional non-state public agencies that perform waiver operational and administrative functions, e.g., Community Services Boards. For the purpose of quality improvement, discovery, and remediation, adding a performance measure to monitor the identification and remediation of deficiencies would strengthen oversight of contracted entities.
Appendix B: Evaluation/Reevaluation of Level of Care - Quality Improvement: Level of Care
3. d. Level of Care Criteria: The Board recommends revising the following statement: "To ensure that Virginia’s home and community-based waiver programs serve only individuals who would otherwise be placed in an ICF/IID…” The eligibility requirement is that individuals meet the ICF/IID institutional level of care, thereby requiring an institutional level of care, not that they would otherwise be placed in an ICF/IID. It should, therefore, read, “To ensure that Virginia’s home and community-based waiver programs serve only individuals who require an ICF/IID institutional level of care…”
In the Board’s 2022 Assessment of Access to Information for People with Disabilities and their Family Members, families report confusion about being asked if their family members will need to be placed in an institutional setting. There are opportunities to better communicate the Level of Care requirements in the waiver application and to family members. The current language is inconsistent with federal principles of person-centered, home, and community-based systems of support. It is also incongruous that it is a key step in a process under a Department of Justice settlement agreement to promote community living outside of institutions. States such as Ohio, Pennsylvania, and Maryland each require a clinician to document the need for an institutional level of care but do not require families to explicitly state the need for eminent placement in an institutional setting.
4. B-8: Access to Services by Limited English Proficiency Persons: The Board recommends updating this section to reflect current information and practice.
For example, the link to the VDH webpage for the application for birth certificates to verify identity and citizenship as part of the application for Medicaid does not work (http://www.vdh.virginia.gov/vital Records/vtlapp.htm); the VDH link to training and services available to providers serving Medicaid applicants and participants does not work (http://www.vdh.virginia.gov/ohpp/CLASact/default.aspx; the link to the DBHDS policies referenced does not work (http://www.dbhds.virginia.gov/library/document-library/adm-sbpolicies1023.pdf).
DMAS has a comprehensive Language and Disability Access Plan and resources to ensure access, such as a Civil Rights Coordinator. Less clear is the sufficiency of language and disability access plans and implementation by DBHDS and CSBs. This section in the waiver application references the DBHDS Office of Cultural Competency and the support and technical assistance provided to CSBs. Information about this office could not be found online. There is a DBHDS webpage titled Cultural and Linguistic Competence. However, this webpage references a Statewide Cultural and Linguistic Competence Advisory Committee (CLCAC) that appears inactive. Even less known is the compliance of CSBs with the State Behavioral Health and Developmental Services Board policies. Per the January 2019 CMS Instructions, Technical Guide, and Review Criteria for Medicaid 1915 (c) waivers, the review criteria for this section state the following: “A variety of accommodations are described, both in conjunction with the waiver entrance process and for communicating with LEP persons on an ongoing basis (e.g., by providing for bilingual case managers). The content of this section should be strengthened to, at a minimum, meet the review criteria requirements and intent, including for DBHDS and CSBs. DBHDS and CSB's compliance with the requirement for language access is questionable.
Appendix C: Participant Services
5. Personal Assistance Services, Legally Responsible Person (LRI): The Board recommends incorporating into the application any new rules regarding LRIs as required by the legislature during the 2024 General Assembly session for CMS approval.
6. Personal Assistance Services: In addition to the above regarding Personal Assistance Services and LRIs:
The delegation of nursing tasks and procedures is an option for people receiving personal assistance services under specific circumstances. Nurse delegation allows for greater autonomy and control by the individual receiving services and should be included in the service definition.
The services definition includes the following statement: Individuals choosing to receive services through the consumer-directed model may do so by choosing a services facilitator to provide the training and guidance needed to be an employer. It should be clarified that an individual can choose CD services and choose not to receive services facilitation. The option for a case manager or another person of the individual’s choosing to serve in this role should be included in the waiver application.
The delegation of nursing tasks and procedures is an option for people receiving CD personal assistance services under specific circumstances. Nurse delegation allows for greater autonomy and control by the individual receiving services and should be included here.
7. Respite Services, Service Definition: The Board recommends including information about nurse delegation (VA Code 18VAC90-19-240).
As mentioned in the recommendations above, the delegation of nursing tasks and procedures is an option for people receiving CD respite services under specific circumstances. Nurse delegation allows for greater autonomy and control by the individual receiving services and should be included here.
8. Respite Services, Specify Applicable Limits on the Amount, Frequency, or Duration of the Service: The Board recommends that clarification regarding the parameters of the 480-hour limit, e.g., per calendar year, state fiscal year, service plan year, be included in the renewal application.
9. Services Facilitation: The Board recommends re-examining the role of the consumer-directed services facilitator to eliminate unnecessary duplication of functions and more clearly delineate the roles of services facilitators, support coordinators, and CCC Plus care coordinators.
Service facilitators, support coordinators, and CCC Plus care coordinators are all responsible for monitoring waiver services. This can result in duplication of effort, diffusion of responsibility, confusion, and reduced individual ownership of responsibility. It can also unduly burden individuals who must accommodate multiple home visits and assessments.
When various parties have overlapping roles, DMAS should either distinguish how each party’s contribution to the overall role differs from the others’ contributions or, if the contributions do not differ, consolidate the role under fewer parties. If the majority of the service facilitator’s roles are shared by other parties, which appears to be the case, DMAS should also consider transferring the remaining roles (such as training employers of record and reviewing timesheets) to the other parties and eliminating the service facilitator position. The cost of this service should be analyzed in relation to the benefit achieved for the funding agency and the consumer.
10. Assistive Technology: Service Definition: The Board recommends clarifying that AT's criteria include the ability to “actively participate in other waiver services that are part of their plan for supports.”
11. Peer Mentor Supports: The Board recommends clarifying what “Prior to accessing funding for this waiver service, all other available and appropriate funding sources must be explored and exhausted” means in the context of eligibility for this service.
12. Peer Mentor Supports: The Board recommends clarifying what it means to have “lived independently in the community” as this phrase is used in the Waiver application to describe the individuals who may provide peer mentor supports.
The application states: “Peer Mentor Supports are provided by an individual with a developmental disability who has lived independently in the community for at least one year and is or has been a recipient of services, including but not limited to, publicly-funded housing, Medicaid waiver services, work incentives, and supported employment.” It is unclear what it means to have “lived independently in the community” to determine one’s qualifications to provide peer mentor supports.
The Board is concerned that the phrase is susceptible to interpretations that would exclude a number of people with developmental disabilities who would be well-suited to delivering the allowable activities defined in the application. The phrase could be interpreted, for instance, to mean that an individual must live in his or her own apartment or home, which could exclude individuals in other types of residential settings, such as supported living, who could prove very capable of acting as peer mentors. The Board recommends that DMAS reconsider and clarify the standard.
13. Environmental Modifications: The Board recommends that language be added to explain that home accessibility modifications may be authorized up to 180 consecutive days in advance of the community transition of an institutionalized person, as provided in CMS guidance.
Appendix D: Participant-Centered Planning and Service Delivery - Quality Improvement: Service Plan
14. “Sub-assurance: Service plans address all participants' assessed needs (including health and safety risk factors) and personal goals, either by provision of waiver services or through other means.” Section: The Board recommends adding performance measures that speak to the satisfaction of the individual and/or their chosen team members with their service plan.
The proposed performance measures focus on whether the service plans address individuals’ assessed risks but do not appear to speak to whether the service plans address participants’ personal goals. Absent standard documentation of individuals’ goals against which to compare the service plans, one source of relevant information is the individuals’ and/or chosen team members’ satisfaction level with the service plans. The waiver application indicates that some form of satisfaction information is obtained during and following service plan development. According to the “Service Plan Development Process” section under Appendix D-1, “An evaluation of how the plan achieves the desired outcomes, from the individual’s and responsible partners’ perspectives, is completed prior to final agreements.” The waiver application should include a performance measure that speaks to the information collected regarding satisfaction with the service plan.
Appendix E: Participant Direction of Services
15. “Election of Participant Direction” Specify the Criteria: The Board recommends changing the first sentence from “Individuals assessed as having an intellectual disability that may limit or prevent…” to “Individuals assessed as having a developmental disability that may limit or prevent…”
Appendix G-1: Response to Critical Events or Incidents
16. “State Critical Event or Incident Reporting Requirements” Section: The Board recommends updating the language regarding required reporting of deaths and serious injuries to account for new requirements added to 12 VAC 35-105-160.
Reporting requirements for DBHDS-licensed providers in 12 VAC 35-105-160 have changed. Previously, providers were required to collect, maintain, and report each death or serious injury. Now, providers are required to collect, maintain, and report Levels II and III serious incidents. Providers must also collect, maintain, and review at least quarterly (but not report) all Level I serious incidents. Definitions of serious incidents at Levels I, II, and III should be included in the application. References to “serious injuries or deaths” throughout Appendix G should be changed to “serious incidents” for consistency.
17. “State Critical Event or Incident Reporting Requirements” and “Responsibility for Review of and Response to Critical Events or Incidents” Sections: The Board recommends adding references, where appropriate, to the roles of the state’s protection and advocacy entity.
The guide referenced pertains to nursing facilities, assisted living facilities, adult day care centers, etc. It does not pertain to HCBS waiver services and does not address the reporting of abuse, neglect, and exploitation as inferred in the waiver application.
18. C. Participant Training and Education: The Board recommends that DMAS remove the reference to the Guide to Long Term Care Services in Virginia contained on the Virginia Health Information website application.
The guide referenced pertains to nursing facilities, assisted living facilities, adult day care centers, etc. It does not pertain to HCBS waiver services and does not address the reporting of abuse, neglect, and exploitation as inferred in the waiver application.
19. Assistive Technology & Electronic Home-Based Supports: Both services have a $5,000 annual limit. The Board recommends that DMAS add clarifying language regarding the “bundling” of these two service limits for a total of $10,000. The $5,000 limit for one of these services may be exceeded based on individual need, not to exceed $10,000 between the two services.