HCBS Settings Updates and

Heightened Scrutiny

October 18, 2016

Intent of New HCBS Rules

Effective 3/2014:

• Better align HCBS Medicaid funding and program requirements with civil rights protections afforded under ADA

• Address concerns that in some states HCBS used to fund “institutional-style” settings lacking opportunities for people to engage meaningfully in their communities

• Ensure that individuals have full access to the benefits of community living and the opportunity to receive services in the most integrated setting appropriate to their needs

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Key Points to keep in mind:

• Outcome oriented – focuses on nature and quality of individuals’ experience in the setting

• The regulations focus on whether individuals supported have the “same degree of access” as others in the community

• 4 Years Left until CMS requires full compliance in March 2019

• Person Centered Planning and Process Requirements effective now — not subject to five year phase in

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NYS’s Transition Plan

• Originally submitted March 2015

• CMS Letter September 2015---requiring more detail, timelines, milestones, etc.

• Amended and published July 2016 for public input through September 9th 2016

https://www.health.ny.gov/health_care/medicaid/redesign/home_community_based_settings.htm

• Anticipated To be resubmitted to CMS Fall/Winter 2016

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Highlights of OPWDD’s

Transition Plan • New policy decision reflected: “OPWDD has

decided to limit the size of group homes for new development to no more than 4 persons by the end of 2019” (unless an exception is approved by the Commissioner)

• Sheltered Work Shop Conversions to Integrated Settings

• ICF Conversions to Waiver Settings

• Assessment Results and Lessons Learned

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Heightened Scrutiny

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What is “Heightened Scrutiny”?

• Process for submitting evidence to the CMS

Secretary for settings that CMS “presumes not to

be HCBS” where the state finds that the setting can

meet HCBS under a “heightened scrutiny”

threshold.

• State must overcome the presumption and prove

that such settings are not institutional in nature

and do not isolate people with disabilities from

the broader community.

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Which settings trigger Heightened

Scrutiny?

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1 • Located in a building on grounds of public institution;

2

• Located in a building that is also publically or privately operated facility providing inpatient institutional treatment;

3 • Immediately adjacent to public institution;

4 • Converted from an ICF on or after March 17, 2014;

5

• Multiple settings collocated and operationally related that isolate and/or inhibit interactions with the broader community

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• Settings that isolate people that receive HCBS from the broader community of people who do not receive HCBS

Why Heightened Scrutiny?

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Exam

ple

s:

1. Gated communities for people with disabilities

2. Farmsteads or disability specific farm communities

3. Residential schools

4. Private campus settings/ Multiple settings co-located and operationally related

Wh

y?

Little ability to access the broader community

People served only interact with others receiving services or paid staff

All activities/services provided on-site so people don’t have to leave

People don’t typically leave to access the community as part of their day to day lives

”Thus, the setting typically does not afford individuals the opportunity to fully engage in community ...”

What we look for when designating a

setting Heightened Scrutiny

“Settings That Isolate”

Does the setting have the effect of isolating

individuals? Practices and operations—what is the

experience of the people in the setting?

and

Does the setting have institutional qualities instead

of HCBS qualities? Again, what is the experience of

people in the setting?

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Heightened Scrutiny Settings

Identified by DQI as of 10/17/16

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Total Settings

Reviewed to

Date

Total Triggered

for Heightened

Scrutiny

%

All Settings 6,430 217 3.4%

Residential 5,654 146 2.6%

Day Program 775 71 9.2%

Residential Heightened Scrutiny - Issues

(out of 146 Settings)

26%

24%

22%

15%

12%

0%

5%

10%

15%

20%

25%

30%

Access to Community Rights Protections SiteOperations/Practices

Individualized HabPlanning

Environmental

Percent Not Met by Protocol Section

Percent Not Met

12

At CMS level, North Dakota - only HS

determination to date

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Each had his/her own room

Homes and rooms reflected individual choice, interests, hobbies

People interacted with broader community on a daily basis, including many community activities

All 10 people engaged in wide variety of employment or education activities including entrepreneurial

Residential (on grounds

of ICF campus)

APPROVED

Majority of participants spend majority of their day on-site

Activities take place on ICF campus alongside ICF residents under the direct supervision of ICF staff

CMS finds that the Day Program does not meet characteristics of HCBS because the majority of individuals receive most of their services at the facility-based program and are not integrated into the greater community.

Day Setting on Grounds of ICF—NOT APPROVED

Remember:

All HCBS waiver services/settings must meet HCBS

standards by 10/1/2018

Only settings triggering “heightened scrutiny,” (HS) according to the criteria (HS), undergo HS process if OPWDD

believes the setting can meet HCBS

characteristics and requirements

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Heightened Scrutiny process is

setting/site specific but all settings

need to meet HCBS rules

What Does a Heightened Scrutiny

Designation Mean for the Setting

and its Provider?

• It does not mean that the setting has to close and/or

that it can no longer be funded by HCBS. However,

the setting must be able to adhere to HCBS

regulations to remain a HCBS waiver service.

• It does mean the setting is subject to a higher burden

of proof that it meets or can meet community

standards and is not isolating/institutional.

– i.e.: Public Input and CMS Submission of Evidence

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Getting Ready for

Heightened Scrutiny

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Person Centered Planning Includes

Habilitation Planning

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PCP is at the center of the HCBS settings rule. This is not just about creating a nice PC plan!

If you don’t know what the person’s interests, likes, dislikes, dreams and aspirations are, or, if the person doesn’t know either – you can’t meet the essence of the rules

On-going discovery and learning has to be part of the service delivery model and practice - making the PCP a living “document”

Requires a transition from a “service life” model to a “community life” model - but this takes learning

Requires training for the entire organization on what person-centered thinking means

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Facilitate Meaningful Community Access

Provide and post information about community events and happenings for residents and facilitate information sharing and informed choice making

1 Incorporate priorities/preferences for meaningful community activities into the Hab Planning process including supports needed for the person to participate

2

Consider adjustments to staff schedules/creative scheduling during peak hours when community events would be occurring even just a day or two a week

3

Encourage people to use natural supports, neighborhood folks, co-workers, etc for community participation when possible. 4

Review and discuss which individuals can participate in a community event without requiring staff support, update the Individual Plans of Protective oversight (IPOP) accordingly and begin allowing alone time in the community when appropriate

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Facilitate Meaningful Community Access:

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Encourage settings to coordinate access to transportation with each other when possible. Encourage people with similar interests to participate in an activity with each other, when desired.

6

Incorporate travel training into routine habilitation activities for increased access to public transportation. Where available, encourage use of public transportation

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Post taxi information, bus lines, etc in a visible location and train people to utilize these services 8

Through person-centered planning meetings, determine what natural support resources are available to assist in carrying out specific community interests. Incorporate this discussion into routine person-centered reviews as a topic of further discussion.

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Heightened Scrutiny Evidence

Needs to Document That:

• Setting is integrated in the community to the extent that a person

without a disability in the same community would consider it a part

of their community and would not associate it with the provision of

services

• Individuals participate regularly in typical community life activities

outside of the setting to the extent the individual desires

• Community activities foster relationships with community members

• Services to the individual, and activities in which the individual

participates are engaged with the broader community

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Services Provided Reflect and

Document:

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Access

• to community based on individual desires

Variety

•of activities/ offerings —both individualized and small group activities

Quality

•cultural competency, measures to increase community access and decrease social isolation (e.g., CQL POMs)

Services Provided Reflect and

Document:

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Choice

Autonomy

Self-direction

Control over

Personal Resources

Individual Rights

Documentation

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• Incorporate “learning logs/ discovery” documentation in

every day progress notes or data collection formats

• Set up easy charting that allow selection from choice of

activities and preferences from PCP assessments’

established list of activities and preferences

• Establish concurrent documentation formats/procedures that

actively engage staff and individuals with documenting

experience and reaction to community/inclusive activities

• Ensure facility-based service activities/programming is

emphasizing self-direction, personal growth and control, has

choice for personal preferences and interests etc.

Considerations 10/25/2016 24

Invest time and resources into effective practices.

Build your social capital at all levels.

Explore traditional and non-traditional revenue

sources.

Do it one person at a time, and do it a lot of times

until you’re done. You’ll get better at what you do.

Start small – clear the path. Don't get stuck in planning, processing and waiting for

the right “time” for change.

Hire for who you want to become, not for who you

are.

Our buildings should be places for people to come

and go – not to stay.

We shouldn’t provide things here that exist

naturally in the community.

General Tips: • Look at existing policies & procedures to determine

whether they are compliant with HCBS settings

requirements. Revise and retrain staff accordingly

based on revisions.

• Provide ongoing staff trainings on HCBS rights,

respectful interactions, privacy, and providing support to

explore individualized personal interests. Explain that

blanket assumptions about capabilities (such as access

to keys) cannot be arbitrarily decided by staff without

informed consent and due process. Remind staff that

blanket schedules and general house rules are

institutional, restrictive, and discouraged.

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• Look at residential physical plant areas to ensure

locks are available, access to typical areas is

present, and overtly institutional appearances are

minimized when possible.

• Train and educate residents on community access,

choice, and overall HCBS rights of individuals

• Incorporate person-centered discussions on

interests, rights, satisfaction, availability of natural

supports, etc into ISP review/Hab Plan expectations

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General Tips:

Where to Get More Information?

OPWDD HCBS Settings Toolkit: http://www.opwdd.ny.gov/opwdd_services_supports/HCBS/hcb

s-settings-toolkit

www.hcbsadvocacy.org

CMS Toolkit: www.medicaid.gov/hcbs

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Type “HCBS Settings Toolkit” in Search on www.opwdd.ny.gov Home

Page

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HCBS Settings

Requirements in

DQI Survey

Redesign

Site Review Activities – What Remains

Required Routine Activities:

• IRMA and RIA review

• Entrance conference (information gathering)

• Request documentation

• Observe individuals in their environment & during their

activities including mealtime (with historical exceptions)

• Converse with individuals, DSPs, and as needed

clinicians and other agency staff

• Review for compliance with regulatory standards

included in Protocol

• Validate effective correction of previous deficiencies

• Exit conference/Exit Conference Form (ECF)

• OFPC Activities

Site Review – What’s New • Consistent gathering of information the site and the

people receiving supports (Info Gathering/Entrance)

• Track documentation requested and agency timely

response

• Integrates routine assessment of HCBS Settings

Requirements

• Includes quality standards in some environments

• Required Conditional Activities: “Qualifier Questions”

(QQs) determine need to review some of the protocol standards

Review that a sample of people with a specific high risk

needs are appropriately supported regarding that need.

Site Review

Site Protocol Sections

• Heightened Scrutiny Triggers (New? Changes?)

• Health Support and Medication

• Personal Funds

• General Operations for: Individualized Choice, Autonomy & Satisfaction

• Delivery of Safeguards, Services and Supports

• Rights and Protections

• Site and Safety

• Fire Safety

• Site Specific Requirements

• Special Risk Factors

Section 1:

Heightened Scrutiny Triggers

• Applies to certified sites where HCBS

waiver services are delivered

• Same 6 standards currently included

on the Heightened Scrutiny/HCBS

Settings Protocol

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Section 4: Individualized Choice, Autonomy & Satisfaction

• Includes HCBS settings expectations

• Mechanism to assess satisfaction with service/service setting; agency response to dissatisfaction

• Autonomy fostered, independent access

• Privacy in physical space

• Access to community activities

• Meaningful activities

• Cultural, Religious, Lifestyle choices supported

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Section 6:

Rights and Protections

• Includes HCBS settings rights

• Respectful Interactions

• Rights assured and protected

• Access to facility not limited

• Privacy of personal information

• Personal control/choice regarding eating

• Incident reporting, protection, prevention

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Section 7: Site and Safety

• Residences: “home-like”

• Site allows visitors a time of choosing

• No surveillance cameras

• Site appropriate to individuals

• Supplies/equipment to meet needs

• Site cleanliness, maintenance and safety

• Time Out Room Requirements

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Site Protocol – Examples of Application of HCBS Standards to Other Settings

Current Protocol Requirement Source New, Reviewing also in these settings:

Are (consumers) afforded all rights guaranteed by regulation?

• Universal 633 rights mesh with HCBS requirements to move the whole service system forward

Encouraged to have full access to the community; Sufficient transportation and sufficient staff allocation for individualized choices of activities and schedules (3 items)

• Heightened Scrutiny (now)

• HCBS Settings Assessments

(2014-2015)

All day programs: Day Treatments, Day Trainings

Private Schools Free Standing Respite

Mechanism to assess living arrangement and roommate choice

• Same as above All sites where individuals reside

Mechanism to assess satisfaction and timely action to address

• Same as above All certified sites

Mechanism for increased independence/access to home, access to environment and control privacy of space and info

• Same as above

Private Schools

Site Protocol – Examples of Application of HCBS Standards to Other Settings

Current Protocol Requirement Source New, Reviewing also in these settings:

Schedules/routines personally determined per needs, interests, and preferences (rather than per staff or agency operations).

• Heightened Scrutiny (now)

• HCBS Settings Assessments

(2014-2015)

All sites where individuals reside

Individuals are supported to exercise control and choice in lives, including cultural, religious and lifestyle choices (2 items)

• Same as above All certified sites

Site absent of rules/policies that limit rights, independence, choice, autonomy. Visitors as preferred. (2 items)

• Same as above All certified sites

Access and choice of food and when to eat.

• Same as above Private Schools

Person Centered Review

• Review of any and all services a person receives from all provider agencies providing their services

• Implemented for provided sample (earlier slide)

• Applicable no matter how or where individual receives services/supports

• Includes service and site specific requirements related to: Person Centered service planning

Person Centered service delivery

HCBS requirements if supported in certified site

Safeguards: minimize risks

Rights, health, safeguards, behavioral supports, protections

Quality of life - Outcomes

PCR Activities • Conversation with individual regarding:

– Services they receive, options they were provided, how they came to decide, planning process to get them there

– What they do, what they want to do, where they see their life going

– Satisfaction… are services meeting expectations, getting them to goals, service delivery, service effectiveness?

• Conversation with relevant service developers, service implementers

• Review of each service the person receives in a manner similar to current practices

• Review of service planning and effectiveness of risk identification and planning

• Verify Desired Outcomes are occurring

Agency Review

• Regulatory and quality expectations designed, implemented and managed at the agency level

• Sample (based on agency size) verification of compliance for selected regulatory requirements: hiring, training, personal allowance, incident management.

• Agency practices and strategies that influence quality outcomes: – Attention to Outcomes for individuals

– Community connections

– Workforce

– Quality improvement planning and strategies

– Agency management

3 Routine Review Types and Protocols

Type-

Name

Start

Date

Purpose of

Activity

Scope of

Activity

Site

Review

10.03.16 Health, safety,

well-being and

HCBS

compliance

≈ 7,300 sites:

100% certified non-ICF sites

Person-

Centered

Review

12.2016 Individual’s

needs, goals &

outcomes are

met through

comprehensive

service planning

& delivery

400 DOH ISP

1100 Statewide

1500 Individuals - Full PCR

+ ≈ 250 Individuals in HS Sites (Partial PCR)

+ ≈1500 WB Individuals in IRAs (Partial PCR)

Agency

Review

01.2017 Verify effective

systems and

quality oversight

700+ agencies

Questions on HCBS Settings

• Maryellen Moeser

Maryellen.Moeser@opwdd.ny.gov

518-473-2599 for Transition Plan, timelines, policy, etc.

• Heightened.scrutiny@opwdd.ny.gov

• Quality@opwdd.ny.gov for DQI site review and heightened scrutiny designations and notifications

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