Application for 1915(c) HCBS Waiver: AL.0068.R06.00

Level(s) of Care. This waiver is requested in order to providehome and community-based waiver services to individuals who, but forthe provision of such services, would require the following level(s) ofcare, the costs of which would be reimbursed under the approved MedicaidState plan (check each that applies):

Hospital

Nursing Facility

Intermediate Care Facility for the Mentally Retarded (ICF/MR) (as defined in 42 CFR §440.150)

Concurrent Operation with Other Programs. This waiver operates concurrently with another program (or programs)approved under the following authorities

Select one:

 Not applicable

 Applicable

 not selected

Dual Eligiblity for Medicaid and Medicare.

Check if applicable:

Waiver Administration and Operation. Appendix A specifies the administrative and operational structure of this waiver.

Participant Access and Eligibility. Appendix B specifies the target group(s) of individuals who are served in this waiver, the number of participants that the State expects to serve during each year that the waiver is in effect, applicable Medicaid eligibility and post-eligibility (if applicable) requirements, and procedures for the evaluation and reevaluation of level of care.

Participant Services. Appendix C specifies the home and community-based waiver services that are furnished through the waiver, including applicable limitations on such services.

Participant-Centered Service Planning and Delivery. Appendix D specifies the procedures and methods that the State uses to develop, implement and monitor the participant-centered service plan (of care).

Participant-Direction of Services. When the State provides for participant direction of services, Appendix E specifies the participant direction opportunities that are offered in the waiver and the supports that are available to participants who direct their services. (Select one):

Participant Rights. Appendix F specifies how the State informs participants of their Medicaid Fair Hearing rights and other procedures to address participant grievances and complaints.

Participant Safeguards. Appendix G describes the safeguards that the State has established to assure the health and welfare of waiver participants in specified areas.

Quality Improvement Strategy. Appendix H contains the Quality Improvement Strategy for this waiver.

Financial Accountability. Appendix I describes the methods by which the State makes payments for waiver services, ensures the integrity of these payments, and complies with applicable federal requirements concerning payments and federal financial participation.

Cost-Neutrality Demonstration. Appendix J contains the State's demonstration that the waiver is cost-neutral.

Comparability. The State requests a waiver of the requirements containedin 1902(a)(10)(B) of the Act in order to provide the services specified in Appendix C that are not otherwise available under the approved Medicaid Stateplan to individuals who: (a) require the level(s) of care specified in Item 1.Fand (b) meet the target group criteria specified in Appendix B.

Income and Resources for the Medically Needy.Indicate whether the Staterequests a waiver of 1902(a)(10)(C)(i)(III) of the Act in order to useinstitutional income and resource rules for the medically needy (select one):

Statewideness.Indicate whether the State requests a waiver of thestatewideness requirements in 1902(a)(1) of the Act (select one):

Health & Welfare: The State assures that necessary safeguards have been taken to protect the health andwelfare of persons receiving services under this waiver. These safeguards include:

As specified in Appendix C, adequate standards for all types of providersthat provide services under this waiver;

Assurance that the standards of any State licensure or certificationrequirements specified in Appendix C are met for services or for individualsfurnishing services that are provided under the waiver. The State assuresthat these requirements are met on the date that the services are furnished;and,

Assurance that all facilities subject to 1616(e) of the Act where home andcommunity-based waiver services are provided comply with the applicable Statestandards for board and care facilities as specified in Appendix C.

Financial Accountability. The State assures financial accountability for fundsexpended for home and community-based services and maintains and makes availableto the Department of Health and Human Services (including the Office of theInspector General), the Comptroller General, or other designees, appropriatefinancial records documenting the cost of services provided under the waiver.Methods of financial accountability are specified in Appendix I.

Evaluation of Need: The State assures that it provides for an initial evaluation (and periodicreevaluations, at least annually) of the need for a level of care specifiedfor this waiver, when there is a reasonable indication that an individual mightneed such services in the near future (one month or less) but for the receiptof home and community based services under this waiver. The procedures forevaluation and reevaluation of level of care are specified in Appendix B.

Choice of Alternatives: The State assures that when an individual is determined to be likely to require the level of care specified for this waiver and is in a target group specified in Appendix B, the individual (or, legal representative, if applicable) is:

Informed of any feasible alternatives under the waiver; and,

Given the choice of either institutional or home and community based waiverservices. Appendix B specifies the procedures that the State employs toensure that individuals are informed of feasible alternatives under thewaiver and given the choice of institutional or home and community-basedwaiver services.

Average Per Capita Expenditures: The State assures that, for any year that the waiver is in effect, the average per capita expenditures under the waiver will not exceed 100 percent of the average per capita expenditures that would have been made under the Medicaid State plan for the level(s) of care specified for this waiver had the waiver not been granted. Cost-neutrality is demonstrated in Appendix J.

Actual Total Expenditures: The State assures that the actual total expenditures for home and community-based waiver and other Medicaid services and its claim for FFP in expenditures for the services provided to individuals under the waiver will not, in any year of the waiver period, exceed 100 percent of the amount that would be incurred in the absence of the waiver by the State's Medicaid program for these individuals in the institutional setting(s) specified for this waiver.

Institutionalization Absent Waiver: The State assures that, absent the waiver, individuals served in the waiver would receive the appropriate type of Medicaid-funded institutional care for the level of care specified for this waiver.

Reporting: The State assures that annually it will provide CMS with information concerning the impact of the waiver on the type, amount and cost of services provided under the Medicaid State plan and on the health and welfare of waiver participants. This information will be consistent with a data collection plan designed by CMS.

Habilitation Services. The State assures that prevocational, educational, or supported employment services, or a combination of these services, if provided as habilitation services under the waiver are: (1) not otherwise available to the individual through a local educational agency under the Individuals with Disabilities Education Act (IDEA) or the Rehabilitation Act of 1973; and, (2) furnished as part of expanded habilitation services.

Services for Individuals with Chronic Mental Illness. The State assures that federal financial participation (FFP) will not be claimed in expenditures for waiver services including, but not limited to, day treatment or partial hospitalization, psychosocial rehabilitation services, and clinic services provided as home and community-based services to individuals with chronic mental illnesses if these individuals, in the absence of a waiver, would be placed in an IMD and are: (1) age 22 to 64; (2) age 65 and older and the State has not included the optional Medicaid benefit cited in 42 CFR 440.140; or (3) age 21 and under and the State has not included the optional Medicaid benefit cited in 42 CFR 440.160.

Service Plan.In accordance with 42 CFR 441.301(b)(1)(i), a participant-centeredservice plan (of care) is developed for each participant employing the proceduresspecified in Appendix D. All waiver services are furnished pursuant to the serviceplan. The service plan describes: (a) the waiver services that are furnished to theparticipant, their projected frequency and the type of provider that furnishes eachservice and (b) the other services (regardless of funding source, including State planservices) and informal supports that complement waiver services in meeting the needsof the participant. The service plan is subject to the approval of the Medicaid agency.Federal financial participation (FFP) is not claimed for waiver services furnishedprior to the development of the service plan or for services that are not included inthe service plan.

Inpatients.In accordance with 42 CFR 441.301(b)(1) (ii), waiver services are not furnishedto individuals who are in-patients of a hospital, nursing facility or ICF/MR.

Room and Board.In accordance with 42 CFR 441.310(a)(2), FFP is not claimedfor the cost of room and board except when: (a) provided as part of respite servicesin a facility approved by the State that is not a private residence or (b) claimed asa portion of the rent and food that may be reasonably attributed to an unrelatedcaregiver who resides in the same household as the participant, as provided in Appendix I.

Access to Services.The State does not limit or restrict participant access to waiver services except as provided in Appendix C.

Free Choice of Provider.In accordance with 42 CFR 431.151, a participant may selectany willing and qualified provider to furnish waiver services included in the serviceplan unless the State has received approval to limit the number of providers under theprovisions of 1915(b) or another provision of the Act.

FFP Limitation.In accordance with 42 CFR 433 Subpart D, FFP is not claimed forservices when another third-party (e.g., another third party health insurer or otherfederal or state program) is legally liable and responsible for the provision andpayment of the service. FFP also may not be claimed for services that are available without charge, or as free care to the community. Services will not be considered to be without charge, or free care, when (1) the provider establishes a fee schedule for each service available and (2) collects insurance information from all those served (Medicaid, and non-Medicaid), and bills other legally liable third party insurers. Alternatively, if a provider certifies that a particular legally liable third party insurer does not pay for the service(s), the provider may not generate further bills for that insurer for that annual period.

Fair Hearing:The State provides the opportunity to request a Fair Hearing under 42 CFR 431Subpart E, to individuals: (a) who are not given the choice of home and community-based waiver services as an alternative to institutional level of care specifiedfor this waiver; (b) who are denied the service(s) of their choice or the provider(s)of their choice; or (c) whose services are denied, suspended, reduced orterminated. Appendix F specifies the State's procedures to provide individualsthe opportunity to request a Fair Hearing, including providing notice of action as required in 42 CFR 431.210.

Quality Improvement.The State operates a formal, comprehensive system to ensure that the waiver meetsthe assurances and other requirements contained in this application. Through anongoing process of discovery, remediation and improvement, the State assures thehealth and welfare of participants by monitoring: (a) level of care determinations;(b) individual plans and services delivery; (c) provider qualifications; (d)participant health and welfare; (e) financial oversight and (f) administrativeoversight of the waiver. The State further assures that all problems identifiedthrough its discovery processes are addressed in an appropriate and timely manner,consistent with the severity and nature of the problem. During the period that thewaiver is in effect, the State will implement the Quality Improvement Strategy specifiedin Appendix H.

Public Input. Describe how the State secures public input into the development of the waiver:

Character Count: out of 6000

During the course of this waiver period no further requests for changes have been received from the public. Comments are gathered by the AMA Quality Improvement Coordination Unit and are given serious consideration in developing waiver improvements. AMA announced the intent to submit the renewal application for the Elderly & Disabled Waiver to Alabamas HCBS operating agencies, state agencies, and coalition groups. During these meetings AMA addressed comments and questions. The State also provided the contact information and deadline for additional comments or questions. The deadline was May 18, 2012. No comments were received.

Notice to Tribal Governments.The State assures that it has notified in writing all federally-recognized TribalGovernments that maintain a primary office and/or majority population within theState of the State's intent to submit a Medicaid waiver request or renewal requestto CMS at least 60 days before the anticipated submission date is provided by PresidentialExecutive Order 13175 of November 6, 2000. Evidence of the applicable notice isavailable through the Medicaid Agency.

Limited English Proficient Persons.The State assures that it provides meaningful access to waiver services byLimited English Proficient persons in accordance with: (a) Presidential ExecutiveOrder 13166 of August 11, 2000 (65 FR 50121) and (b) Department of Health and HumanServices "Guidance to Federal Financial Assistance Recipients Regarding Title VIProhibition Against National Origin Discrimination Affecting Limited EnglishProficient Persons" (68 FR 47311 - August 8, 2003). Appendix B describeshow the State assures meaningful access to waiver services by Limited EnglishProficient persons.

The Medicaid agency representative with whom CMS should communicate regarding the waiver is:

If applicable, the State operating agency representative with whom CMS should communicate regarding the waiver is:

State Line of Authority for Waiver Operation.Specify the state line of authority for the operation of the waiver (select one):

 The waiver is operated by the State Medicaid agency.

 The waiver is operated by a separate agency of the State that is not a division/unit of the Medicaid agency.

In accordance with 42 CFR 431.10, the Medicaid agency exercises administrative discretion in the administration and supervision of the waiver and issues policies, rules and regulations related to the waiver. The interagency agreement or memorandum of understanding that sets forth the authority and arrangements for this policy is available through the Medicaid agency to CMS upon request. (Complete item A-2-b).

 not selected

Oversight of Performance.

Use of Contracted Entities.Specify whether contracted entities perform waiver operational and administrative functions on behalf of the Medicaid agency and/or the operating agency (if applicable) (select one):

 Yes. Contracted entities perform waiver operational and administrative functions on behalf of the Medicaid agency and/or operating agency (if applicable).

Specify the types of contracted entities and briefly describe the functions that they perform. Complete Items A-5 and A-6.:

Character Count: out of 6000

Based on the provisions within the 1915(j)State Plan Program, Personal Choices waiver participants will be given the opportunity to self-direct personal care services in specfic counties. Personal Choices serves seniors, adults with physical disabilities and children who will recieve personal. This option is administred through the Alabama Department of Senior Services. The operating agency will use a FMSA contractor that has the capabilities to perform the required tasks in accordance with Section 3504 of the IRS CODE and Revenue Procedure 70-6. The FMSA will assist waiver participants who have chosen to self-direct services with hiring and paying their staff, completing background checks on potential Personal Choices employees, address all applicable payroll taxes of Personal Choices employees, processing time sheets, and paying the employees. The FMSA is paid a flat rate per month per participant. The monthly rate of an initial enrollee is slightly higher for the first month to accomodate the cost of the background screening and enrollment.

 No. Contracted entities do not perform waiver operational and administrative functions on behalf of the Medicaid agency and/or the operating agency (if applicable).

 not selected

Role of Local/Regional Non-State Entities. Indicate whether local or regional non-state entities perform waiver operational and administrative functions and, if so, specify the type of entity (Select One):

 not selected

 Not applicable

 Applicable - Local/regional non-state agencies perform waiver operational and administrative functions.

Responsibility for Assessment of Performance of Contracted and/or Local/Regional Non-State Entities. Specify the state agency or agencies responsible for assessing the performance of contracted and/or local/regional non-state entities in conducting waiver operational and administrative functions:

Character Count: out of 6000

The Operating Agency will assess the performance of the contracted entity.

Assessment Methods and Frequency. Describe the methods that are used to assess the performance of contracted and/or local/regional non-state entities to ensure that they perform assigned waiver operational and administrative functions in accordance with waiver requirements. Also specify how frequently the performance of contracted and/or local/regional non-state entities is assessed:

Character Count: out of 12000

The Operating Agency will perform annual audits on the contracted entity. GENERAL OBJECTIVES To determine the effectiveness of the HCBS Waiver Quality Assurance Program To assure waiver participants have access to waiver services through the process of monitoring quality assurance procedures To assure waiver participants are able to exercise the right of freedom of choice of waiver services and providers, and to choose between home and community based services and institutionalization. To assure the health and welfare of waiver participants, and to identify, address, and prevent abuse, neglect and exploitation of individuals served by the waiver To assure waiver participants are receiving services identified in the plan of care by qualified personnel through monitoring a sample of recipient records and personnel records To assure implementation and ongoing utilization of quality assurance standards of the OA, AMA, and the Center for Medicare and Medicaid Services (CMS) through evaluation of the organizational structures of direct service providers, and reports of quality assurance activities. These objectives will be met by conducting an annual review of the OA. AMA Nurse reviewers will conduct the review, and the following elements will be evaluated: A sample of Recipient records will be reviewed to ensure: 1.Level of care and admission criteria are met 2.Plan of care is appropriate 3.Freedom of choice 4.Patient rights 5.Services reimbursed by Medicaid were provided. OA policies, procedures, organizational structure and staff qualifications will be reviewed to ensure the OA is operating in accordance with waiver guidelines. OA documentation of contractual agreements between the OA and the DSP will be reviewed to ensure that qualified providers are rendering services to Medicaid waiver recipients. OA documentation of QA visits to DSP will be reviewed to ensure: 1.OA is conducting QA reviews 2.DSP is providing services in accordance with waiver guidelines. OA complaint and grievance procedures will be reviewed to ensure: 1.A process is in place in accordance with Medicaid waiver guidelines 2.Complaints/grievances are tracked through to resolution 3.Adverse findings are reported to the appropriate authority for final determination 4.Health and safety of the client is not at risk 5.An appeals process is in place in accordance with waiver guidelines. Visits to client homes may be done to determine: 1.Effectiveness of service provision 2.Appropriateness of services 3.Adequacy of equipment and supplies 4.Accessibility of general condition of home 5.Safety of home and equipment. 6.Participant satisfaction

Distribution of Waiver Operational and Administrative Functions. In the following table, specify the entity or entities that have responsibility forconducting each of the waiver operational and administrative functions listed (check each that applies):

In accordance with 42 CFR 431.10, when the Medicaid agency does not directly conduct a function, it supervises the performanceof the function and establishes and/or approves policies that affect the function. All functions not performed directly by the Medicaid agency must be delegated in writing and monitored by the Medicaid Agency. Note: More than one box may be checked per item. Ensure that Medicaid is checked when the Single State Medicaid Agency (1) conducts the function directly; (2) supervises the delegated function; and/or (3) establishes and/or approves policies related to the function.

Methods for Discovery: Administrative Authority

The Medicaid Agency retains ultimate administrative authority and responsibility for the operation of the waiver program by exercising oversight of the performance of waiver functions by other state and local/regional non-state agencies (if appropriate) and contracted entities.

Performance Measures

For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.

Character Count: out of 6000

The Alabama Medicaid Agency (AMA) exercises administrative authority and responsibility of all waiver related policies and the OA's adherence to rules and regulations governing the E&D Waiver. AMA conducts annual training to disseminate policies, rules and regulations in an effort to ensure consistent application of the policies related to the E&D Waiver program. AMA reviews participant files, personnel files and performs home visits as a method to monitor compliance in: The level of care determination process; The appropriateness of the plan of care; and The monitoring of services to ensure quality care is provided by providers contracted with the OA.

Methods for Remediation/Fixing Individual Problems

Describe the States method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.

Character Count: out of 6000

AMA LTC Division is responsible for collecting data from the OA quarterly and annually regarding the quality of services provided from various sources for the E&D Waiver program. The Quality Framework is used as a guide to assess seven Program Design Focus areas: samples of waiver participants, case management and direct service providers records, on-site home visits when deemed necessary, and onsite visits to adult day health facilities. In addition, participant satisfaction surveys and complaints and grievances logs are reviewed quarterly. Adverse responses to surveys and/or complaints received are tracked to resolution. Adverse responses are also re-tracked with targeted surveys to determine participants satisfaction with resolutions. Data is collected through annual record reviews and the review of the OA which may include policies and procedures, contracts with subcontractors, on-going training of subcontractors, quality assurance system, and billing and service provision. More specifically, a sample of all participants records approved is conducted to ensure that the processes and instruments described in the approved waiver are applied in determining the Level of Care. Additionally, a sample of the waiver population is chosen for record review to ensure coordination of care, quality of care, outcomes and billing accuracy. A sample of personnel records of Case Managers and other employees is reviewed to ensure that basic and continuing education requirements are met. Home visits may be made to ensure quality of care, health and safety, ongoing needs of the participant are being met, and to gain input about the quality of the services received. Remediation for non-compliance issues identified during data collection is handled by requesting the entity involved to submit a plan of correction within 15 days of notification. If the problem is not corrected, the entity is monitored every three months. After the third request for a plan of correction, and the entity continues to be non-compliant, a letter to terminate the Memorandum of Agreement will be issued. The collected data is reported quarterly and annually to the Operating Agency. AMA LTC Division will evaluate reports and make recommendations for improvements to the program. The AMA LTC Division will determine if changes are to be made to the program. In order to measure and improve performance, data is collected, reviewed and reported using the seven focus areas of the Quality Framework. Participant Access Sources of data:Case Management RecordsHome VisitsDSS Queries Consumer Surveys ParticipantCentered Service Planning and Delivery Sources of data:Consumer SurveysCase Management RecordsSite VisitsHome Visits Provider Capacity and Capabilities Sources of data:Consumer SurveysCase Management RecordsPersonnel and Training Records of Operating Agency and Subcontractors Home Visits Participants Safeguards Sources of data:Case Management RecordsConsumer SurveysHome VisitsSite Visits Participants Rights and Responsibilities Sources of data:Consumer SurveysCase Management Records Complaint and Grievances Logs Targeted Surveys Patient Satisfaction Sources of data:Consumer SurveysCase Management RecordsHome Visits Site Visits System Performance Sources of data:Review of Operating Agency Quality Assurance SystemReview of Operating Agency Billing and Service Provision Collaborative Meeting with Operating Agency to enhance the administration of the Program Subcontractor Client Records The following indicators are reported to the operating agency and Medicaids Long Term Care Division: Percentage of participant/family reporting satisfaction with waiver services and needs met. Percentage of participant/family reporting they feel safe and secure in the home and community. Percentage of participant/family reporting they have ready access to services and were informed of sources of support available in the community. Percentage of participant/family reporting knowledge of rights and responsibilities. Percentage of records indicating services are planned and implemented according to the participants needs and preferences. Evidence that the operating agency has a Quality Assurance System in place that monitors subcontractors. Evidence that the operating agency has a system in place to ensure only qualified providers are enrolled, credentials are verified and training of personnel is ongoing. The State develops policies and procedures, conduct meetings with the Operating Agency, and implement techniques to improve and enhance the quality measures for the program. Example- The State uses a web-based application called ODM (Online Document Management) to report information such as critical incidents, complaints, and grievances reporting. ODM is a web-based electronic data management system with extensive routing, tracking, imaging, and reporting capabilities. Documents are shared through a queue functionality which tracks incoming documents. The electronic files are routed between authorized users ensuring information is submitted and resolved timely without the delay of manually sending the paper documents.

Remediation Data Aggregation

Timelines

Target Group(s). Under the waiver of Section 1902(a)(10)(B) of the Act, the State limits waiver services to a group or subgroups of individuals. Please see the instruction manual for specifics regarding age limits. In accordance with 42 CFR 441.301(b)(6), select one waiver target group, check each of the subgroups in the selected target group that may receive services under the waiver, and specify the minimum and maximum (if any) age of individuals served in each subgroup:

Additional Criteria. The State further specifies its target group(s) as follows:

Character Count: out of 12000

The E&D Waiver requires all clients to meet the nursing facility level of care.

Transition of Individuals Affected by Maximum Age Limitation. When there is a maximum age limit that applies to individuals who may be served in the waiver, describe the transition planning procedures that are undertaken on behalf of participants affected by the age limit (select one):

Specify:

Character Count: out of 12000

There is not transition an age limit. The radio button is not working properly.

Individual Cost Limit.The following individual cost limit applies when determining whether to deny home and community-based services or entrance to the waiver to an otherwise eligible individual (select one)Please note that a State may have only ONE individual cost limit for the purposes of determining eligibility for the waiver:

 No Cost Limit. The State does not apply an individual cost limit. Do not complete Item B-2-b or item B-2-c.

 Cost Limit in Excess of Institutional Costs. The State refuses entrance to the waiver to any otherwise eligible individual when the State reasonably expects that the cost of the home and community-based services furnished to that individual would exceed the cost of a level of care specified for the waiver up to an amount specified by the State. Complete Items B-2-b and B-2-c.

 Institutional Cost Limit. Pursuant to 42 CFR 441.301(a)(3), the State refuses entrance to the waiver to any otherwise eligible individual when the State reasonably expects that the cost of the home and community-based services furnished to that individual would exceed 100% of the cost of the level of care specified for the waiver. Complete Items B-2-b and B-2-c.

 Cost Limit Lower Than Institutional Costs. The State refuses entrance to the waiver to any otherwise qualified individual when the State reasonably expects that the cost of home and community-based services furnished to that individual would exceed the following amount specified by the State that is less than the cost of a level of care specified for the waiver.

 not selected

Method of Implementation of the Individual Cost Limit. When an individual cost limit is specified in Item B-2-a, specify the proceduresthat are followed to determine in advance of waiver entrance that the individual's healthand welfare can be assured within the cost limit:

Character Count: out of 12000

Participant Safeguards.When the State specifies an individual cost limit in Item B-2-a and there is a changein the participant's condition or circumstances post-entrance to the waiver that requiresthe provision of services in an amount that exceeds the cost limit in order to assure theparticipant's health and welfare, the State has established the following safeguards to avoidan adverse impact on the participant (check each that applies):

The participant is referred to another waiver that can accommodate the individual's needs.

Additional services in excess of the individual cost limit may be authorized.

Other safeguard(s)

Unduplicated Number of Participants.The following table specifies the maximum number of unduplicated participantswho are served in each year that the waiver is in effect. The State will submita waiver amendment to CMS to modify the number of participants specified for anyyear(s), including when a modification is necessary due to legislative appropriationor another reason. The number of unduplicated participants specified in this tableis basis for the cost-neutrality calculations in Appendix J:

Limitation on the Number of Participants Served at Any Point in Time.Consistent with the unduplicated number of participants specified in Item B-3-a, theState may limit to a lesser number the number of participants who will be served atany point in time during a waiver year. Indicate whether the State limits the numberof participants in this way: (select one):

The limit that applies to each year of the waiver period is specified in the following table:

Reserved Waiver Capacity.The State may reserve a portion of the participant capacity of the waiverfor specified purposes (e.g., provide for the community transition ofinstitutionalized persons or furnish waiver services to individualsexperiencing a crisis) subject to CMS review and approval. The State(select one):

Purposes
Nursing Facility Transition Assistance

Scheduled Phase-In or Phase-Out.Within a waiver year, the State may make the number of participants who are served subject to a phase-in or phase-out schedule (select one):

Select one:

Selection of Entrants to the Waiver. Specify the policies that apply to the selection of individuals for entrance to the waiver:

Character Count: out of 12000

Entry to the waiver is prioritized based on the imminent need for services that is determined through an assessment process or on the date of application or referral.

Medicaid Eligibility Groups Served in the Waiver.Individuals who receive services under this waiver are eligible under thefollowing eligibility groups contained in the State plan. The State appliesall applicable federal financial participation limits under the plan.Check all that apply:

Eligibility Groups Served in the Waiver (excluding the special home and community-based waiver group under 42 CFR 435.217)

Low income families with children as provided in §1931 of the Act

SSI recipients

Aged, blind or disabled in 209(b) states who are eligible under 42 CFR §435.121

Optional State supplement recipients

Optional categorically needy aged and/or disabled individuals who have income at:

Working individuals with disabilities who buy into Medicaid (BBA working disabled group as provided in §1902(a)(10)(A)(ii)(XIII)) of the Act)

Working individuals with disabilities who buy into Medicaid (TWWIIA Basic Coverage Group as provided in §1902(a)(10)(A)(ii)(XV) of the Act)

Working individuals with disabilities who buy into Medicaid (TWWIIA Medical Improvement Coverage Group as provided in §1902(a)(10)(A)(ii)(XVI) of the Act)

Disabled individuals age 18 or younger who would require an institutional level of care (TEFRA 134 eligibility group as provided in §1902(e)(3) of the Act)

Medically needy

Medically needy in 209(b) States (42 CFR §435.330)

Medically needy in 1634 States and SSI Criteria States (42 CFR §435.320, §435.322 and §435.324)

Other specified groups (include only statutory/regulatory reference to reflect the additional groups in the State plan that may receive services under this waiver)

Specify:

Character Count: out of 6000

Individuals deemed eligible for SSI under 42 CFR 435.122, 435.134, 435.137, 435.138, Section 6 of Public Law 99-643, and individuals eligible under 42 CFR 435.145 and 435.227.

Special home and community-based waiver group under 42 CFR 435.217) Note: When the special home and community-based waiver group under 42 CFR 435.217 is included, Appendix B-5 must be completed

Use of Spousal Impoverishment Rules.Indicate whether spousal impoverishment rules are used to determine eligibility for the special home and community-based waiver group under 42 CFR 435.217(select one):

Regular Post-Eligibility Treatment of Income: SSI State.

The State uses the post-eligibility rules at 42 CFR 435.726. Payment for home and community-based waiver services is reduced by the amount remaining after deducting the following allowances and expenses from the waiver participant's income:

Allowance for the needs of the waiver participant (select one):

 The following standard included under the State plan

 The following dollar amount

 The following formula is used to determine the needs allowance:

Specify:

Character Count: out of 6000

The maintenance needs allowance is equal to the individual's total income as determined under the post eligibility process which includes income that is placed in a Miller Trust.

 Other

 not selected

Allowance for the spouse only (select one):

 Not Applicable (see instructions)

 SSI standard

 Optional State supplement standard

 Medically needy income standard

 The following dollar amount:

 The amount is determined using the following formula:

 not selected

Allowance for the family (select one):

 Not Applicable (see instructions)

 AFDC need standard

 Medically needy income standard

 The following dollar amount:

 The amount is determined using the following formula:

 Other

 not selected

Amounts for incurred medical or remedial care expenses not subject to payment by a third party, specified in 42 CFR 435.726:

Regular Post-Eligibility Treatment of Income: 209(B) State.

Answers provided in Appendix B-4 indicate that you do not need to complete this section and therefore this section is not visible.

Post-Eligibility Treatment of Income Using Spousal Impoverishment Rules

The State uses the post-eligibility rules of §1924(d) of the Act(spousal impoverishment protection) to determine the contribution of a participantwith a community spouse toward the cost of home and community-based care if itdetermines the individual's eligibility under §1924 of the Act. There is deductedfrom the participants monthly income a personal needs allowance (as specified below),a community spouse's allowance and a family allowance as specified in the State Medicaid Plan..The State must also protect amounts for incurred expenses for medical or remedial care(as specified below).

Answers provided in Appendix B-5-a indicate that you do not need to complete this section and therefore this section is not visible.

Reasonable Indication of Need for Services.In order for an individual to be determined to need waiver services, an individual must require:(a) the provision of at least one waiver service, as documented in the service plan, and(b) the provision of waiver services at least monthly or, if the need for services is less than monthly,the participant requires regular monthly monitoring which must be documented in the service plan.Specify the State's policies concerning the reasonable indication of the need for services:

Minimum number of services.

Frequency of services. The State requires (select one):

 The provision of waiver services at least monthly

 Monthly monitoring of the individual when services are furnished on a less than monthly basis

If the State also requires a minimum frequency for the provision of waiver services other than monthly (e.g., quarterly), specify the frequency:

Character Count: out of 4000

All clients are monitored through at least one monthly face-to-face visit by the case manager only. The monthly face-to-face visit is the minimum monthly contact. Monitoring of participants is conducted more frequently if there is a change in the participants medical condition or if there is a change in the participants environmental circumstances. The frequency of other waiver services is determined by the physician based upon the needs of the waiver participant and is specified on the participants individual plan of care.

 not selected

Responsibility for Performing Evaluations and Reevaluations.Level of care evaluations and reevaluations are performed (select one):

 Directly by the Medicaid agency

 By the operating agency specified in Appendix A

 By an entity under contract with the Medicaid agency.

 Other

 not selected

Character Count: out of 6000

The OA have Nurse Consultants on staff that perform the initial evaluations. They are Registered Nurses with a State of Alabama license.

Character Count: out of 12000

The E&D Waiver recipients must meet the nursing facility level of care. The tool used to determine the NF LOC is the Alabama Home and Community Based Services Program Assessment (HCBS-1) form. New admissions and re-determinations must meet two of the criteria listed in A-K. Supporting documentation must be submitted with the application. The admission criteria is as follows: A. Administration of a potent and dangerous injectable medication and intravenous medication and solutions on a daily basis or administration of routine oral medications, eye drops or ointment. (Cannot be counted as a second criterion if used in conjunction with criterion K-7) B. Restorative nursing procedures (such as gait training and bowel and bladder training) in the case of clients who are determined to have restorative potential and can benefit from the training on a daily basis per physician's orders. C. Nasopharyngeal aspiration required for the maintenance of a clear airway D. Maintenance of tracheostomy, gastrostomy, colostomy, ileostomy and other tubes indwelling in body cavities as an adjunct to active treatment for rehabilitation of disease for which the stoma was created. (Cannot be counted as a second criterion if used in conjunction with criterion K-3 if the ONLY stoma (opening) is a G or PEG tube.) E. Administration of tube feedings by naso-gastric tube. F. Care of extensive decubitus ulcers or other widespread skin disorders. G. Observation of unstable medical conditions required on a regular and continuing basis that can only be provided by or under the direction of a registered nurse. (Cannot be counted as a second criterion if used in conjunction with criterion K-9) H. Use of oxygen on a regular or continuing basis. I. Application of dressing involving prescription medications and aseptic techniques and/or changing of dressing in non-infected, postoperative, or chronic conditions per physicians orders. J. Comatose client receiving routine medical treatment. K. Assistance with at least one of the activities of daily living below on an ongoing basis: 1. Transfer- The individual is incapable of transfer to and from bed, chair, or toilet unless physical assistance is provided by others on an ongoing basis (daily or two or more times per week). 2. Mobility- The individual requires physical assistance from another person for mobility on an ongoing basis (daily or two or more times per week). Mobility is defined as the ability to walk, using mobility aids such as a walker, crutch, or cane if required, or the ability to use a wheelchair if walking is not feasible. The need for a wheelchair, walker, crutch, cane or other mobility aid shall not by itself be considered to meet this requirement. 3. Eating The individual requires gastrostomy tube feedings or physical assistance from another person to place food/drink into the mouth. Food preparation, tray set-up, and assistance in cutting up foods shall not be considered to meet this requirement. (Cannot be counted as a second criterion if used in conjunction with criterion D if the ONLY stoma (opening) is a G or PEG tube.) 4. Toileting The individual requires physical assistance from another person to use the toilet or to perform incontinence care, ostomy care or indwelling catheter care on an ongoing basis (daily or two or more times per week). 5. Expressive and Receptive Communication The individual is incapable of reliably communicating basic needs and wants (e.g., need for assistance with toileting; presence of pain) using verbal or written language: or the individual is incapable of understanding and following very simple instructions and commands (e.g., how to perform of complete basic activities of daily living such as dressing or bathing) without continual staff intervention. 6. Orientation The individual is disoriented to person (e.g., fails to remember own name or recognize immediate family members) or is disoriented to place (e.g., does not know residence is a Nursing Facility). 7. Medication Administration The individual is not mentally or physically capable of self-administering prescribed medications despite the availability of limited assistance from another person. Limited assistance includes but not limited to, reminding when to take medications, encouragement to take reading medication labels, opening bottles, handing to individual, and reassurance of the correct dose. (Cannot be counted as a second criterion if used in conjunction with criterion A) 8. Behavior The individual requires persistent staff intervention due to an established and persistent pattern of dementia- related behavioral problems (e.g., aggressive physical behavior, disrobing or repetitive elopement attempts). 9. Skilled Nursing or Rehabilitative Services the individual requires daily skilled nursing or rehabilitative services at a greater frequency, duration or intensity than for practical purposes would be provided through a daily home health visit. Cannot be counted as a second criterion if used in conjunction with criterion G) Criterion K should reflect the individuals capabilities on an ongoing basis and not isolated, exceptional, or infrequent limitations of function in a generally independent individual who is able to function with minimal supervision or assistance. Multiple items being met under (K) will still count as one criterion.

Level of Care Instrument(s).Per 42 CFR 441.303(c)(2), indicate whether the instrument/toolused to evaluate level of care for the waiver differs from theinstrument/tool used to evaluate institutional level of care(select one):

 The same instrument is used in determining the level of care for the waiver and for institutional care under the State Plan.

 A different instrument is used to determine the level of care for the waiver than for institutional care under the State plan.

 not selected

Character Count: out of 12000

Waiver applicants for whom there is a reasonable indication that services may be needed in the future are provided an individual Level of Care (LOC) evaluation. The case managers submit a Home and Community Based Waiver (HCBS-1) application to the nurse reviewer on staff at the Operating Agency to evaluate and make the level of care determination. The nurse reviewers evaluate the application to make sure it is complete, supports the need for waivers services, establishes the risk of nursing home placement and the medical criteria is met and level of care is approved. The approval of the appropriateness of admission or continued eligibility is assessed from the documentation as per the HCBS-1 assessment tool and other documents which may include physician progress notes, and/or hospital records. A review not only includes meeting the level of care criteria as developed by the Alabama Medicaid Agency but also the assessment of the support systems within the home, the functional limitations of the recipient, the diagnosis and any factors that would place the recipient at risk of institutionalization. Medicaid may also assist with difficult LOC evaluations. Once the application is approved its entered electronically into the Hewlett Packard/Medicaid system. If no problems are identified, Hewlett Packard enters the approval in the AMA Long Term Care file and writes a waiver eligibility segment indicating the beginning and ending eligibility dates. Verification and acceptance will be returned overnight to ADSS.

Reevaluation Schedule.Per 42 CFR 441.303(c)(4), reevaluations of the level of carerequired by a participant are conducted no less frequently thanannually according to the following schedule(select one):

 Every three months

 Every six months

 Every twelve months

 Other schedule

 not selected

Qualifications of Individuals Who Perform Reevaluations.Specify the qualifications of individuals who perform reevaluations(select one):

 The qualifications of individuals who perform reevaluations are the same as individuals who perform initial evaluations.

 The qualifications are different.

 not selected

Character Count: out of 6000

Reevaluations of eligibility for the E&D Waiver must be completed every twelve months. This process is the same as the initial application packet which includes a new level of care, and plan of care. Reevaluations must be done on a timely basis so that services and payment will not be interrupted. Billing for Waiver services is bounced against the Waiver Service Long Term Care Benefit Plan, and if eligibility for Waiver Services is current, the claim is paid. The Alabama Medicaid Agency will not back date reevaluations not received in a timely manner. All recipients enrolled in the Elderly & Disabled waiver must have an annual re-determination of need for the nursing facility level of care to continue to qualify for services through these waivers. The first re-determination of need for the level of care is to be made within a year of the individuals initial determination. PROCEDURE: 1.The Case Manager must complete the re-determination application, the HCBS Medical Form, Form 204/205, and obtain medical documentation to support the re-determination. This documentation should include hospital notes, lab, x-rays, etc., to support the diagnosis and should also include the most recent 6 months to 1 year of physician office notes. The Case Manager will route this packet of information to the Operating Agency Nurse Reviewer. The Operating Agency Nurse Reviewer will determine Level of Care (LOC). If LOC is met, the Operating Agency Nurse Reviewer will complete and attach the Waiver Medical Form/Waiver Slot Confirmation Form (Form 376) to the packet will be submitted to the Alabama Medicaid Agency for processing. The Medicaid District Office will issue a financial award notice or denial notice. A copy of the notice will be faxed by the Medicaid District Office to the appropriate Operating Agency. Once the Operating Agency receives the financial award notice the application will be processed into the LTC Admission Notification software. The operating agency may submit an early re-determination application as early as 90 days before the annual re-determination date. Applications received prior to 90 days of the annual date will be returned. All re-determinations must be completed before the LOC segment date expires. The Operating Agency will print a list of participants who has a redetermination date within 90 days. If an application is not process within 15 days of the re-determination date, the OA will research and solve the problem before the determination expires. If the re-determination does not process due to an error beyond the control of the OA or AMA (IT glitches, appeal process, etc), the waiver participant will not be disenrolled from the program. Waiver services will continue and be paid upon the receipt of the claim. The OA will request AMA to manually make these changes as directed by the policy and procedures. Case Managers also keep a copy of the clients reevaluation dates in a tickler file to ensure timely re-evaluations are accomplished.

Character Count: out of 6000

All evaluations and reevaluations are maintained for a minimum period of 3 years. The clients records are located at: 1.Direct Service Providers 2.Operating Agency Case Record

Methods for Discovery: Level of Care Assurance/Sub-assurances

Sub-Assurances:

Sub-assurance: An evaluation for LOC is provided to all applicants for whom there is reasonable indication that services may be needed in the future.

Performance Measures

For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

Sub-assurance: The levels of care of enrolled participants are reevaluated at least annually or as specified in the approved waiver.

Performance Measures

For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

Sub-assurance: The processes and instruments described in the approved waiver are applied appropriately and according to the approved description to determine participant level of care.

Performance Measures

For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.

Character Count: out of 6000

The Alabama Medicaid Agency (AMA) has granted the OA Nurse Consultant the authority to make the level of care (LOC) determinations and annual redeterminations (reevaluations). The AMA may assist the OA with difficult LOC evaluations. The AMA Nurse Reviewer will randomly select a percentage of applications for a monthly retrospective review. The AMA Nurse Reviewer will review the Home and Community Based Waiver (HCBS-1), the admission and evaluation data sheet, physician's progress notes, and/or any other documentation to support the participant's need for services. Documentation must include, the support systems within the home, the functional limitations of the recipient, medical diagnosis, unstable medical condition, and any factors that would place the recipient at risk of institutionalization. Redetermination (reevaluation) must be completed every twelve months. The process is the same as for an initial evaluation. The OA is responsible for completing the reevaluations in a timely manner, or the claim will deny. The AMA conducts quarterly Quality Assurance meetings which includes staff from LTC and representatives from staff of the E&D (and other waivers) waiver. These meetings are designed to inform, educate, discuss matters of concern etc.

Methods for Remediation/Fixing Individual Problems

Describe the States method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.

Character Count: out of 6000

The Elderly and Disabled Waiver (E&D) is administered by the Long Term Care Division of the Alabama Medicaid Agency (AMA) and operated by ADSS. AMA exercises administrative discretion in the management and supervision of the waiver and issues policies, rules and regulations related to the waiver. AMA assumes the responsibility of: (1) Conducting joint trainings with direct service providers enrolled to provide services through the Elderly and Disabled waiver program; (2) Providing periodic training to discuss policies and procedures in an effort to consistently interpret and apply policies related to the E&D Waiver program, which are outlined in the E&D Waiver manual, (3) Conducts annual training to disseminate policies, rules and regulations regarding the home and community-based waiver programs and, (4) signs all qualified direct service providers contracts enrolled with ADSS to provide waiver services. The AMA Long Term Care (LTC) Waiver Quality Improvement Coordination Unit has developed a Quality Management Strategy for the E&D Waiver Program. The following activities are components of the Quality Assurance Strategy: (1) Collect ongoing monthly data to monitor appropriateness of level of care determinations; (2) Collect quarterly data from registered nurses by any of the following sources; reviewing a sample of waiver case management records, direct service provider records, conducting on-site visits to participants homes, conduct consumer satisfactions surveys and tracking complaints and grievances; (3) Identify remediation for non-compliance issues and complaints identified during data collection are handled by requesting the entity involved to submit a plan of correction with 15 days of notification. If non-compliance is not resolved, the entity will be monitored every three months until compliance is achieved; and (4) Collect data and submit quarterly and annual reports to the Alabama Department of Senior Services and AMA staff for evaluation and recommendations for program improvements. Egregious non-compliant issues are addressed differently and on case by case bases. The State will contact the Operating Agency upon receipt of notification and establish a 24 hour action plan.

Remediation Data Aggregation

Timelines

Procedures. Specify the State's procedures for informingeligible individuals (or their legal representatives) of the feasiblealternatives available under the waiver and allowing these individualsto choose either institutional or waiver services. Identify the form(s)that are employed to document freedom of choice. The form or forms areavailable to CMS upon request through the Medicaid agency or the operatingagency (if applicable).

Character Count: out of 12000

Freedom of Choice: being informed of feasible alternatives under the waiver. As part of the assessment and service coordination visit, clients and/or responsible parties are provided with adequate information to make an informed decision as to where the clients care will be received. Service coordination addresses problems and feasible solutions. It also includes an exploration of all the resources utilized by the client, both formal and informal, as well as those waiver services which may be available to meet the clients needs and those needs which cannot be met. Freedom of Choice: Case Managers inform applicants of all direct service providers and allowed his or her freedom of choice of providers; and the choice of either institutional or home and community based services. Each waiver client must make a written choice for either institution or community care, which will remain in effect until such time as the client changes his/her choice. The only exception to making a written choice is when the client is not capable of signing the form. In such cases, services are not denied if a written choice cannot be obtained. The reason(s) for absence of a signed choice must be carefully documented by the case manager. A responsible party should be encouraged to assume responsibility for working with the case manager in arranging for an appropriate plan of care. This may include the responsible party signing the forms.

Maintenance of Forms. Per 45 CFR §92.42, written copies or electronically retrievablefacsimiles of Freedom of Choice forms are maintained for a minimumof three years. Specify the locations where copies of theseforms are maintained.

Character Count: out of 4000

The forms are maintained in the Operating Agency Case Record.

Waiver Services Summary. List the services that are furnished under the waiver in the following table. If case management is not a service under the waiver, complete items C-1-b and C-1-c:

Provision of Case Management Services to Waiver Participants. Indicate how case management is furnished to waiver participants (select one):

 not selected

 Not applicable - Case management is not furnished as a distinct activity to waiver participants.

 Applicable - Case management is furnished as a distinct activity to waiver participants.

 None of the above apply - Case management is furnished as a waiver service (Do not complete item C-1-c).

Delivery of Case Management Services. Specify the entity or entities that conduct case management functions on behalf of waiver participants:

Character Count: out of 4000

Criminal History and/or Background Investigations. Specify the State's policies concerning the conduct of criminal history and/or background investigations of individuals who provide waiver services (select one):

Specify: (a) the types of positions (e.g., personal assistants, attendants) for which such investigations must be conducted; (b) the scope of such investigations (e.g., state, national); and, (c) the process for ensuring that mandatory investigations have been conducted. State laws, regulations and policies referenced in this description are available to CMS upon request through the Medicaid or the operating agency (if applicable):

Character Count: out of 12000

Background checks will be required for direct service provider employees who operate within the State of Alabama and who either provide direct services to the participant and/or who have access to client records. The state background checks will be conducted by the provider agency and will also include a reference check with previous employers and the Nurse/Aid Registry. Verification of investigations will be conducted during periodic audit reviews of the service providers by the OA.

Abuse Registry Screening. Specify whether the State requires the screening of individuals who provide waiver servicesthrough a State-maintained abuse registry (select one):

Services in Facilities Subject to §1616(e) of the Social Security Act. Select one:

Provision of Personal Care or Similar Services by Legally Responsible Individuals. Alegally responsible individual is any person who has a duty under State law to care for another person and typically includes:(a) the parent (biological or adoptive) of a minor child or the guardian of a minor child who must provide care to the child or(b) a spouse of a waiver participant. Except at the option of the State and under extraordinary circumstances specified by the State,payment may not be made to a legally responsible individual for the provision of personal care or similar services that the legallyresponsible individual would ordinarily perform or be responsible to perform on behalf of a waiver participant.Select one:

 No. The State does not make payment to legally responsible individuals for furnishing personal care or similar services.

 Yes. The State makes payment to legally responsible individuals for furnishing personal care or similar services when they are qualified to provide the services.

 not selected

Other State Policies Concerning Payment for Waiver Services Furnished by Relatives/Legal Guardians.Specify State policies concerning making payment to relatives/legal guardians for the provision of waiver services over and above the policies addressed in Item C-2-d. Select one:

 The State does not make payment to relatives/legal guardians for furnishing waiver services.

 The State makes payment to relatives/legal guardians under specific circumstances and only when the relative/guardian is qualified to furnish services.

 Relatives/legal guardians may be paid for providing waiver services whenever the relative/legal guardian is qualified to provide services as specified in Appendix C-1/C-3.

Specify the controls that are employed to ensure that payments are made only for services rendered.

Character Count: out of 12000

A) Services provided by relatives or friends may be covered only if relatives or friends meet the same qualifications as other direct care providers and are employed by an approved provider of service. Relatives who are providers of services cannot be a parent/guardian of a minor or spouse of the individual receiving services, when the services are those that these persons are legally obligated to provide. There must be justification as to why the relative of friend is the provider of care and documentation in the case managers file showing the lack of other qualified providers. (B) The strict controls to assure that payment is made to relatives or friends as providers in return for authorized services include the following: 1) The relative or friend must be employed by a Direct Service Provider (DSP) Agency. 2) Meet the qualifications outlined in the scope of service as any other personal care, respite, homemaker, or companion worker employed by a DSP agency. 3) Complete a service log reflecting the type of service provided including the number of hours of service, the date and time of service. 4) Have the client/or representative sign the service log at each visit. If the relative or friend normally acts as a representative another individual must sign the service log. 5) The service log is reviewed by a DSP supervisor at least once biweekly. 6) Supervisory visits to the participants residence at 60 day intervals. 7) Direct on-site supervision of the DSP worker providing the authorized service at least once every 6 months and more frequently if warranted. 8) Monthly visits by the case managers to address client satisfaction with the provision of services and to question the client confidentially about the adequacy of the services received and their needs are met as well as to observe the client or friend as services are provided. (C) While each service may be offered by a relative the state will ensure that no conflict of interest will occur because the relative providing the direct service will not be involved in the development of the care plan or allowed to sign service logs which serve as documentation that the authorized services have been provided when the participant is unable to do so. When the primary care giver or authorized representative for the participant must also act as the direct service provider worker another individual must be assigned the aforementioned responsibilities as well as assume responsibility for any other functions which could potentially result in a conflict of interest. The case manager must be available during the monthly visits to observe the provision of the direct service by the guardian and question the participant confidentially about their satisfaction with those services. D. Personal Choices participants may hire legally liable relatives as paid providers of services. However, restrictions do apply on participant living arrangements, when homes or property are owed, operated or controlled by a provider of services, not related by blood or marriage to the participant.

 Other policy.

 not selected

Open Enrollment of Providers. Specify the processes that are employed to assure that all willing and qualified providers have the opportunity to enroll as waiver service providers as provided in 42 CFR §431.51:

Character Count: out of 12000

When a prospective provider calls and expresses interest in providing waiver services, a contracting package is prepared; and mailed that outlines all the certificcation requirements to become a waiver provider. After the package is returned it is reviewed for completeness of information. The OA will conduct an initial on-site visit to verify that the provider is in compliance with Medicaid Waiver standards and regulations before approval as a direct service provider is made. Every new provider is also required to attend a waiver training conducted by the OA. When all information from the potential provider has been reviewed and verified, a financial amount is established and a contract is signed by the appropriate authorities. If the provider is not a certified home health agency, a letter is prepared requesting the Commissioner of the Alabama Medicaid Agency to exempt the provider from the certification requirement of the Elderly and Disabled Waiver based on the OAs review of the provider. Once the exemption is granted, the contract may be signed. After the contract is finalized, the provider is mailed a confirmation letter. Potential providers may also view enrollment information, rules, and regulations on www.medicaid.alabama.gov. All willing and qualified providers are given an opportunity to enroll as an waiver provider.

Methods for Discovery: Qualified Providers

Sub-Assurances:

Sub-Assurance: The State verifies that providers initially and continually meet required licensure and/or certification standards and adhere to other standards prior to their furnishing waiver services.

Performance Measures

For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

Sub-Assurance: The State monitors non-licensed/non-certified providers to assure adherence to waiver requirements.

For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

Sub-Assurance: The State implements its policies and procedures for verifying that provider training is conducted in accordance with state requirements and the approved waiver.

For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.

Character Count: out of 6000

Methods for Remediation/Fixing Individual Problems

Describe the States method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.

Character Count: out of 6000

The OA must investigate all high risk health and safety issues upon receipt of notification and initiate action within 24 hours. If necessary the recipient and/or DSP will be interviewed. The OA must also notify AMA within two working days. ADSS and AMA will review the issue to determine if there is a pattern of problems and no health and safety risks exist. AMA will contact the client via telephone to ensure full resolution to the incident has been completed satisfactorily. Any final determinations including any DSP probations and or termination will be reported to the AMA.

Remediation Data Aggregation

Timelines

Additional Limits on Amount of Waiver Services.Indicate whether the waiver employs any of the following additional limits on the amount of waiver services (select one).

 not selected

 Not applicable- The State does not impose a limit on the amount of waiver services except as provided in Appendix C-3.

 Applicable - The State imposes additional limits on the amount of waiver services.

Responsibility for Service Plan Development.Per 42 CFR 441.301(b)(2), specify who is responsible for thedevelopment of the service plan and the qualifications of theseindividuals (select each that applies):

Registered nurse, licensed to practice in the State

Licensed practical or vocational nurse, acting within the scope of practice under State law

Licensed physician (M.D. or D.O)

Case Manager (qualifications specified in Appendix C-1/C-3)

Case Manager (qualifications not specified in Appendix C-1/C-3).

Character Count: out of 6000

Routine, ongoing, case management services will be conducted by Case Managers who meet minimum qualifications as described below: a.Professionals having earned a Bachelor of Arts degree or a Bachelor of Science degree, preferably in social work, psychology or related field, from an accredited college or university, or having earned a degree from an accredited School of Nursing. All case managers will be required to attend a Case Managers Orientation Program provided by the operating agency and approved by the Alabama Medicaid Agency and attend on-going training and in-service programs deemed appropriate. Initial orientation and training must be completed within the first three months of case manager employment. Proof of the training must be recorded in the Case Managers personnel file. Case management training must be completed prior to case managers being authorized to provide waiver services. Any exception to this requirement must be approved by the Alabama Medicaid Agency. b.The Operating Agency will be responsible for providing a minimum of six hours relevant in-service training per calendar year for Case Managers. This annual in-service training requirement may be provided during one training session or may be distributed (prorated) throughout the year. Documentation of the training shall include: topic, name and title of trainer, training objectives, and outline of content, length of training, list of trainees, location and outcome of training. Topics for specific in-service training may be mandated by the Alabama Medicaid Agency. Annual in-service training is in addition to the required orientation and training. Proof of training must be recorded in the personnel file. The operating agency shall submit proposed programs to Medicaid at least 45 days prior to the planned implementation. Any exception must be approved by the Alabama Medicaid Agency. The Operating Agency must have a Quality Assurance Program for case management services in place and approved by the Alabama Medicaid Agency. The Quality Assurance program shall include Case Manager record reviews at a minimum of every 90 days. Documentation of quality assurance reviews and corrective action plans must be maintained by the operating agency and will be subject to review by the Alabama Medicaid Agency.

Social Worker.

Other

Character Count: out of 6000

The DSP must provide all of the following and may make sub-contractual arrangements for some, but not all of the following: 1. The registered nurse(s) must meet the following requirements: a.Currently licensed by the Alabama State Board of Nursing to practice nursing. b. Must pass a statewide and local background check. c.At least two years experience as a registered nurse d.Make the initial visit to the participant's residence prior to the start of services for the purpose of reviewing the Plan of Care and giving the participant written information regarding advance directives. e. Current verification of an annual TB Skin Test and CPR certification must be in the employees personnel record. The DSP may employ or may make sub-contractual arrangements for a Licensed Practical Nurse who must meet the following requirements: 2. A licensed practical nurse(s) must work under the supervision of the registered nurse and must meet the following requirements: a.Currently licensed by the Alabama State Board of Nursing to practice nursing. b.At least two years experience as a licensed practical nurse c.Must pass a local and statewide background check. d.Capable of evaluating the worker in terms of his or her ability to carry out assigned duties and his/her ability to relate to the client. e.Ability to assume responsibility for in-service training for workers by individual instruction, group meetings or workshops. f.Current verification of an annual TB Skin Test and CPR certification must be in the employees personnel record. 3. Personal Care Workers who meet the following qualifications and requirements: a.Must have references which will be verified thoroughly. b.Must pass a local and statewide background check. c.Must be able to read and write. d.Must have at least completed eighth grade. e.Must be able to follow the Plan of Care with minimal supervision unless there is a change in the participants condition. f. Current verification of an annual TB Skin Test and CPR certification must be in the employees personnel record. g.Must have no physical/mental impairment to prevent lifting, transferring, or providing any other assistance to the participant. h.Must assist participant appropriately with daily living activities related to personal care. i.Current verification of an annual TB Skin Test must be in the employees personnel record. j. Must complete a probationary period determined by the employer with continued employment contingent on completion of personal care in-service training program and participants satisfaction. k.Must be employed by a certified Home Health Agency or other Health Care Agencies approved by the Commissioner of the Alabama Medicaid Agency. l.Services provided by family members or friends may be covered only if the family members or friends meet qualifications for providers of care; there are strict controls to assure that payment is made to the relative or friends as providers only in return for personal care services; there is adequate justification as to why the relative or friend is the provider of care; and proof showing lack of other qualified providers in applicable remote areas. The Case Manager must have documentation in the participants file showing that attempts were made to secure other qualified providers before a family member or friend is considered. Under no circumstances will payment be made for services furnished to an adult disabled child by the parent, to a parent by their child, to a recipients spouse, or to a minor by a parent or stepparent. The OA is responsible for reviewing these records and verifying there is proper supportive documentation to the lack of qualified providers living in a remote area. l. Personal Choices participants may hire legally liable relatives, as paid providers of services. However, restrictions do apply on participant living arrangements, when homes or property are owned, operated or controlled by a provider of services, not related by blood or marriage to the participant. (refer to: AL SPA 07-002; Attachment 3.1-A 1915 (J) vi.) Services must be provided under the supervision of a nurse as noted under 1.a.-e. above. a.Make visits to the participants residence after the initial visit by the registered nurse

Character Count: out of 6000

Services and supports to clients are monitored directly by case managers on a monthly basis or as needed and peer reviews are done on an annual basis by ADSS. In addition, the Operating Agency perform a review of the case managers records at least every two months. The Operating Agency also conduct random home visits to monitor service plan implementation and assess the health and welfare of clients. Annual desk reviews performed by the AMA Quality Improvement Coordination Unit may include case management personnel files, client files, and visits to participants in their homes. The AMA Quality Improvement Coordination Unit will also conduct retrospective reviews. A client, responsible party, and/or significant other must make a choice of providers for each waiver service that he or she desires. The initial choice is documented in the narrative, during the assessment visit. The case manager will supply a list to the client, responsible party, and/or significant other of all providers listed in alphabetical order for all waiver services available in the area. These waiver services are discussed with the client, responsible party, and/or significant other during the case managers initial visit. At the initial assessment visit, a written choice should be made for each waiver service that the client desires to access. Subsequent changes or additions of providers are made verbally and documented in the narrative. It is important that the client, responsible party, and/or significant other make this decision independently, and the case manager is cautioned not to influence a clients choice of providers. The client, responsible party, and/or significant other are encouraged to choose at least three providers. If more than two providers are available for the chosen service, the client must prioritize the choices by numbering them 1, 2, and 3. Special needs of the client, such as weekend service or specific hours of the day or evening, should be reflected on the Service Authorization Form and documented in the narrative. These needs should be presented to the chosen provider, giving the provider the opportunity to accept or reject the referral. Because the condition of the client is the primary consideration and the timely initiation of services is paramount, the case manager will have the option of referring to the next provider (as prioritized by the client, responsible party, and/or significant other) if an affirmative response has not been received from the chosen provider within three (3) working days. The same will hold true if the chosen provider does not respond to a call-back message. When this occurs, dates and persons contacted and other pertinent information must be documented in the narrative. Prior to initiating a service authorization, the case manager must contact the provider to determine the start date and discuss any special needs to the client. Identification is required of the client whose needs are such that the absence of an authorized waiver service would have a substantial impact on the clients health and safety. The Service Authorization Form must be specific and accurate, including the appropriate service. It must also include the number of units per day and days of the week (e.g. 2 units 3 x week - MWF). The hours of service should appear on the form only if the hours indicate specific times which are essential to meeting the clients service needs. Unless specific hours are absolutely essential, rejection of a provider due to inability to provide requested hours is neither appropriate nor allowable. The provider must, however, be given the opportunity to accept or reject the hours. The case manager must ascertain that such specific hours requested are required and not simply desired by the client. Desired hours may, of course, be negotiated with the client and with the provider during the providers initial contact. Case managers must contact the client, responsible party, and/or significant other within ten (10) working days after the service authorization start date to ensure services are implemented and to review client/agency responsibilities. This contact may be made either by telephone, home visit, or in written form. Follow-up contact with the provider(s) may be necessary to resolve questions or problems with contracted services. Regular contact must be maintained with the providers of waiver services.

Supporting the Participant in Service Plan Development. Specify: (a) the supports and information that are made available tothe participant (and/or family or legal representative, asappropriate) to direct and be actively engaged in the service plandevelopment process and (b) the participant's authority to determinewho is included in the process.

Character Count: out of 12000

The case manager, the client, family member or legal representative/other person designated by the client, meet to develop the plan of care. During the meeting, all parties may discuss the needs of the client; informal supports provided by the family and/or other community services to identify the gaps in support and are informed by the case manager of waiver services which may fill the gaps. Replacement services for these gaps will be addressed by the case manager of waiver services at this time. The participant decides which personal representative(s) will be involved in development of the plan of care.

Character Count: out of 24000

Following referral, intake and temporary case assignment, the Case Manager makes a face-to-face visit with the client for evaluation and completion of the HCBS application. To clarify the assessment information, the Case Manager may consult with the client and/or family, and physician, with regard to medical, behavioral, functional and social information. Once the Case Manager feels that he or she has adequate information for a level of care determination, an initial Plan of Care is completed. The HCBS application is reviewed by a Registered Nurse at the Operating Agency's state office for appropriateness of waiver admission. Justification for level of care determination must be properly documented in the client's file. The Plan of Care encompasses a comprehensive review of the clients problems and strengths. Based on identified needs, mutually agreed upon goals are set. The Plan of Care development should include participation by the client and/or family/primary caregiver, and Case Manager. The Plan of Care development process provides involved persons with information necessary to make an informed choice regarding the location of care and services to be utilized. All waiver and non-waiver services provided to meet a clients needs should be included in the Plan of Care. The Case Manager will submit a written Service Authorization Form to the DSP Agency authorizing waiver service(s) and designating the units, frequency, beginning and ending dates of service, and types of duties in accordance with the individual client's needs as set forth in the Plan of Care. To coordinate the provision of a direct E/D Waiver service to be delivered at the client's place of residence, an initial visit should be held at the client's place of residence and should include at a minimum the Case Manager, the DSP Supervisor, the client and caregiver as applicable. It is advisable to also include the DSP Worker in the initial visit. An initial visit is required when a DSP begins to provide services to a client in the client's place of residence. If a client receives more than one direct service from a DSP, only one initial visit is required. If a client has more than one DSP, an initial visit should be conducted with each DSP. Each case will be monitored monthly through contacts and at least one face-to-face visit with the client. Special emphasis will be put on discussion of the clients current health/impairment status, appropriateness of the Plan of Care, and verification that all formal and informal providers included on the Plan of Care are delivering the amount and type of services that were committed. The amount, frequency and beginning date of service depend on the client's needs. Some cases may require monitoring more frequently than monthly. Contacts for these cases will be scheduled by prioritizing clients according to medical conditions that are unstable, clients who require extensive care, and/or clients who have limited support systems. Clients and/or responsible relatives shall be instructed to notify the Case Manager if services are not provided as planned, or if the clients condition changes. However, it is the responsibility of the Case Manager to promptly identify and implement needed changes in the Plan of Care. Providers will be contacted, as necessary, to discuss the appropriate amount of service to be delivered. The Plan of Care and service authorizations will be updated to reflect any changes in service needs. Services may be initiated or changed at any time within an authorization period to accommodate a clients changing needs. Any change in Waiver Services necessitates a revision of the Plan of Care. The revised Plan of Care must coincide with the narrative explaining the change and a new Service Authorization Form should be submitted by the Case Manager to DSP. If the DSP identifies additional duties that would be beneficial to the client's care, but are not specified on the Plan of Care, the DSP will contact the Case Manager to discuss having these duties added. (a)The Case Manager will review the DSP's request to modify services and respond within one (1) working day of the request. (b) The Case Manager will approve any modification of duties to be performed by the Waiver Service Worker and re-issue the Service Authorization Form accordingly. (c) Documentation of any change in a Plan of Care will be maintained in the client's file. (i)If the total number of hours of service is changed, a new Service Authorization Form is required from the Case Manager. (ii)If the types or times of services are changed, a new Service Authorization Form is required from the Case Manager. (iii)If an individual declines waiver services or has become ineligible for services, a Service Authorization Form indicating termination is required from the Case Manager. (iv)A new Service Authorization is required following each redetermination of eligibility, even if there are no changes to the authorized services.

Character Count: out of 12000

Potential risks to the participants safety are addressed in the development of the plan of care. Plans are individualized and should take into consideration the participants rights, values and preferences as related to any potential risks to health and safety. During the monthly face-to-face case management visit, the participants health and welfare is reviewed, the plan of care adjusted accordingly and evaluated for appropriateness. During the monthly visit the case manager assesses the home to ensure the participant is safe, questions the participant regarding satisfaction with services and providers, as well as makes observations to ensure the health needs are met, and notes any changes that may require modifications to the POC. The case manager also documents, addresses and monitors any health and safety concerns. When the participant is considered highly at risk the case manager may visit more often to monitor the situation to ensure the participants health and safety is not jeopardized. When a risk has been reported or identified, a home visit to monitor the health and safety of the client is required as soon as it can be arranged. Additionally, DSP staff must visit the participants home as ordered in the POC. DSPs are trained and expected to observe and report any concerns about a participants health and welfare to the case manager and in writing to supervision of the DSP agency. Direct Service Providers have policy/procedures established for serving clients in the event the assigned worker is unable to provide the service. As part of this back-up protocol the DSPs are notified of high risk clients so that any participant designated by the case manager as at risk should be given first priority when service visits must be temporarily prioritized and/or reduced by the DSP Prior to initiating a service authorization, the case manager must contact the provider to determine the start date and discuss any special needs to the client. Identification is required of the client whose needs are such that the absence of an authorized waiver service would have a substantial impact on the clients health and safety. An emergency backup plan for those applicants who are considered at risk if visits are not made. (A disaster preparedness plan should also be in place.) In cases where the client is determined to be at risk for missed visits, the authorization will be flagged when initiated. If the at-risk status changes, the existing authorization is revised and sent to the provider indicating the current status. An emergency/disaster priority status is entered on the Service Authorization Form according to the description below and service planning is required in an attempt to meet the needs of a client who would be vulnerable during the emergency/disaster:(1)Not Priority - Client is not vulnerable during emergency/disaster or has adequate supports to meet his or her needs. (Example: Client with functional deficits, but family willing and able to evacuate and/or meet needs.)(2)Priority, Client Lives Alone - Client lives alone and is vulnerable in emergency/disaster due to limitation of support system. (Example: Client lives alone and has no one available to evacuate him or her or has no one to give insulin.)(3)Priority, Advanced Medical Need - Client has advanced medical needs and would be vulnerable during an emergency/disaster. (Example: Client is on ventilator, dialysis, or other specialized equipment/service.)

Character Count: out of 6000

Prior to assessment for the waiver program, the case management staff for the EDW program screens the applicant for their desire for waiver participation and their likelihood to meet financial and level of care eligibility criteria. These activities are preliminary requirements for waiver enrollment and are distinct from case management activities but are included in this scope of service and are recorded as administrative activities. These activities are documented in the case record. The intake and screening process is involved and must include documentation regarding the following: a.The applicant has been informed about the application process; b.The applicant has been informed of all direct service providers and allowed his or her freedom of choice of providers; c.The applicant has been informed of all HCBS programs of which he or she may benefit and allowed freedom of choice of programs; d.The applicant has been informed of choice options regarding case management services; e.The applicant must indicate a written choice between institutional or community care. The only exception to a written choice is when the client is not capable of signing the form. In this situation, approval for waiver services should not be denied if a written choice cannot be obtained. The reason for the absence of a signed choice should be well documented in the case record. Signatures with the mark of an X are accepted followed by a statement Mark of recipients name and the mark must be witnessed. If the applicant is physically impaired to the extent that he or she is unable to sign for him or herself, the legal representative may sign the form as follows: Jack Jones signed by Joe Scott. It must be clearly documented why the applicant did not sign;

Character Count: out of 6000

The AMA will conduct a random sample of all plans of care for persons receiving waiver services. The AMA Quality Improvement Coordination Unit reviews a sample of plans of care and related documents annually for providers. This assures that the clients that are receiving services under the waiver have a plan of care in effect for the period of time that the services were provided. This review ensures that the need for services that were provided was documented in the plan, and that all service needs were addressed in the plan of care prior to delivery. A copy of the plan of care is maintained by the case managers, service provider and in the clients home.

Maintenance of Service Plan Forms.Written copies or electronic facsimiles of service plans aremaintained for a minimum period of 3 years as required by 45 CFR 92.42.Service plans are maintained by the following(check each that applies):

Medicaid agency

Operating agency

Case manager

Other

Character Count: out of 24000

The client and or responsible person is encouraged to notify the case manager if services are not being provided as planned and if the clients needs or situation changes. The case manager identifies and promptly carries out needed changes in coordination with the client and or responsible person and other care providers. The plan of care is revised as needed to adapt to a clients changing needs. Ongoing reviews, completed by the AMA Quality Improvement Coordination Unit staff, monitor case managers and clients records for service implementation and adherence to the plan of care. These reviews also ensure that the plans of care are reviewed at least monthly during a face to face visit. During the review, incidents and complaints are reviewed to assure that they are addressed and resolved appropriately. AMA Quality Improvement Coordination staff may also visit clients in their homes to assure that health and safety standards are being met.

Methods for Discovery: Service Plan Assurance/Sub-assurances

Sub-Assurances:

Sub-assurance: Service plans address all participants assessed needs (including health and safety risk factors) and personal goals, either by the provision of waiver services or through other means.

Performance Measures

For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

Sub-assurance: The State monitors service plan development in accordance with its policies and procedures.

Performance Measures

For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

Sub-assurance: Service plans are updated/revised at least annually or when warranted by changes in the waiver participants needs.

Performance Measures

For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

Sub-assurance: Services are delivered in accordance with the service plan, including the type, scope, amount, duration and frequency specified in the service plan.

Performance Measures

For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

Sub-assurance: Participants are afforded choice: Between waiver services and institutional care; and between/among waiver services and providers.

Performance Measures

For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.

Character Count: out of 6000

The Alabama Medicaid Agency (AMA) has granted the OA the authority to determine participant service plans. The AMA is available to assist the OA in these determinations, if needed. The AMA will conduct retrospective record reviews on a monthly basis. The AMA will also review a percentage of case management records on a quarterly basis.

Methods for Remediation/Fixing Individual Problems

Describe the States method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.

Character Count: out of 6000

The Elderly and Disabled Waiver (E&D) is administered by the Long Term Care Division of the Alabama Medicaid Agency (AMA) and operated by ADSS. The AMA exercises administrative discretion in the management and supervision of the waiver and issues policies, rules and regulations related to the waiver. The AMA assumes the responsibility of: (1) Conducting joint trainings with direct service providers enrolled to provide services through the Elderly and Disabled waiver program; (2) Providing periodic training to discuss policies and procedures in an effort to consistently interpret and apply policies related to the E&D Waiver program, which are outlined in the E&D Waiver manual, (3) Conducts annual training to disseminate policies, rules and regulations regarding the home and community-based waiver programs and,(The AMA Long Term Care (LTC) Waiver Quality Assurance Unit has developed a Quality Management Strategy for the E&D Waiver Program. The following activities are components of the Quality Assurance Strategy: (1) Collect ongoing monthly data to monitor appropriateness of level of care determinations; (2) Collect quarterly data from registered nurses by any of the following sources; reviewing a sample of waiver case management records, direct service provider records, conducting on-site visits to participants homes, conduct consumer satisfactions surveys and tracking complaints and grievances; (3) Identify remediation for non-compliance issues and complaints identified during data collection are handled by requesting the entity involved to submit a plan of correction with 15 days of notification. If non-compliance is not resolved, the entity will be monitored every three months until compliance is achieved; and (4) Collect data and submit quarterly and annual reports to the Department of Senior Services and AMA staff for evaluation and recommendations for program improvements.

Remediation Data Aggregation

Timelines

Availability of Additional Dispute Resolution Process.Indicate whether the State operates another dispute resolutionprocess that offers participants the opportunity to appealdecisions that adversely affect their services while preservingtheir right to a Fair Hearing. Select one:

 No. This Appendix does not apply

 Yes. The State operates an additional dispute resolution process

 not selected

Description of Additional Dispute Resolution Process. Describe the additional dispute resolution process,including: (a) the State agency that operates the process; (b)the nature of the process (i.e., procedures and timeframes),including the types of disputes addressed through the process;and, (c) how the right to a Medicaid Fair Hearing is preservedwhen a participant elects to make use of the process: Statelaws, regulations, and policies referenced in the description areavailable to CMS upon request through the operating or Medicaid agency.

Character Count: out of 12000

The Alabama Medicaid Agency does operate another dispute resolution process, the informal conference process, which offers participants the opportunity to appeal decisions that adversely affect their services, while preserving their right to a fair hearing. An individual choosing to use the informal conference to resolve a dispute is informed in writing by the case manager that if the informal conference decision is not favorable, they maintain their right to have a fair hearing. At the conference, the person may present the information or may be represented by a friend, relative, attorney, or other spokesperson of their choice. If the dispute is not resolved through the informal conference, the participant, applicant, or his/her legal representative can submit a written request for a fair hearing within thirty (30) days of the date of the notice of action. The document referring to the participants appeal rights is maintained in the waiver participants home for future reference. The Alabama Medicaid Agency will provide an opportunity for a fair hearing under 42 C.F.R. Part 431 Subpart E for individuals who are still dissatisfied after the above procedure has been completed. If the request for the hearing is made by someone other than the person who wishes to appeal, the person requesting the hearing must make a definite statement that he/she has been authorized to do so by the person for whom the hearing is being requested. Information about the hearings will be forwarded and plans will be made for the hearing and a date and place convenient to the person will be arranged. If the person is satisfied before the hearing and wants to withdraw his/her request, he/she or his/her legally appointed representative or other authorized person should write the Alabama Medicaid Agency that he/she wishes to do so and give the reason for withdrawing. When benefits are terminated, they can be continued if a hearing request is received within ten (10) days following the effective date of termination. If benefits are continued pending the outcome of the hearing and the Hearing Officer decides that termination was proper, Alabama Medicaid Agency may recover from the terminated recipient or sponsor, the costs of all benefits paid after the initial termination date. Regulations found at 42 CFR 431.222 allow the State to consolidate individual requests for a hearing into a single group hearing for cases where the sole issue involved is one of Federal or State law or policy. However, the state does offer a hearing in these cases. The Alabama Medicaid Agency need not grant a request for a hearing if the sole issue is a federal or state law or policy which requires an automatic change adversely affecting some or all recipients.

Operation of Grievance/Complaint System.Select one:

 No. This Appendix does not apply

 Yes. The State operates a grievance/complaint system that affords participants the opportunity to register grievances or complaints concerning the provision of services under this waiver

 not selected

Operational Responsibility. Specify the State agency that is responsible for the operationof the grievance/complaint system:

Character Count: out of 4000

The following State Agencies are responsible for the operation of the grievance/complaint system: 1.Alabama Department of Senior Services(ADSS) 2.Alabama Medicaid Agency(AMA)

Description of System. Describe the grievance/complaint system, including: (a) the typesof grievances/complaints that participants may register; (b) theprocess and timelines for addressing grievances/complaints; and,(c) the mechanisms that are used to resolve grievances/complaints.State laws, regulations, and policies referenced in thedescription are available to CMS upon request through the Medicaid agency or theoperating agency (if applicable).

Character Count: out of 12000

ADSS is responsible for explaining the procedures to clients of filing complaints and grievances. ADSS must also have procedures in place that will assure AMA that DSP have explained to clients the process on how to register a complaint. Waiver applicants/participants are informed of procedures necessary to file a formal complaint or grievance regarding availability, delivery or quality of services at application, readmission, redetermination, reinstatement or transfer of eligibility. Written information is maintained in the participants home about this process as well. The DSP supervisor will investigate any complaints registered by a client against any DSP workers. Any action taken will be documented in the client's record. If the client is dissatisfied with the action taken by the provider they should forward their complaint to appropriate agency and/or AMA.a. Complaints are submitted to ADSS or the AMA and are investigated through resolution. A tracking log will be used to document the incidents and resolutions in the AMA Quality Improvement Coordination Unit. The OA will also maintain a log of complaints and grievances received.b. If complaints are received by the AMA, a copy will be forwarded to ADSS within two (2) working days. If they are received by ADSS a copy will be forwarded to AMA LTC Program Management Unit within two (2) working days if the clients health and safety are at risk. Otherwise, the complaint/grievance should be entered on the quarterly log that is submitted to AMA.c. ADSS must investigate all complaints upon receipt of notification. Appropriate parties must initiate action within 24 hours if it appears that a client's health and safety is at risk. If necessary the complainant will be interviewed.d. A summary and plan of correction will be sent from the OA to the AMA Quality Improvement Coordination Unit for all complaints reported within 30 days of the request for the summary or plan of correction from the AMA. The providers must forward their plan of corrections to the OA who will in turn forward to AMA. The OA will evaluate the plan of correction within seven (7) days of receipt. If the plan of correction is not responsive to the complaint, it will be returned to the provider within two (2) days. The revised plan of correction will be resubmitted to the OA within two (2) working days. If the summary or plan of correction carried out is found not to be responsive, the provider will have up to seven (7) days to revise the plan and carry out the appropriate action.e. ADSS will review all complaints and grievances to determine a pattern of problems in order to assure that no health and safety risk exist.f. Final determinations including any adverse findings will be reported to the AMA, LTC Program Management Unit.g. The AMA will contact the client via telephone or targeted survey to ensure full resolution to the incident has been completed in a satisfactory manner.h. On a quarterly basis, ADSS will forward all grievance logs to AMA Quality Improvement Coordination Unit for review, tracking, and assurance that resolutions have been completed.

Critical Event or Incident Reporting and Management Process. Indicate whether the State operates Critical Event or Incident Reporting andManagement Process that enables the State to collect information on sentinel eventsoccurring in the waiver program.Select one:

 not selected

 Yes. The State operates a Critical Event or Incident Reporting and Management Process (complete Items b through e)

 No. This Appendix does not apply (do not complete Items b through e)

State Critical Event or Incident Reporting Requirements. Specify the types of critical events or incidents (including allegedabuse, neglect and exploitation) that the State requires to bereported for review and follow-up action by an appropriateauthority, the individuals and/or entities that are required toreport such events and incidents and the timelines for reporting.State laws, regulations, and policies that are referencedare available to CMS upon request through the Medicaid agency or the operating agency(if applicable).

Character Count: out of 24000

State Critical Event or Incident Requirements Incident Types Timeframes Physical Abuse Immediate Sexual Abuse Immediate Verbal Abuse Immediate Neglect Immediate Mistreatment Immediate Death Immediate Exploitation 24-hours Moderate Injury 24-hours Major Injury 24-hours Natural Disaster 24-hours Fire 24-hours Fall 24-hours Definitions Physical Abuse-the infliction of physical pain, injury or the willful deprivation by a care giver or other person of necessary services to maintain physical and mental health. Sexual Abuseany conduct that is a crime as defined in Sections 13A-6-60 to 13A-6-70, inclusive of the Code of Alabama. Forms of sexual abuse include rape, incest, sodomy, and indecent exposure. Verbal Abuse-the infliction of disparaging and angry outbursts such as name calling, blaming, or accusatory comments. Neglect- the failure of a caregiver to provide food, shelter, clothing, medical services, or healthcare for the person unable to care for himself or herself; or the failure of the person to provide these basic needs for himself or herself when the failure is the result of the persons mental or physical inability. Mistreatment-Actions that cause harm or create serious risk of harm whether intended or not, to a vulnerable person, by the caregiver or another person, or failure of a caregiver to satisfy the basic need or to protect the child or adult from harm. Death-the permanent suspension of consciousness and the end of life. Exploitation-the expenditure, diminution or use of the property, assets or resources of a person subject to protection under the provision of Sections 38-9-1 through 11, Code of Alabama, without the express voluntary consent of that person or legally authorized representative. Moderate Injury-any observable and substantial impairment of a persons physical health such as temporary loss or impairment. Major Injury-any observable and substantial impairment that results in permanent or temporary impairment, such as fractures, injury to internal organs, burns, or physical disfigurement of the body. These injuries may result in hospitalization. Natural Disaster-the consequence of the combination of a natural hazard such as tornadoes, hurricanes, floods, power outages and winter weather. Fire a situation in which something such as a building or an area of land is destroyed or damaged by burning. Fall- an incident that causes a person to drop suddenly from an up-right position which may result in harm. All Medicaid approved providers who provide home and community-based services in Medicaid recipients homes shall report incidents of abuse, neglect, and exploitation immediately to the Department of Human Resources, or law enforcement as required by the Alabama Adult Protective Services Act of 1976. The Alabama Adult Protective Services Act of 1976 outlines the specific responsibilities of the Department of Human resources, law enforcement authorities, physicians, caregivers individuals and agencies in reporting and investigating such cases, and in providing the necessary services. Alabama Code §§ 38-9-1-11 Adult Protective Services Act of 1976 All physicians, osteopaths, chiropractors and caregivers are required by law to report instances of suspected abuse, neglect or exploitation, sexual abuse, or emotional abuse. An oral report, either by telephone or in person must be made immediately if there is reasonable cause to believe that an adult has been subjected to abuse, neglect, or exploitation, followed by a written report to the chief of police or sheriff, the County Department of Human Resources or the Adult Protective Services Hotline (1800-458-7214). Other incidents such as falls must be reported within 24 hours to the Provider Agency, the Alabama Medicaid Agency, and the Alabama Department of Senior Services in a timely manner based upon the circumstances surrounding the incident. Child Abuse Prevention and Treatment Act 1974 Alabama law is clear on reporting abuse and neglect of children under the age of 18. For example, physicians, teachers, social workers, nurses, day care workers or anyone who comes in contact with suspected child abuse or neglect should make a report to those who can take action. An oral report, either by telephone or in person must be made immediately if there is reasonable cause to believe that a child has been subjected to abuse, neglect, or exploitation, followed by a written report to the chief of police or sheriff, the County Department of Human Resources or the State Child Abuse Reporting Hotline (334- 242-9500).

Participant Training and Education. Describe how training and/or information is provided to participants(and/or families or legal representatives, as appropriate) concerningprotections from abuse, neglect, and exploitation, including how participants(and/or families or legal representatives, as appropriate) can notifyappropriate authorities or entities when the participant may haveexperienced abuse, neglect or exploitation.

Character Count: out of 12000

The case manager and the direct service provider are responsible for ensuring that the participants, and/families or legal representatives are informed about their rights concerning abuse, neglect and exploitation at least annually. Case managers maintain relationships with consumers to encourage them to talk about what is important to them as well as what they do not like. Each recipient is informed of his/her rights and responsibilities during the initial assessment. The legal guardian and/or advocate is informed of the recipients rights, responsibilities, protections or means to enforce the protections, if the recipient is not able to understand. The case manager and the DSP is responsible for informing the client/or responsible party of their right to lodge a complaint and how to register a complaint alleging abuse, neglect/ or exploitation.

Responsibility for Review of and Response to Critical Events or Incidents. Specify the entity (or entities) that receives reports of criticalevents or incidents specified in item G-1-a, the methods that areemployed to evaluate such reports, and the processes and time-framesfor responding to critical events or incidents, including conductinginvestigations.

Character Count: out of 12000

The Alabama Department of Senior Services is the entities that receive reports of critical events or incidents. The operating agency (OA) will investigate the critical events reported and make a decision within seven (7) working days. If a decision cannot be reached, additional information is requested. Resolution is reached within seven (7) working days from receipt of the additional information with a response disseminated to all parties involved. All allegations of abuse require an investigation. If the OA determines that an incident requires follow-up, the Case Manager will monitor the situation and make referrals to the appropriate reporting agency or follow-up on referrals previously made to ensure that the issue has been satisfactorily resolved. If other services or supports are needed to resolve the situation, the Case Manager will seek available resources and arrange when appropriate. Responses to the critical events or incidents are appropriately coordinated and assigned with a completion date not to exceed 30 days based on the nature of the incident.

Responsibility for Oversight of Critical Incidents and Events. Identify the State agency (or agencies) responsible for overseeingthe reporting of and response to critical incidents or events thataffect waiver participants, how this oversight is conducted, and how frequently.

Character Count: out of 12000

The Alabama Department of Senior Services is responsible for overseeing the reporting of and response to critical incidents or events that affect waiver participants through individual/family interviews. The operating agency will notify Medicaids E & D Waiver Coordinator of critical incidents and events as they occur and any follow-up action taken. In addition, Medicaids Quality Improvement Coordination Unit is responsible for overseeing the reporting of and response to critical incidents through a review of quarterly participation satisfaction surveys, a review of complaint logs, medical record reviews, DSP personnel record reviews, and onsite home and provider visits, when deemed necessary.

Use of Restraints or Seclusion.(Select one):

 The State does not permit or prohibits the use of restraints or seclusion

Specify the State agency (or agencies) responsible for detecting the unauthorizeduse of restraints or seclusion and how this oversight is conducted and its frequency:

Character Count: out of 12000

The Alabama Department of Senior Services (ADSS): Monthly monitoring of participants health and welfare and provider quality reviews. The Department of Human Resources (ADHR): certain incidents of abuse, neglect and exploitation must be reported to ADHR by law. The Alabama Medicaid Agency: Annual review of ADSS investigations.

 The use of restraints or seclusion is permitted during the course of the delivery of waiver services. Complete Items G-2-a-i and G-2-a-ii.

 not selected

Use of Restrictive Interventions.(Select one):

 The State does not permit or prohibits the use of restrictive interventions

Specify the State agency (or agencies) responsible for detecting the unauthorizeduse of restrictive interventions and how this oversight is conducted and its frequency:

Character Count: out of 12000

The Alabama Department of Senior Services is responsible for detecting the unauthorized use of restrictive interventions through monthly face to face visits as well as supervisory visits every 60 days

 The use of restrictive interventions is permitted during the course of the delivery of waiver services Complete Items G-2-b-i and G-2-b-ii.

 not selected

Applicability.Select one:

 No. This Appendix is not applicable (do not complete the remaining items)

 Yes. This Appendix applies (complete the remaining items)

 not selected

Medication Management and Follow-Up

Responsibility. Specify the entity (or entities) that have ongoing responsibility formonitoring participant medication regimens, the methods for conducting monitoring,and the frequency of monitoring.

Character Count: out of 12000

Methods of State Oversight and Follow-Up. Describe: (a) the method(s) that the State uses to ensure that participantmedications are managed appropriately, including: (a) the identification of potentiallyharmful practices (e.g., the concurrent use of contraindicated medications); (b) the method(s)for following up on potentially harmful practices; and, (c) the State agency (or agencies) thatis responsible for follow-up and oversight.

Character Count: out of 12000

Medication Administration by Waiver Providers

Answers provided in G-3-a indicate you do not need to complete this section

Provider Administration of Medications.Select one:

 Not applicable. (do not complete the remaining items)

 Waiver providers are responsible for the administration of medications to waiver participants who cannot self-administer and/or have responsibility to oversee participant self-administration of medications. (complete the remaining items)

 not selected

State Policy. Summarize the State policies that apply to the administration of medications bywaiver providers or waiver provider responsibilities when participants self-administermedications, including (if applicable) policies concerning medication administration bynon-medical waiver provider personnel. State laws, regulations, and policies referencedin the specification are available to CMS upon request through the Medicaid agency or theoperating agency (if applicable).

Character Count: out of 12000

Medication Error Reporting.Select one of the following:

 Providers that are responsible for medication administration are required to both record and report medication errors to a State agency (or agencies).

 Providers responsible for medication administration are required to record medication errors but make information about medication errors available only when requested by the State.

 not selected

State Oversight Responsibility. Specify the State agency (or agencies) responsible for monitoring the performance ofwaiver providers in the administration of medications to waiver participants and how monitoringis performed and its frequency.

Character Count: out of 12000

Methods for Discovery: Health and Welfare

The State, on an ongoing basis, identifies, addresses and seeks to prevent the occurrence of abuse, neglect and exploitation.

Performance Measures

For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.

Character Count: out of 6000

The Case Manager will monitor participants through monthly home visits to observe the participant in the home and note any critical events/incidents appropriately. The Case Manager will also report any events of this nature to the waiver administrator in the approved format who will forward to AMA within the required guidelines. The Case Manager will track reports to resolution for documentation and will report the resolution to the waiver administrator to forward to AMA.

Methods for Remediation/Fixing Individual Problems

Describe the States method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.

Character Count: out of 6000

The Elderly and Disabled Waiver (E&D) is administered by the Long Term Care Division of the Alabama Medicaid Agency (AMA) and operated by ADSS. The AMA exercises administrative discretion in the management and supervision of the waiver and issues policies, rules and regulations related to the waiver. The AMA assumes the responsibility of: (1) Conducting joint trainings with direct service providers enrolled to provide services through the Elderly and Disabled waiver program; (2) Providing periodic training to discuss policies and procedures in an effort to consistently interpret and apply policies related to the E&D Waiver program, which are outlined in the E&D Waiver manual, and (3) Conducts annual training to disseminate policies, rules and regulations regarding the home and community-based waiver programs. The AMA Quality Improvement Coordination Unit has developed a Quality Management Strategy for the E&D Waiver Program. The following activities are components of the Quality Assurance Strategy: (1) Collect ongoing monthly data to monitor appropriateness of level of care determinations; (2) Collect quarterly data from registered nurses by any of the following sources; reviewing a sample of waiver case management records, direct service provider records, conducting on-site visits to participants homes, conduct consumer satisfactions surveys and tracking complaints and grievances; (3) Identify remediation for non-compliance issues and complaints identified during data collection are handled by requesting the entity involved to submit a plan of correction with 15 days of notification. If non-compliance is not resolved, the entity will be monitored every three months until compliance is achieved; and (4) Collect data and submit quarterly and annual reports to the Department of Senior Services and AMA staff for evaluation and recommendations for program improvements. When complaints and grievances arise every attempt is made to resolve them at the local level. When this effort is not successful the grievance process is initiated. Waiver participants are encouraged to advise the case manager of any dissatisfaction relative to any aspect of the care or services received through the E&D Waiver. Clients may register a complaint or grievance relating to denial, reduction or change in waiver services, financial eligibility, Direct Service Providers, Direct Service Workers or with the case manager. If the complaint or grievance is lodged against the case manager the operating agency is responsible for resolving the concerns. If the complaint or grievance is lodged against the operating agency the Medicaid Agency is responsible for resolving the concerns. If complaints are received by the Medicaid Agency, a copy will be forwarded to E&D Waiver program administrator within two (2) working days. All complaints are investigated upon receipt of notification. Appropriate parties must initiate follow-up within 24 hours if it appears that a client's health and safety is at risk. If necessary the complainant will be interviewed. A summary and plan of correction will be developed by the Medicaid Reviewer for complaints reported with the exception of those reported to the Direct Service Provider (DSP) Agency. The DSP must forward their summaries and plans of correction to the Medicaid Agency, who will in turn forward them to the AIDS Waiver program administrator for review. The administrator will evaluate the plans of correction within seven (7) days of receipt. If the plan of correction submitted by the DSP Agency is found not to be responsive to the complaint, the administrator will return the plan to the DSP Agency requesting a resubmitted plan within two (2) working days of receipt of notice. If the summary or plan of correction carried out by the DSP Agency continues to be unresponsive, the DSP Agency will have up to forty-five (45) days to revise the plan and carry out the appropriate action. Final determinations including any adverse findings will be reported to the E&D Waiver program administrator. The Medicaid Agency will contact the client via telephone to ensure full resolution to the incident has been completed satisfactory. Complaints received by the Medicaid Agency will be submitted to the operating agency within 2 working days. If complaints are submitted to the OA, Medicaid must be notified within 2 working days after the complaint is received. The OA must investigate all complaints upon receipt of notification. Appropriate parties must take action if it appears that a recipients health and safety is at risk within 24 hours. In these cases, the Medicaid Agency must be notified within one (1) working day of the action taken. The complainant will be interviewed if necessary. A summary and plan of correction will be sent from the OA or the provider for all complaints reported to the Medicaid Agency Quality Assurance Division. The Medicaid Agency will evaluate the plan of correction. If the plan of correction is not responsive to the complaint it will be returned to the OA. The corrective plan of correction will be sent to the Medicaid Agency within 2 working days. The Medicaid Agency will contact the recipient and/or responsible party and the case manager via telephone to ensure full complaint resolution has been reached.

Remediation Data Aggregation

Timelines

System Improvements

Describe the process(es) for trending, prioritizing, and implementing system improvements(i.e., design changes) prompted as a result of an analysis of discovery andremediation information.

Character Count: out of 12000

Description of the Quality Management Program for the Elderly and Disabled Waiver The Quality Management Strategy for the Elderly and Disabled (E & D) Waiver is: AMA Quality Improvement Coordination Unit is responsible for collecting data quarterly and annually regarding the quality of services provided from various sources for the E & D Waiver program. The Quality Framework is used as a guide to assess seven (7) Program Design Focus areas from samples of waiver participants, case management and direct service providers records, on-site home visits when deemed necessary, and onsite visits to adult day health facilities. In addition, consumer satisfaction surveys and complaints and grievances logs are reviewed quarterly. Adverse responses to surveys and/or complaints received are tracked to resolution. Adverse responses are also re-tracked with targeted surveys to determine clients satisfaction with resolutions.

System Design Changes

Describe the process for monitoring and analyzing the effectivenessof system design changes. Include a description of the various roles andresponsibilities involved in the processes for monitoring & assessing systemdesign changes. If applicable, include the States targeted standards forsystems improvement.

Character Count: out of 12000

Data is collected through an annual review of each operating agency which may include policies and procedures, contracts with subcontractors, on-going training of subcontractors, quality assurance system, and billing and service provision. More specifically, a sample of all applicants approved by the AMA is conducted to ensure that the processes and instruments described in the approved waiver are applied in determining the Level of Care. Additionally, a sample of the waiver population is chosen for record review to ensure coordination of care, quality of care, outcomes and billing accuracy. A sample of personnel records of case managers and other employees personnel records are reviewed to ensure basic and continuing education requirements are met. Home visits may be made to ensure quality of care, health and safety, ongoing needs of the client are being met, and to gain input about the quality of the services received. Remediation for non-compliance issues identified during data collection is handled by requesting the entity involved to submit a plan of correction within 15 days of notification. If the problem is not corrected, the entity is monitored every three months until they are found to be in compliance.

Describe the process to periodically evaluate, as appropriate,the Quality Improvement Strategy.

Character Count: out of 12000

The collected data is reported quarterly and annually to each Operating Agency. AMA Quality Improvement Coordination Unit in collaboration with the LTC Division, will evaluate reports and make recommendations for improvements to the program. The AMA LTC Division will determine if changes are made to the program. In order to measure and improve performance, data is collected, reviewed and reported using the seven focus areas of the Quality Framework. Participant Access: Sources of dataCase Management RecordsHome VisitsDSS Queries Consumer Surveys Participant Centered Service Planning and Delivery: Sources of dataConsumer SurveysCase Management RecordsSite VisitsHome Visits Provider Capacity and Capabilities: Sources of dataConsumer SurveysCase Management RecordsPersonnel and Training Records of Operating Agency and Subcontractors Home Visits Participants Safeguards: Sources of dataCase Management RecordsConsumer SurveysHome VisitsSite Visits Participants Rights and Responsibilities: Sources of dataConsumer SurveysCase Management Records Complaint and Grievances Logs Targeted Surveys Patient Satisfaction: Sources of dataConsumer SurveysCase Management RecordsHome Visits Site Visits System Performance: Sources of dataReview of Operating Agency Quality Assurance SystemReview of Operating Agency Billing and Service Provision Collaborated Meeting with Operating Agency to enhance the administration of the Program Subcontractor Client Records The following indicators are reported to the operating agency and Medicaids Long Term Care Division:Percentage of client/family reporting satisfaction with waiver services and needs met.Percentages of client/family reporting they feel safe and secure in the home and community.Percentage of client/family reporting they have ready access to services and were informed of sources of support available in the community.Percentage of client/family reporting knowledge of rights and responsibilities.Percentage of records indicating services are planned and implemented according to the clients needs and preferences.Evidence that each operating agency has a Quality Assurance System in place that monitors subcontractors.Evidence that each operating agency has a system in place to ensure only qualified providers are enrolled, credentials are verified and training of personnel is ongoing.

Methods for Discovery: Financial Accountability

State financial oversight exists to assure that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver.

Performance Measures

For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.

Character Count: out of 6000

The AMA has contracted with a fiscal agent to maintain the payment records on services received and billed under the E&D Waiver. The OA ensures that all services and corresponding payments are coded and documented properly. The OA ensures that only those services included on the plan of care are billed for the E&D Waiver participant. The Fiscal Intermediary has edits in the system to ensure that the participant has Medicaid financial eligibility and E&D Waiver eligibility before the claims are paid. The AMA reviews selected claim data to ensure that services are billed appropriately and according to the plan of care. To ensure maximum reimbursement to services providers, the AMA is notified of any claims payment issues and will work with the OA and the fiscal intermediary to resolved the issues. The AMA through the Decision Support System can generate adhoc reports to track payments and denials for each waiver participant as well as the cost for the entire waiver program.

Methods for Remediation/Fixing Individual Problems

Describe the States method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.

Character Count: out of 6000

The Elderly and Disabled Waiver (E&D) is administered by the Long Term Care Division of the Alabama Medicaid Agency (AMA) and operated by ADSS. The AMA exercises administrative discretion in the management and supervision of the waiver and issues policies, rules and regulations related to the waiver. The AMA assumes the responsibility of: (1) Conducting joint trainings with direct service providers enrolled to provide services through the Elderly and Disabled waiver program; (2) Providing periodic training to discuss policies and procedures in an effort to consistently interpret and apply policies related to the E&D Waiver program, which are outlined in the E&D Waiver manual, (3) Conducts annual training to disseminate policies, rules and regulations regarding the home and community-based waiver programs and, (4) signs all qualified direct service providers contracts enrolled with ADSS to provide waiver services. The AMA Quality Improvement Coordniation Unit has developed a Quality Management Strategy for the E&D Waiver Program. The following activities are components of the Quality Assurance Strategy: (1) Collect ongoing monthly data to monitor appropriateness of level of care determinations; (2) Collect quarterly data from registered nurses by any of the following sources; reviewing a sample of waiver case management records, direct service provider records, conducting on-site visits to participants homes, conduct consumer satisfactions surveys and tracking complaints and grievances; (3) Identify remediation for non-compliance issues and complaints identified during data collection are handled by requesting the entity involved to submit a plan of correction with 15 days of notification. If non-compliance is not resolved, the entity will be monitored every three months until compliance is achieved; and (4) Collect data and submit quarterly and annual reports to the Department of Senior Services and AMA staff for evaluation and recommendations for program improvements.

Remediation Data Aggregation

Timelines

Rate Determination Methods. In two pages or less, describe the methods that are employed to establish providerpayment rates for waiver services and the entity or entities that are responsible for ratedetermination. Indicate any opportunity for public comment in the process. If differentmethods are employed for various types of services, the description may group services forwhich the same method is employed. State laws, regulations, and policies referenced in thedescription are available upon request to CMS through the Medicaid agency or the operatingagency (if applicable).

Character Count: out of 12000

Rates for E & D Waiver services are established by Medicaid. They are prospective rates that are based on audited historical costs with consideration given to the health care index and renegotiated contracts. Medicaid pays private and public contractors the same rate. An OA may request an interim increase or decrease at any time. If approved by Medicaid, the adjusted rate allows claims to be paid at a rate that is closer to the providers actual cost. If a rate adjustment is retroactive, previously paid claims are recouped and repaid at the adjusted rate. At fiscal year end, the total amount paid by the OA is divided by the total number of units served, and an average rate per service is determined. Medicaid uses the average rate to determine the final settlement. For each waiver service, a HCPC code is determined with a rate assigned to each code. The Medicaid Management Information system (MMIS) pays the claim based upon the States determined pricing methodology applied to each service by provider type, claim type, recipient benefits and policy limitations. All claims submitted for adjudication must pass certain edits in the MMIS. Once a claim passes through edits, the system reviews each claim to make sure it complies with AMA policies. The MMIS then performs audits by validating claims history information against information on the current claim. Audits check for duplicate services, limited services, and related services and compare them to Alabama Medicaid policy to ensure that recipient benefits are paid according to current policies. As each waiver year is audited, this cost like the benefit cost, will be determined and lump sum settlement will be made to adjust that years payments to actual cost. Cost Reports from the OAs are due to Medicaid by December 31. Cost settlements are made no later than September 30 of the following year.

Flow of Billings. Describe the flow of billings for waiver services, specifying whether provider billingsflow directly from providers to the State's claims payment system or whether billings are routedthrough other intermediary entities. If billings flow through other intermediary entities,specify the entities:

Character Count: out of 6000

Each waiver participant, once approved, is added to the Alabama Medicaids Long Term Care File. This file holds approved dates of eligibility for waiver services. Providers billings flow directly from the providers to the Medicaid MMIS through Hewlett Packard System (EDS), the Fiscal Intermediary as follows:Payments made by Medicaid to providers are on a cost reimbursement basis. Each covered service is identified on a claim by a HCPC code.For each recipient, the claim allows span billing for a period up to one month. There may be multiple claims in a month; however no single claim can cover services performed in different months. Each service type is identified by Procedure Code and will include all units of that service provided during that month. Specific dates for each unit can be identified on the Service Authorization Form.If the submitted claims covers dates of service where part, or all of which were covered in a previously paid claim is rejected. The provider is required to make the corrections on the claim and resubmit for processing.Payment is based on the number of units of service reported on the claim for each procedure code.Accounting for actual costs and units of services provided during the waiver year, are captured on the CMS 372 Report.All claims must be filed within twelve months from the date of service. Medicaid recovers payments that exceed actual allowable cost.Payment is based on the number of units of service reported on a claim for each procedure code. There is a clear differentiation between waiver services and non-waiver services and a clear audit trail exists from point of service through billing and reimbursement

Certifying Public Expenditures(select one):

Billing Validation Process. Describe the process for validating provider billings to produce the claimfor federal financial participation, including the mechanism(s) to assure that allclaims for payment are made only: (a) when the individual was eligible for Medicaidwaiver payment on the date of service; (b) when the service was included in the participant'sapproved service plan; and, (c) the services were provided:

Character Count: out of 6000

The system performs validation edits to ensure the claim is filled out correctly and contains appropriate information for processing. Edits ensure the recipients name matches the recipient identification number (RID); the HCPC code is valid for the diagnosis; the recipient is eligible and the provider is active for the dates of service; and other similar criteria are met. For electronically submitted claims, the edit process is performed several times per day. For paper claims, it is performed five (5) times per week. If a claim fails any of these edits, it is returned to the provider. Once claims pass through edits, the system reviews the claim history information against information on the current claim. Audits check for duplicate services, service limitation, and related services and compare them to Alabama Medicaid policy. The system then prices the claim using the State determined pricing methodology applied to each service by provider type, claim type, recipient benefits, or policy limitations. Once the system completes claim processing, it assigns each claim a status: approved to pay, denied, or suspended. Approved to pay and denied claims are processed through the financial cycle twice a month, at which time an Explanation of Payment (EOP) report is produced and checks are written, if applicable. Suspended claims must be worked by EDS personnel or reviewed by Alabama Medicaid Agency personnel, as required. Claims approved for payment are paid with a single check or electronic funds transfer (EFT) transaction according to the check writing schedule published by the Alabama Medicaid Agency. The check is sent to the providers payee address with an EOP, which also identifies all denied claims, pending claims, and adjustments. If the provider is enrolled in the electronic funds (EFT) transfer process, the payment is deposited directly into the providers bank account and the EOP is mailed separately to the provider.

Billing and Claims Record Maintenance Requirement.Records documenting the audit trail of adjudicated claims (including supporting documentation) aremaintained by the Medicaid agency, the operating agency (if applicable), and providers of waiver servicesfor a minimum period of 3 years as required in 45 CFR 92.42.

Method of payments -- MMIS(select one):

 Payments for all waiver services are made through an approved Medicaid Management Information System (MMIS).

 Payments for some, but not all, waiver services are made through an approved MMIS.

 Payments for waiver services are not made through an approved MMIS.

 Payments for waiver services are made by a managed care entity or entities. The managed care entity is paid a monthly capitated payment per eligible enrollee through an approved MMIS.

 not selected

Direct payment.In addition to providing that the Medicaid agency makes payments directly to providers of waiver services, payments for waiver services are made utilizing one or more of the following arrangements (select at least one):

The Medicaid agency makes payments directly and does not use a fiscal agent (comprehensive or limited) or a managed care entity or entities.

The Medicaid agency pays providers through the same fiscal agent used for the rest of the Medicaid program.

The Medicaid agency pays providers of some or all waiver services through the use of a limited fiscal agent.

Providers are paid by a managed care entity or entities for services that are included in the State's contract with the entity.

Supplemental or Enhanced Payments.Section 1902(a)(30) requires that payments for services be consistent with efficiency, economy, and quality of care. Section 1903(a)(1) provides for Federal financial participation to States for expenditures for services under an approved State plan/waiver.Specify whether supplemental or enhanced payments are made. Select one:

Payments to State or Local Government Providers.Specify whether State or local government providers receive payment for the provision of waiver services.

 No. State or local government providers do not receive payment for waiver services. Do not complete Item I-3-e.

 Yes. State or local government providers receive payment for waiver services. Complete Item I-3-e.

Specify the types of State or local government providers thatreceive payment for waiver services and the services that the Stateor local government providers furnish: Complete item I-3-e.

Character Count: out of 4000

The Alabama Department of Senior Services is the operating agencies for the E/D Waiver. The State agency provide EDW services such as: case management, personal care, homemaker, etc.

 not selected

Amount of Payment to State or Local Government Providers.

Specify whether any State or local government provider receives payments(including regular and any supplemental payments) that in the aggregateexceed its reasonable costs of providing waiver services and, if so,whether and how the State recoups the excess and returns the Federalshare of the excess to CMS on the quarterly expenditure report.Select one:

Provider Retention of Payments.Section 1903(a)(1) provides that Federal matching funds are only available for expenditures made by statesfor services under the approved waiver. Select one:

 Providers receive and retain 100 percent of the amount claimed to CMS for waiver services.

 Providers do not receive and retain 100 percent of the amount claimed to CMS for waiver services.

 Providers are paid by a managed care entity (or entities) that is paid a monthly capitated payment.

 not selected

Additional Payment Arrangements

Voluntary Reassignment of Payments to a Governmental Agency.Select one:

Specify the governmental agency (or agencies) to which reassignment may be made.

Character Count: out of 4000

ADSS

Organized Health Care Delivery System.Select one:

Specify the following: (a) the entities that are designated as an OHCDS and how theseentities qualify for designation as an OHCDS; (b) the procedures for direct provider enrollmentwhen a provider does not voluntarily agree to contract with a designated OHCDS; (c) the method(s)for assuring that participants have free choice of qualified providers when an OHCDS arrangementis employed, including the selection of providers not affiliated with the OHCDS; (d) the method(s)for assuring that providers that furnish services under contract with an OHCDS meet applicableprovider qualifications under the waiver; (e) how it is assured that OHCDS contracts with providersmeet applicable requirements; and, (f) how financial accountability is assured when an OHCDS arrangement is used:

Character Count: out of 18000

The Thirteen Area Agencies on Aging provide one or more Medicaid service and are eligible to be OHCDS. Providers may enroll directly with the Medicaid Agency if they wish. Free choice of providers is assured by the policies and procedures in effect and practices carried out are case managers. All providers are certified and monitored by Quality Assurance reviews performed ADSS or Medicaid. All subcontractors are submitted to the state for review of applicable provisions.

Contracts with MCOs, PIHPs or PAHPs.Select one:

 The State does not contract with MCOs, PIHPs or PAHPs for the provision of waiver services.

 The State contracts with a Managed Care Organization(s) (MCOs) and/or prepaid inpatient health plan(s) (PIHP) or prepaid ambulatory health plan(s) (PAHP) under the provisions of §1915(a)(1) of the Act for the delivery of waiver and other services. Participants may voluntarily elect to receive waiver and other services through such MCOs or prepaid health plans. Contracts with these health plans are on file at the State Medicaid agency.

 This waiver is a part of a concurrent §1915(b)/§1915(c) waiver. Participants are required to obtain waiver and other services through a MCO and/or prepaid inpatient health plan (PIHP) or a prepaid ambulatory health plan (PAHP). The §1915(b) waiver specifies the types of health plans that are used and how payments to these plans are made.

 not selected

State Level Source(s) of the Non-Federal Share of Computable Waiver Costs.Specify the State source or sources of the non-federal share of computable waiver costs. Select at least one:

Appropriation of State Tax Revenues to the State Medicaid agency

Appropriation of State Tax Revenues to a State Agency other than the Medicaid Agency.

If the source of the non-federal share is appropriations to another state agency (or agencies), specify:(a) the State entity or agency receiving appropriated funds and(b) the mechanism that is used to transfer the funds to theMedicaid Agency or Fiscal Agent, such as an IntergovernmentalTransfer (IGT), including any matching arrangement, and/or,indicate if the funds are directly expended by State agencies as CPEs,as indicated in Item I-2-c:

Character Count: out of 6000

The source of non-federal funds for the HCBS Waiver for the Elderly and Disabled Waiver is the general fund appropriations to ADSS. These funds are 106, general fund; 349, other funds such as federal, intergovernmental transfers, drug rebates, and other small amounts; 564, Health Care Trust Funds for provider taxes; and 1047, tobacco revenue. These funds are for the sole use of Medicaid once the appropriation is made by the Legislature. The Alabama Legislature does not line item budget any revenue or expenditure for Medicaid. In other words, no revenue comes to Medicaid earmarked for certain expenditures. It is up to Medicaid how a voucher is coded and thus charged. If Medicaid has any balance in fund 106 at the end of the year, it does not revert back to the State general fund.

Other State Level Source(s) of Funds.

Local Government or Other Source(s) of the Non-Federal Share of Computable Waiver Costs.Specify the source or sources of the non-federal share of computable waiver costs that are not from state sources. Select One:

 Not Applicable. There are no local government level sources of funds utilized as the non-federal share.

 Applicable

 not selected

Information Concerning Certain Sources of Funds.Indicate whether any of the funds listed in Items I-4-a or I-4-b that make upthe non-federal share of computable waiver costs come from the following sources:(a) health care-related taxes or fees;(b) provider-related donations; and/or,(c) federal funds.Select one:

 None of the specified sources of funds contribute to the non-federal share of computable waiver costs

 The following source(s) are used

 not selected

Services Furnished in Residential Settings.Select one:

 No services under this waiver are furnished in residential settings other than the private residence of the individual.

 As specified in Appendix C, the State furnishes waiver services in residential settings other than the personal home of the individual.

 not selected

Method for Excluding the Cost of Room and Board Furnished in Residential Settings. The following describes the methodology that the State uses to exclude Medicaid payment for room and board in residential settings:

Character Count: out of 12000

Co-Payment Requirements.Specify whether the State imposes a co-payment or similar charge upon waiver participants forwaiver services. These charges are calculated per service andhave the effect of reducing the total computable claim for federal financial participation.Select one:

 No. The State does not impose a co-payment or similar charge upon participants for waiver services.

 Yes. The State imposes a co-payment or similar charge upon participants for one or more waiver services.

 not selected

Co-Payment Requirements.

Participants Subject to Co-pay Charges for Waiver Services.

Answers provided in Appendix I-7-a indicate that you do not need to complete this section.

Co-Payment Requirements.

Amount of Co-Pay Charges forWaiver Services.

Answers provided in Appendix I-7-a indicate that you do not need to complete this section.

Co-Payment Requirements.

Cumulative Maximum Charges.

Answers provided in Appendix I-7-a indicate that you do not need to complete this section.

Other State Requirement for Cost Sharing.Specify whether the State imposes a premium, enrollment fee or similar cost sharing onwaiver participants. Select one:

Number Of Unduplicated Participants Served. Enter the total number of unduplicated participants from Item B-3-a who will be served each year that the waiver is in operation. When the waiver serves individuals under more than one level of care, specify the number of unduplicated participants for each level of care:

Average Length of Stay. Describe the basis of the estimate of the average length of stay on the waiver by participants in item J-2-a.

Character Count: out of 6000

Average length of stay is derived by dividing the total number of days in a waiver year by the total number of clients served. This information is based on data in the CMS-372 Report for year 10/01/2009-09/30/2010.

Derivation of Estimates for Each Factor. Provide a narrative description for the derivation of the estimates of the following factors.

Character Count: out of 12000

Factor D is derived from data shown by the CMS-372 Report, Waiver #0068, for Waiver Year 2010, with a 3 percent inflation factor applied to each year of the renewal period.

Character Count: out of 12000

Factor D is derived from data shown by the CMS-372 Report, Waiver #0068, for Waiver Year 2010, with a 3 percent inflation factor applied to each year of the renewal period.

Character Count: out of 12000

Factor G is derived from data shown by the CMS-372 Report, Waiver #0068, for Waiver Year 2010, with a 3 percent inflation factor applied to each year of the renewal period.

Character Count: out of 12000

Factor G is derived from data shown by the CMS-372 Report, Waiver #0068, for Waiver Year 2010, with a 3 percent inflation factor applied to each year of the renewal period.

Estimate of Factor D.

i. Non-Concurrent Waiver. Complete the following table for each waiver year.Enter data into the Unit, # Users, Avg. Units Per User, and Avg. Cost/Unit fieldsfor all the Waiver Service/Component items.Select Save and Calculate to automatically calculate and populate the Component Costs and Total Costs fields.All fields in this table must be completed in order to populate the Factor D fields in the J-1 Composite Overview table.

Estimate of Factor D.

i. Non-Concurrent Waiver. Complete the following table for each waiver year.Enter data into the Unit, # Users, Avg. Units Per User, and Avg. Cost/Unit fieldsfor all the Waiver Service/Component items.Select Save and Calculate to automatically calculate and populate the Component Costs and Total Costs fields.All fields in this table must be completed in order to populate the Factor D fields in the J-1 Composite Overview table.

Estimate of Factor D.

i. Non-Concurrent Waiver. Complete the following table for each waiver year.Enter data into the Unit, # Users, Avg. Units Per User, and Avg. Cost/Unit fieldsfor all the Waiver Service/Component items.Select Save and Calculate to automatically calculate and populate the Component Costs and Total Costs fields.All fields in this table must be completed in order to populate the Factor D fields in the J-1 Composite Overview table.

Estimate of Factor D.

i. Non-Concurrent Waiver. Complete the following table for each waiver year.Enter data into the Unit, # Users, Avg. Units Per User, and Avg. Cost/Unit fieldsfor all the Waiver Service/Component items.Select Save and Calculate to automatically calculate and populate the Component Costs and Total Costs fields.All fields in this table must be completed in order to populate the Factor D fields in the J-1 Composite Overview table.

Estimate of Factor D.

i. Non-Concurrent Waiver. Complete the following table for each waiver year.Enter data into the Unit, # Users, Avg. Units Per User, and Avg. Cost/Unit fieldsfor all the Waiver Service/Component items.Select Save and Calculate to automatically calculate and populate the Component Costs and Total Costs fields.All fields in this table must be completed in order to populate the Factor D fields in the J-1 Composite Overview table.