Delaware – DDDS Lifespan Waiver (0009.R08.00)

Waiver Title

DDDS Lifespan Waiver (0009.R08.00)

Description of Emergency

The Governor issued a State of Emergency declaration on March 12, 2020 that became effective on March 13, 2020 ordering Delawareans to stay at home whenever possible and closing all non-essential businesses in Delaware to help fight the spread of COVID19. The declaration will remain in effect until May 15 or until the public health threat is eliminated. The COVID-19 pandemic has required all Delawareans to take dramatic emergency actions to slow the transmission of the virus from person to person. This includes practicing “social distancing” which is impeding DDDS’s ability to ensure that individuals are engaged in the community, as this is contraindicated at this time for their health and well-being. DDDS is also preparing for the impact on its employees and provider direct support professionals of staffing shortages that may result from individuals being quarantined or isolated, in addition to the potential for quarantine or isolation of waiver members. This emergency impacts all the 1,650+ enrolled waiver members. Many of the DDDS Lifespan Waiver members are over 60 or have an underlying health condition, making them particularly vulnerable to the virus. DDDS and its provider network are limiting face to face contact between waiver members and individuals who may have been exposed to the virus to limit spread. Delaware is seeking temporary changes to the DDDS Lifespan Waiver to minimize the need for waiver administrative activities to be conducted in person, to address issues of provider staffing shortages by revising service definitions and expanding settings in which services can be delivered and to assist providers to be financially viable so that they can resume normal activities after the emergency.

Waiver Description

Provides day habilitation, personal care, prevocational services, residential habilitation, respite, supported employment – individual, supported employment – small group, assistive technology for individuals not otherwise covered by Medicaid, behavioral consultation, community transition, home or vehicle accessibility adaptations, nurse consultation, specialized medical equipment and supplies not otherwise covered by Medicaid, supported living for individuals w/autism and ID ages 12 – no max age

Start Date

27-01-20

End Date

26-01-21

Description of Transition Plan

Not applicable

Area(s) Affected

Area Affected

Entire state

Increase Cost Limits

N/A

Modify Targeting Criteria

N/A

Modify Scope or Coverage

Home Delivered Meals; Shift Nursing

Exceed Service Limitations

N/A

Add Services

Specialized Medical Equipment and Supplies

Expand Settings

Allow day habilitation and prevocational services to be delivered in a provider-managed residential setting, in a private home or in another setting as approved by DDDS. Direct care services, including Residential Habilitation and Medical Residential Habilitation may be provided in a hotel, shelter, church, or alternative facility-based setting or the home of a direct care worker, with permission from DDDS, when the waiver participant is displaced from their home because of quarantine or hospitalization or when providers are unavailable due to illness or business closure. During the declared State of Emergency, DDDS requests to suspend the requirement 42 CFR 441.301(c)(4)(vi)((B)(2) that each waiver member must have choice of housemates in order to allow DDDS to designate residential settings where individuals who have tested positive for the COVID-19 virus may be isolated with other individuals who test positive for a temporary period until they are no longer contagious.

Provide Service Out of State

N/A

Allow Payment for Services by Families

X

Modification of Provider Qualifications

Residential Habilitation Agencies – Residential Habilitation agencies may hire relatives or legally responsible individuals to provide services authorized in the Person-Centered Plan. Relatives and legally responsible individuals must receive training on the participant’s ISP for whom they are rendering these services. Training on the ISP must consist of basic health and safety support needs for that participant including the fatal four diagnoses. The provider agency is responsible for ensuring that services are provided as authorized in the ISP and that billing occurs in accordance with DDDS requirements.

Modify Provider Types

X

Modify Licensure/Requirements for Waiver Settings

Required staffing ratios for a participant, as outlined in his/her Person-Centered Plan, may be modified to allow a participant to receive services in safe and accessible environments, if the participant’s needs are being met. State survey staff are postponing annual agency on-site certification reviews of facility-based settings for the safety of the survey staff, provider staff and waiver participants until the emergency period is over. State survey staff will continue to monitor provider compliance with waiver standards through review of data captured in the electronic case record, telephone interviews and reviews of other available written documentation. DDDS may accept a provisional Neighborhood Group Home or Family Care Home license issued by the Delaware Division of Health Care Quality during the declared State of Emergency.

Modification LOC Eval and Re-Eval Processes

The state is modifying the requirement that a waiver service is delivered monthly to a waiver participant. Waiver members must receive monthly monitoring when services are furnished on a less than monthly basis during the emergency period due to inability to access services because of COVID-19.

Increase Payment Rates

To respond effectively to the COVID-19 outbreak, the state requires flexibility to adjust providers’ rates to ensure a sufficient supply of providers are available for individuals. The state may temporarily increase payment rates to specified providers of residential habilitation by up to 5% above the regular payment rate using the CMS-approved methodology described in the waiver. The rate will only be increased when it is necessary to enable the provider to maintain the DSP workforce due to increased risk to the DSPs who are required to support COVID-19 positive members or to cover DSPs who must work higher than normal overtime that is not already factored into the provider rate.

Modifications of ISP

N/A

Modify Incident Reporting/Med Management Safeguards

State Critical Event or Incident Reporting Requirements: Allow for entry of incidents into the Incident Reporting System within 48 hours of the event and notification of service recipients, legal guardians, and other state agencies within 5 days of the event. Response to incidents will not be impacted. Allow requirements for demographically appropriate health screenings to be suspended during the emergency. Doctors are not seeing patients for preventive appointments and preventive health care screenings have been postponed during the emergency. Allow for investigations to be conducted within 10 days from the date of the report and for investigators to use telephonic, video and other electronic means to the greatest extent practicable. Reported allegations of “Neglect” related to failure to carry out prescribed treatment plan and/or inadequate staffing will not be investigated as a “critical” reportable incident under DHSS Policy Memorandum 46 unless there is a significant adverse impact such as hospitalization or death. Allegations of Medication Administration Errors and Medication Diversion will only be investigated if there is a severe adverse outcome to participant. Allegations of incidents of Financial Exploitation of an amount less than $100 will be reported but not investigated. Only allegations of Financial Exploitation in the amount of $100 or more will be investigated. Medication Management and Administration: Methods of State Oversight and Follow-up: The Nurse Consultant will conduct Monthly Medication and Health Audits remotely and will not visit a provider-managed residential setting. Therefore, the Nurse Consultant will not check the waiver participant’s current Medication Administration Record (MAR) maintained in the home against the Physician’s Orders and against medication labels to assure they all align. The Nurse Consultant will also not be able to physically verify that the medications are adequately stocked, properly stored, and not expired. The Nurse Consultant will not be able to compare count sheets and the amount of medication remaining against the amount noted on the count sheet. The Nurse Consultant will ensure that the residential habilitation agency has completed their internal audits which include all of these on-site tasks. Medication Management and Administration: State Policy: LLAM Guidelines-Initial LLAM trainings will be offered remotely for the procedural portion of LLAM. DDDS will suspend the in-person demonstration of skills and will suspend the requirement to complete 10 Supervised Field Medication Pass Observations. DDDS will allow “Unlicensed Assistive Personnel” (UAP) who have successfully passed the remote procedural portion of the initial LLAM training to assist with medications, if necessary, without having taken the demonstration exam. DDDS program evaluators will not cite providers for failing to comply with DDDS training requirements in these instances.

Allow Payment for Services During Acute Care Hospital/Short Term Institutional Stay

DDDS may authorize providers of residential habilitation, day habilitation, prevocational service or behavior consultation to deliver services to a waiver member who is hospitalized, or who requires a short term stay in a nursing facility when the waiver member requires communication, behavioral stabilization or intensive personal care that cannot be delivered by the institutional provider. Personal care payments may not exceed the lesser of 30 consecutive days or the number of days for which the State authorizes a payment for hospital “bed-hold” days in nursing facilities.

Inclusion of Retainer Payments

DDDS may make retainer payments to providers of residential habilitation that includes personal care as a component part when the member is hospitalized due to a COVID-19 infection or absent from the home. DDDS may make retainer payments to providers for the following habilitative services that include personal care as a component part: day habilitation, prevocational service and supported employment to preserve provider networks. DDDS may make retainer payments for providers whose attendance and utilization for the service drops by at least 50% due to COVID-19 containment efforts. Retainer payments will be made at a percentage of the regular service rate using the CMS-approved methodology described in the waiver, not to exceed 75% of the regular rate. Retainer payment units are limited to average prior utilization for each member. The resulting payment will not exceed the total amount that the provider would have received had services been provided as expected. DDDS will use prior authorization and billing procedures to ensure that there are no duplicative payments. Retainer payments cannot exceed 30 consecutive days Retainers will occur on a case by case basis when the provider is directly affected by COVID-19. Retainer payments will not be authorized for a participant for units of service for which a provider is authorized to be paid for actual service delivery.

Institute/Expand Opportunities for Self-Direction

N/A

Increase Factor C

N/A

Other Changes Necessary

Participant Rights: DDDS will suspend the right to not have to share a bedroom as may be necessary to isolate COVID-19 positive individuals together or to separate healthy individuals from individuals who are or who may have been exposed to the COVID-19 virus. Providers must receive approval from DDDS before requiring participants to share a bedroom. Facility Limits in Appendix C-2-c – The facility capacity limit of 4 may be exceeded with permission from DDDS.

Addendum

HCBS Regulations

Not comply with the HCBS settings requirement at 42 CFR 441.301(c)(4)(vi)(D) that individuals are able to have visitors of their choosing at any time, for settings added after March 17, 2014, to minimize the spread of infection during the COVID-19 pandemic.

Services

Add Electronic Method of Service Delivery

Case management, personal care services that only require verbal cueing, in-home habilitation, monthly monitoring, and other: Nurse Consultation – During the declared State of Emergency, Nurse Consultants
will be allowed to remotely perform monitoring activities that would normally be
performed in a provider-managed setting. Nurse Consultants will endeavor to
perform as many of the duties specified in Appendix C that can be done remotely
using telephonic and video technology.
Behavior Consultation – During the declared State of Emergency, the Behavior
Analyst must have direct observation of the waiver member in order to develop
the Functional Behavior Assessment. The development of the Behavior Support
Plan, the training of Direct Support Professionals on how to execute the plan and
monitoring of the participant’s response to the plan may be done remotely using
telephonic and video technology whenever practicable. If the provider can
document that a Behavior Support Plan continues to meet the needs of the
individual, the state may allow the BSP to remain in effect for up to 90 day after
the renewal date. The state will ensure that the BSP is modified if it no longer
meets the needs of the member. If psychiatric appointments can be held via
telehealth, the Behavior Analyst must join the session via electronic means if
their attendance is requested by the waiver member.

Add Home Delivered Meals

X

Add Medical Supplies, Equipment and Appliances

X

Add Assistive Technology

N/A

Conflict of Interest

Other Changes Necessary

Participant Rights: DDDS will suspend the right to not have to share a bedroom as may be necessary to isolate COVID-19 positive individuals together or to separate healthy individuals from individuals who are or who may have been exposed to the COVID-19 virus. Providers must receive approval from DDDS before requiring participants to share a bedroom. Facility Limits in Appendix C-2-c – The facility capacity limit of 4 may be exceeded with permission from DDDS.

Other Changes Necessary

Participant Rights: DDDS will suspend the right to not have to share a bedroom as may be necessary to isolate COVID-19 positive individuals together or to separate healthy individuals from individuals who are or who may have been exposed to the COVID-19 virus. Providers must receive approval from DDDS before requiring participants to share a bedroom. Facility Limits in Appendix C-2-c – The facility capacity limit of 4 may be exceeded with permission from DDDS.

Provider Qualifications

Allow Spouses and Parents of Minor Children to Provide Personal Care Servcies

X

Allow a Family Member to be Paid to Render Services to an Individual

X

Allow Other Practitioners in Lieu of Approved Providers Within the Waiver

X DDDS may allow redeployment of direct support and clinical staff to needed
service settings during the emergency. Staff qualified under residential, day
habilitation, prevocational service, supported employment, nurse consultation or
behavior consultation in the DDDS Lifespan Waiver may be used for provision of
any non-professional service under another service definition in C-1/C-3.
Self-Directed Personal Care – DDDS may allow relative caregivers of self-directed
personal care to provide services prior to completing background checks and
training requirements for CPR and first aid. Caregivers may meet the training
requirement for CPR by completing the on-line “classroom” portion of the
training. The requirement for the hands-on demonstration is suspended. It is
understood that the background check will be submitted by the agency within 30
days after the service begins and training will occur within 90 days of hire without
leaving the beneficiary without necessary care.
The state is modifying provider standards for relatives to qualify as a direct care
worker while his/her background check and pre-employment screenings are in
pending status. Further, should a pending screening come back demonstrating
concerns with the background check and/or pre-employment screening that would
not allow the worker to continue employment long term that worker continues to
be qualified until an alternative employee is identified unless the worker poses an
immediate jeopardy to health, safety, and/or welfare of the participant (i.e. has
tested positive for infectious disease) or is found to be guilty of past abuse, neglect,
exploitation or violent felony and therefore is immediately unqualified.
Supported Living: DDDS may pay relative caregivers to deliver Supported Living
in the home of a waiver member.
Specialized Medical Equipment and Supplies: (See Section A) During the
COVID-19 emergency, DDDS will authorize additional provider types that can
provide Specialized Medical Equipment and Supplies for newly covered items
related to health and safety such as personal protective equipment, disinfectant
supplies, and emergency nutritional supplies related to the COVID-19 emergency.
Additional provider types include authorized providers of: Residential
Habilitation, both agency and individual (Shared Living), Day Habilitation,
Prevocational Service and Supported Employment.

Direct Support Professionals Employed in other states: Many DDDS providers
operate in multiple states. If a Delaware DDDS authorized provider agency has
staff from another state who are available to provide services in Delaware, DDDS
will honor the background and training requirements from the other state. In those
cases, the provider agency must notify DDDS if they are using staff from another
state. Staff must receive training on any participant’s ISP for whom they are
providing support.
DDDS will allow staff to continue to provide services for the duration of the
emergency when CPR, Limited Lay Administration of Medication (LLAM) and
Mandt crisis response certification has lapsed.
During the period of the emergency, Direct Support Professionals may meet the
requirement for initial LLAM certification by completing the “procedural” portion of LLAM via webinar that would normally be attended in person. New hires will
not be required to attend the in-person demonstration of skills and will not be
required to perform the 10 Supervised Field Medication Pass Observations. DDDS
will allow “Unlicensed Assistive Personnel” (UAP) who have successfully passed
the remote procedural portion of the initial LLAM training to assist with
medications. When possible, given staffing shortages, the provider will endeavor
to pair staff who have not been certified for field operations with staff that meet
the full LLAM requirements. DDDS program evaluators will not cite providers
for failing to comply with DDDS training requirements in these instances.

Modify Service Providers for Home-Delivered Meals to Allow for Additional Providers, Including Non-Traditional Providers

N/A

Processes

Allow an Extension for Reassessments and Reevaluations for up to One Year Past the Due Date

X

Allow the Option to Conduct Evaluations, Assessments, and Person-Centered Service Planning Meetings Virtually/Remotely in lieu of Face-to-Face Meetings

X

Adjust Prior Approval/Authorization Elements Approved in Waiver

N/A

Adjust Assessment Requirements

X

Add an Electronic Method of Signing Off on Required Documents Duch As The Person-Centered Service Plan

X

Link To Application

https://www.medicaid.gov/state-resource-center/downloads/de-0009-appendix-k-appvl.pdf

Link to Approval Letter

https://www.medicaid.gov/state-resource-center/downloads/de-appendix-k-appvl-ltr.pdf