Application for 1915(c) HCBS Waiver: MO.0026.R07.00

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 Individuals with Intellectual Disabilities (ICF/IID) (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/IID.

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-basedwaiver 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

Comments and recommendations are obtained from/through the Missouri Alliance for Home Care, Missouri Council for In-Home Services, the Department of Health and Senior Services' Board of Senior Services, and participant feedback through Division of Senior and Disability Services' and DSDS Bureau of Home and Community Services field staff.

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).

 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

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

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

• Uniformity of development/execution of provider agreements throughout all geographic areas covered by the waiver
• Equitable distribution of waiver openings in all geographic areas covered by the waiver
• Compliance with HCB settings requirements and other new regulatory components (for waiver actions submitted on or after March 17, 2014)

Where possible, include numerator/denominator.

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

Issues which require individual remediation may come to MHDs attention through review of DSDS reports, as well as through day-to-day activities of the MO HealthNet Division, e.g., review/approval of provider agreements, utilization review and quality Review processes, complaints from MO HealthNet recipients related to waiver participation/operation by phone or letter, etc. MHD addresses individual problems related to delegated functions as they are discovered by contacting DSDS and advising them of the problem. A follow-up memo or email is sent from MHD to DSDS identifying the problem and if appropriate a corrective action resolution. While some issues may need to be addressed immediately DSDS is required to provide a written response to MHD that specifically addressed the problem identified by MHD. Written documentation will be maintained by both MHD and DSDS and as needed discussions will be included at the quarterly meeting. Any trends or patterns will be discussed and resolved as appropriate. Individual problems that are part of the report process will be included in the appropriate reports.

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 one or more groups 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 or more waiver target groups, check each of the subgroups in the selected target group(s) 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

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

Physically disabled participants reaching the age of 65 remain eligible for services through the Aged and Disabled Waiver as a result of the "Aged" category.

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):

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

It is the states intent to have adequate slots to allow all eligible participants to enroll in the waiver. Should this waiver ever require a waiting list the state will enroll participants based on the date of their 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

Elect to serve all other mandatory and optional groups covered in State Plan.

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.

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

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

The State uses more restrictive eligibility requirements than SSI and uses the post-eligibility rules at 42 CFR 435.735. Payment for home and community-based waiver services is reduced by the amount remaining after deducting the following amounts 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 state uses the following dollar amount $1,241. For each subsequent year for the duration of the waiver period, the special income level will be increased by a percentage equal to the social security cost of living adjustment. These increases will be effective January of the applicable year.

 Other

 not selected

Allowance for the spouse only (select one):

 Not Applicable (see instructions)

 The following standard under 42 CFR §435.121

Specify:

Character Count: out of 6000

The Federal Benefit Rate.

 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:

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 participant's 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

 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

Division of Senior and Disability Services staff, at a minimum, meet the following experience and educational requirements. One or more years of experience as an Adult Protective and Community Worker I, Social Service Worker I, or children's Service Worker I with the Missouri Uniform Classification and Pay System; OR a Bachelor's degree from an accredited college or university in Social Work, Psychology, Sociology, Gerontology, Nursing, Health Care Administration, Education, Counseling, Criminal Justice, or closely related social or behavioral sciences. Position definition of those performing the initial evaluations are as followed: Adult Protective and Community Worker 1(formerly SSW I): This is entry-level professional social service work in the Department of Health and Senior Services providing protective services and/or coordinating in-home services on behalf of senior and/or disabled adults. Children’s Service Worker 1(formerly SSW I): This is entry-level professional social service work in the Children's Division of the Department of Social Services providing protective services on behalf of children and families in instances of abuse, neglect, or exploitation.

Character Count: out of 12000

In order to be eligible for entry to the Aged and Disabled Waiver, individuals must meet nursing facility level of care as specified in state regulation at 19 CSR 30-81.030. Points are assigned based on the degree of human assistance needed by the individual (or the frequency of physician's ordered care) in nine categories that explore areas of daily living. The categories are: (1) Monitoring: the amount of medical oversight needed to remain independent. (2) Medications: the ability to administer medicine and difficulty of drug regime. (3) Treatments: physician ordered medical procedure(s)intended to treat a specific medical condition. (4) Restorative: teaching and/or training activities designed to maintain or restore a person to a higher level of functioning. (5) Rehabilitative: physician ordered rehabilitation therapy (speech, occupational, physical) - points are based on frequency of services. (6) Personal Care: bowel or bladder problems or the ability to bathe, shampoo, etc. (7) Dietary: the degree of specialized diet or the ability to prepare and eat meals. (8) Mobility: the ability to move from place to place. (9) Behavior: any problems associated with orientation, memory recall, and judgment. Scoring Methodology: any combination of 21 points qualifies an individual to receive Aged and Disabled Waiver services. Points are assigned in each of the nine categories in three point increments: 0 points: assigned if the individual requires no assistance, is independent, does not have the treatment/therapy/problem, etc. 3 points: assigned if problems are identified: personal oversight or management is required; minimum numbers of treatments/therapies/medications are ordered. 6 points: assigned if problems are moderate; daily or regular human assistance is required; moderate frequency of treatments/therapies ordered by a physician. 9 points: assigned when maximum physical/medical problems require total human assistance. Waiver applicants are initially evaluated for waiver services through the use of a prescreen process. Potential waiver participants will be screened based on the nine level of care categories outlined in B-6 d. Participant information gathered during the prescreen process will be data entered into the web-based system and behind the scenes the level of care will be calculated to determine if the participant meets the criteria for level of care eligibility. Once level of care eligibility is initially determined, a home visit will be scheduled to complete the InterRAI HC. The InterRAI HC will confirm or deny the prescreen level of care determination through the use of behind the scenes decision tree algorithms based on the nine categories outlined in B-6 d. Reevaluations of level of care will utilize the InterRAI HC © with the same algorithms determining continued level of care eligibility utilizing the same nine categories in B-6 d. The InterRAI HC has been designed to be a user-friendly, reliable person-centered assessment system that informs and guides comprehensive care and service planning in community-based settings around the world. It focuses on the person's functioning and quality of life by assessing needs, strengths, and preferences. It also facilitates referrals when appropriate. When used on multiple occasions, it provides the basis for an outcome-based assessment of the persons response to care or services. The interRAI HC can be used to assess persons with chronic needs for care, as well as with post-acute care needs (e.g., after hospitalization or in a hospital at home situation). The interRAI HC has been designed to be compatible with the suite of interRAI assessment and problem identification tools. Such compatibility advances continuity of care through a seamless assessment system across multiple health care settings, and promotes a person-centered evaluation rather than fragmented site-specific assessments. The Home Care assessment system, or HC, was developed to provide a common language for assessing the health status and care needs of frail elderly and disabled individuals living in the community. The system was designed to be compatible with the Long Term Care Facility system that was implemented in US nursing homes in 1990-91. Target Population The HC was developed for use with adults in home and community-based settings. The instrument is generally used with the frail elderly or persons with disabilities who may or may not be receiving formal health care or supportive services. The HC was designed to highlight issues related to functioning and quality of life for community-residing individuals. Information is gathered in the following domains:Identification InformationIntake and Initial HistoryCognitionCommunication and VisionMood and BehaviorPsychosocial Well-BeingFunctional StatusContinenceDisease DiagnosesHealth ConditionOral and Nutritional StatusSkin ConditionMedicationsTreatment and ProceduresResponsibilitySocial SupportsEnvironmental AssessmentDischarge Potential and Overall StatusDischargeAssessment Information

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.

Describe how and why this instrument differs from the form used to evaluate institutional level of care and explain how the outcome of the determination is reliable, valid, and fully comparable.

Character Count: out of 12000

The difference (other than lay-out/format) between the level of care determination tools utilized for determining eligibility for nursing facility admission and waiver services is additional information is obtained to assist in service plan development. Both tools use the same scoring methodology described in Appendix B-6-d. The nine categories and scoring methodology are established in the state nursing home regulation. As both tools utilize the same categories and scoring methodology based on the same state regulation, the outcomes from the DSDS level of care instruments are reliable, valid, and fully comparable to the nursing facility level of care instrument.

 not selected

Character Count: out of 12000

An interview is scheduled with a potential waiver participant by a qualified individual as specified in B-6-c. Initial evaluations are conducted face-to-face at the participant’s residence and reevaluations are usually conducted face-to-face but may be performed by phone by DSDS staff. Sufficient information is obtained during this interview to complete the LOC evaluation utilizing the HCBS Web Tool as described in the administrative section of the application. Potential waiver applicants will initially be evaluated for waiver services through the use of a prescreen process. Potential waiver participants will be screened based on the nine level of care categories outlined in B-6-d. Participant information gathered during the prescreen process will be data entered into the HCBS Web Tool system and behind the scenes the level of care will be calculated to determine if the participant meets the criteria for level of care eligibility. Once level of care eligibility is initially determined, an interview will be scheduled to complete the InterRAI HC©. The InterRAI HC will confirm or deny the prescreen level of care determination through the use of behind the scenes decision tree algorithms based on the nine categories outlined in B-6-d. Reevaluations of level of care will utilize the InterRAI HC © with the same algorithms determining continued level of care eligibility utilizing the same nine categories in B-6-d. The HCBS Web Tool requires LOC reassessments be completed within 365 days of the initial assessment or the last reassessment. Within the HCBS Web Tool the service plan and prior authorization are tied to a current assessment. This design will ensure that services are not reimbursed unless there is a current assessment. In addition to the DSDS State staff, waiver providers may complete the InterRAI HC© reassessment. The actual LOC determination will be made by the State, based on the information in the InterRAI HC©. The DSDS Regional Mangers will be notified 60 days prior to the date the reassessments are due to allow adequate time to schedule a reassessment with the participant to complete the InterRAI©. Regional Managers will be responsible for assigning the reassessments and monitoring this report on a monthly basis to ensure all reassessments are completed within 365 days of the last assessment. In addition DSDS Central Office staff will monitor reassessment reports to ensure they are completed within required timeframes. Should a backlog develop as we move forward the state will address it through remediation based on the specific issue. The State has taken action to prevent overdue reassessment through system design and change. The State feels timely reassessments have been addressed in a manner that will prevent overdue reassessments as we move forward in the HCBS Web Tool. Should there be any overdue reassessments due to state staff, the error will be addressed and remediated on an individual basis. Participant services will not be impacted due to any state issue with reassessments. Overdue reassessments as a result of a participants unavailability will be handled based on the individual situation of the participant (i.e., hospitalization; nursing home; out of state visiting family, etc.). Services may not resume until the participant receives a reassessment. Waiver services for individuals who refuse a reassessment will be terminated and the participant will receive a fair hearing notice. The provider’s aides are required to report to their supervisor when the care needs of the participant changes. The providers, in turn, are required to report to DSDS anytime there is a change in the participant’s needs. DSDS then has further discussion with the participant to discuss any potential care plan changes. Also, during provider nurse visits, the nurse goes over the care plan to assure the adequacy of the care plan. Pursuant to state statute, at any time the provider owner, operator, or any employee is aware of, or suspects any abuse, neglect, or exploitation has occurred, the provider is required to immediately report that information to the Department of Health and Senior Services’ Central Registry Unit (CRU) for further investigation. In addition, DSDS conducts, no less than annually, case record reviews on a statistically valid sample of waiver participants. This includes reviewing the care plan and all supporting documentation in that participant's case record. Direct care staff must be at least eighteen (18) years of age; be able to read, write and follow directions; and have at least six (6) months paid work experience as an agency homemaker, nurse aide, maid or household worker - or - at least one (1) years experience, paid or unpaid, in caring for children or for sick or aged individuals - or successful completion of formal training in nursing arts or as a nurse aide or home health aide. Twenty (20) hours of orientation training must be provided within the first 30 days of employment.

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

DSDS Regional staff receive a report of participants, 60 days prior to the date the reassessments are due, to allow adequate time to schedule a reassessment with the participant to complete the InterRAI©. Regional Managers will be responsible for assigning the reassessments and monitoring this report on a monthly basis to ensure all reassessments are completed within 365 days of the last assessment. In addition, DSDS Central Office staff will monitor reassessment reports to ensure they are completed within required timeframes. The department secured Fiscal Year 2013 funding totaling $3 million for providers to conduct reassessments of clients who receive Medicaid Home and Community Based Services (HCBS). Three million dollars was also requested for Fiscal Year 2014 for the same purpose. Reassessments for level of care of current participants are scheduled for completion based upon the anniversary date of the last assessment. Department staff review and approve all reassessments submitted by HCBS providers. The uptake of HCBS providers in conducting reassessments has been slower than anticipated. Full participation of HCBS providers is critical to meeting the revised goal of having all client reassessments current by the close of Fiscal Year 2014.

Character Count: out of 6000

Per 42 CFR §441.303(c)(3), DSDS assures that written and/or electronically retrievable documentation of all evaluations and reevaluations are maintained for a minimum period of 3 years as required in 45 CFR §92.42. Records regarding the evaluation/reevaluation are maintained in the HCBS Web Tool system, a component of MO HealthNet Divisions' CyberAccess

The state demonstrates that it implements the processes and instrument(s) specified in its approved waiver for evaluating/reevaluating an applicant's/waiver participant's level of care consistent with level of care provided in a hospital, NF or ICF/IID.

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 the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

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 the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

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 the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

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

When an error is discovered during a DSDS case record review or one is identified in a DSDS report, a DSDS supervisor reviews the error, and works with the worker who completed the assessment to appropriately address the error. The worker then documents the action taken. The DSDS supervisor reviews the action taken by the worker to correct the error. General methods of remediation may include: performing a LOC evaluation for those that were not done or re-training staff, discussions during area and regional meetings and/or change in Division policy or procedure.

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

At the initial evaluation qualified individuals as specified in B-6-c explain to the potential waiver participant the services that can be provided through the Aged and Disabled Waiver. Individuals can then make an informed choice between receiving services through a nursing facility or the Home and Community-Based Services, state plan and/or waiver. The form that documents participant choice is the Home and Community Based Services Care Plan and Participant Choice Statement. Individuals are required to document his/her choice via a dated signature on the form, which is also signed and dated by the individual performing the assessment. Per 45 CFR §92.42, written copies or electronically retrievable facsimiles of Freedom of Choice forms are maintained for a minimum of three years in the HCBS web-based system. Copies are maintained in the HCBS web-based system or the DSDS case record until such time the participant is in the HCBS web-based system. Participants are also provided with a signed copy.

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

At the initial evaluation qualified individuals as specified in B-6-c explain to the potential waiver participant the services that can be provided through the Aged and Disabled Waiver. Individuals can then make an informed choice between receiving services through a nursing facility or the Home and Community-Based Services, state plan and/or waiver. The form that documents participant choice is the Home and Community Based Services Care Plan and Participant Choice Statement. Individuals are required to document his/her choice via a dated signature on the form, which is also signed and dated by the individual performing the assessment. Per 45 CFR §92.42, written copies or electronically retrievable facsimiles of Freedom of Choice forms are maintained for a minimum of three years in the HCBS Web-based system. Copies are maintained in the HCBS web-based system or the DSDS case record until such time the participant is in the HCBS web-based system. Participants are also provided with a signed copy.

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

Waiver providers are required to perform criminal/background investigations on staff that provide direct care to Waiver eligible individuals prior to employment. Providers request these investigations through the Missouri Department of Health and Senior Services, Family Care Safety Registry. The Registry helps to protect Waiver eligible individuals by compiling and providing access to background information. The Registry accesses the following background information from Missouri data only and through the following cooperating state agencies: 1) State criminal background records maintained by the Missouri State Highway Patrol 2) Sex Offender Registry information maintained by the Missouri State Highway Patrol 3) Child abuse/neglect records maintained by the Missouri Department of Social Services 4) The Employee Disqualification List maintained by the Missouri Department of Health and Senior Services 5) The Employee Disqualification Registry maintained by the Missouri Department of Mental Health 6) Child-Care facility licensing records maintained by the Missouri Department of Health and Senior Services 7) Foster parent licensing records maintained by the Missouri Department of Social Services Criminal background checks may also be submitted directly to the MO State Highway Patrol. Missouri Medicaid Audit & Compliance (MMAC) and Division of Registration and Licensure (DRL) are responsible for monitoring providers to assure that background investigations are conducted as required by statute and regulation. This monitoring will be conducted during regular monitoring visits, requested technical assistance visits and complaint investigations. Monitoring providers for compliance will be conducted during regular monitoring visits and complaint investigations. DRL staff verify, annually, during the state inspection that the facility conducts criminal background checks (CBC). MMAC verifies every three years during the post payment review. ADC Waiver providers are required to perform abuse registry screening on all staff employed by the agency.

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

Specify: (a) the entity (entities) responsible for maintaining the abuse registry; (b) the types of positions for which abuse registry screenings must be conducted; and, (c) the process for ensuring that mandatory screenings have been conducted. State laws, regulations and policies referenced in this description are available to CMS upon request through the Medicaid agency or the operating agency (if applicable):

Character Count: out of 12000

Aged and Disabled Waiver Providers are required to perform abuse registry screening on all staff employed by the agency. ADW Home Delivered Meal Providers are required to perform abuse registry screening on all staff that will provide direct services to waiver participants. Any potential employee listed on the DHSS Employee Disqualiafication List (EDL) is deemed ineligible for employment. The EDL is maintained by the Department of Health and Senior Services. Screenings against the EDL can be handled through the Family Care Safety Registry (explained in C-2-a). DSDS Quality Assurance Specialist and the Bureau of Senior Programs are responsible for monitoring the providers to assure that EDL screenings are conducted as required by statute and regulation. This monitoring will be conducted during regular monitoring visits, requested technical assistance visits and complaint investigations.

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

State adult day care licensure laws do not restrict relatives or legal guardians from the provision of adult day care services to relatives as long as services are provided in accordance with state licensure laws governing adult day care and the individual meets all provider qualification. This includes owner/operator and/or employees of the adult day care facility were a waiver participant receives waiver adult day care services.

 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

Interested providers contact Missouri Medicaid Audit & Compliance, Provider Enrollment Unit. Any provider who meets provider qualifications is allowed to enroll. Specific criteria regarding programs and provider enrollment requirements are available to all individuals through MMAC at http://mmac.mo.gov. There are several statewide Associations for the home and community-based services industry which provide additional information to association members regarding provider enrollment information. There are no timeframes for provider enrollment. Open enrollment is ongoing throughout the year. Providers may contact the MO HealthNet Provider Enrollment Unit for information on how to enroll. Enrollment timeframes vary and are dependent upon the volume of requests for enrollment being processed by the Missouri Medicaid Audit and Compliance (MMAC) Provider Enrollment Unit.

The state demonstrates that it has designed and implemented an adequate system for assuring that all waiver services are provided by 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 the State will use to assess compliance with the statutory assurance, complete the following. Where possible, include numerator/denominator.

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 the State will use to assess compliance with the statutory assurance, complete the following. Where possible, include numerator/denominator.

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 the State will use to assess compliance with the statutory assurance, complete the following. Where possible, include numerator/denominator.

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

Missouri Medicaid Audit and Compliance (MMAC) notifies the provider in writing immediately when problems are discovered. MMAC forwards a copy of the notification letter to MHD and DHSS when actions are taken against a provider. Remediation may include recoupment of provider payments or termination of provider enrollment. MMAC monitors the provider for compliance. Information is provided to MHD and DHSS regarding the problems identified, remediation actions required and changes made by the provider to come into compliance. This information is tracked and trended to ensure problems are corrected. As required by Section 660.403, RSMo, the Missouri Department of Health and Senior Services conducts the onsite inspections needed to license ADC programs to ensure that they meet the minimum standards for insuring the health and safety of the participants. The Section for Long Term Care Regulation is divided into seven regional offices, where inspectors are employed to inspect ADC programs. When an individual Adult Day Care is found out of compliance with a state regulation for Adult Day Care programs, the program director/designee is informed that he/she will receive a letter and a Statement of Deficiencies from the regional office within ten (10) working days of the Exit Conference. The letter that accompanies the Statement of Deficiencies (SOD) outlines the outcome of the inspection and requests the director submit a plan of correction (POC) including time frames of that action. DHSS staff will review the POC to ensure it will be sufficient to correct the citation and prevent future reoccurrence.

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.

Description of the settings and how they meet federal HCB Settings requirements, atthe time of submission and in the future.

Description of the means by which the state Medicaid agency ascertains that all waiversettings meet federal HCB Setting requirements, at the time of this submission and ongoing.

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).

Social Worker

Other

Character Count: out of 6000

Division of Senior and Disability Services staff, at a minimum, meet the following experience and educational requirements. One or more years of experience as an Adult Protective and Community Worker I, Social Service Worker I, or children's Service Worker I with the Missouri Uniform Classification and Pay System; OR a Bachelor's degree from an accredited college or university in Social Work, Psychology, Sociology, Gerontology, Nursing, Health Care Administration, Education, Counseling, Criminal Justice, or closely related social or behavioral sciences. Position definition of those performing the initial evaluations are as followed: Adult Protective and Community Worker 1(formerly SSW I): This is entry-level professional social service work in the Department of Health and Senior Services providing protective services and/or coordinating in-home services on behalf of senior and/or disabled adults. Children’s Service Worker 1(formerly SSW I): This is entry-level professional social service work in the Children's Division of the Department of Social Services providing protective services on behalf of children and families in instances of abuse, neglect, or exploitation.

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

Qualified individuals who perform the assessment will review the list of available HCBS Services (both state plan and waiver services) with each potential applicant. The HCBS Web Tool provides all users a comprehensive definition of each HCBS service which can then be provided to the potential participant and others involved in the development of the care plan. The participant signs the completed plan to indicate his/her participation in the development of, and agreement with, the care plan. The signed document also provides a phone number of the appropriate DSDS Regional Evaluation Team for the participant to utilize when changes in circumstances that may affect the care plan occur. Discussions are then held with the participant to determine if care plan changes are necessary. DSDS recognizes that participants and other individuals are an integral part of the service planning process. The participant is informed by qualified staff specified in D-1-a that s/he may elect to include anyone s/he wants to contribute to the discussions and the actual plan. Prior to initiation of the service plan development, services available through the Aged and Disabled Waiver are discussed with the participant and his/her invitees. Participant rights and responsibilities are discussed with the participant along with the appeal process.

Character Count: out of 24000

(a) The care plan is developed at the time of the assessment or reassessment with the participant and anyone they choose. The individual performing the assessment contacts the participant to schedule an appointment convenient for the participant. This process allows the participant to have anyone they choose there during the care planning process. The care plan is updated when DSDS staff is contacted by the provider or participant that there has been a change in the participant’s circumstances or needs. (b) The InterRAI HC is a comprehensive internationally recognized home care assessment that supports service plan development including the needs, preferences, goals, risks, and health status of the participant. (c) The services available through the Aged and Disabled Waiver are described/explained to the participant and other attendees during the assessment and service plan development process. The actual provider is selected through the participant's choice and provider availability. (d) During the comprehensive assessment, the goals, needs, and preferences of the participant are identified and addressed in the service plan. The InterRAI HC is comprehensive assessment tool which not only determines the Level of Care of the individual, but looks at the participant risks and strengths as related to community living. Although necessary at times, independent contact with other individuals shall not compromise the rights and preferences of the participants. If additional information gathered during the design of a service plan creates a discrepancy with the expressed wishes of a participant, additional discussions and documentation shall take place. Additional medical issues may be identified that require the participants to be informed of any potential barriers, which will prompt additional discussion about how to address these issues. Appropriate referrals are made to other resources necessary to assist the participant in achieving optimal independence. When the participant receives services from other agencies, coordination of services to assure continuity of care without duplication of services may be necessary. DSDS staff and the waiver provider will assist participants in the implementation of services authorized or other areas identified within the service plan. (e) DSDS staff, the waiver provider staff, and the participant coordinate the implementation of the service plan, including non-waiver services. (f) DSDS staff, the participant, and the waiver provider are responsible for implementation and compliance with the service plan. The right of self-determination shall necessitate the individual's participation and approval of the service plan. (g) Service plans are reviewed by qualified individuals as warranted, but no less than annually.

Character Count: out of 12000

During the assessment, evaluation and care planning process risks are assessed such as: identifying support systems or lack thereof, and confusion factors. Once the assessment/evaluation process identifies possible risk factors and needs, a determination is made as to whether or not these factors will be alleviated through service planning, or if referrals should be made to and coordinated with other community supports. These needs are noted on the HCBS Care Plan and Participant Choice Statement (DA-3) in order to document what actions are taken to mitigate any risk problems. During the assessment process, participants are made aware of the need to have in place back-up plans to address contingencies such as emergencies, natural or man-made disasters, failure of the waiver provider staff to show up as scheduled, etc. Types of back-up arrangements that could be utilized are discussed and identified with the participant and documented on the assessment tool, which is a companion document to other service planning documents. These arrangements could include but are not limited to: awareness of emergency contact number for the waiver provider, contact names/phone numbers of individuals that could be reached 24/7, listing of family members or others that are willing/ready to act as back-up aides or assist participant in various ways, arrangements with someone to check on participants on an at least daily basis, and registration with utility companies to ensure utilities are returned to service quickly, if necessary. Waiver participants are also advised of the "Ready in 3" portion of the Department's website (http://health.mo.gov/emergencies/ert/index.php). Endorsed by the American Red Cross and the State Emergency Management Agency, the "Ready in 3" information focuses on 3 steps that participants can take to prepare for many kinds of emergencies: 1) create a plan, 2) prepare a kit, and 3) Listen for information. Additionally all qualified providers are subject to universal reporting of abuse, neglect, or exploitation. Missouri statute also includes specific language in certain sections that mandate various entities to report abuse, neglect, or exploitation. When abuse, neglect, or exploitation indicators are noted during assessment/evaluation process, a report is to be made to the DHSS Central Registry Unit as outlined in G-1 b. Response to the report is further defined in G-1 d. Strategies to mitigate identified risk of abuse, neglect, or exploitation to the participant are discussed with the participant by DSDS staff and developed within a protective service plan as outlined in G-1 e.

Character Count: out of 6000

A list of eligible providers is reviewed with the participant during the initial service planning process. Participants may choose the provider they want from this list. Participants can also access a MO HealthNet Provider Search function on the DSS/MHD website (www.dss.mo.gov). Participant choice is documented on the care plan by the participant's signature. A copy of the statement documenting participant choice is maintained in the HCBS Web-based system. A list of all qualified providers is available to the participant upon request at reassessment, or any time they request a provider change. New providers are added to the provider list on a continuous and ongoing basis.

Character Count: out of 6000

DSDS staff develop the initial service plan and review the service plan no less than annually. A change to the service plan may be requested by anyone including the participant when there is a change in the participants needs however all service plan changes are subject to the review and approval of DSDS staff and include discussion with the participant. Additionally DSDS staff complete a statistically valid number of record reviews no less than annually on an ongoing basis to assure service plans are completed in accordance with waiver policies and procedures. Reports are produced and sent to MHD no less than annually which document the outcome of the reviews. MHD will review the report no less than annually. Supporting documentation will be available to MHD upon request. At any time, MHD may conduct a record review of the service plan by accessing the HCBS Web Tool. However, making the service plan subject to the approval of the state Medicaid agency (MHD) will normally be through reports generated by DSDS to negate the need for redundancy and duplication of efforts related to record reviews.

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

a) DSDS staff are responsible for monitoring and assuring the implementation of the service plan. (b) DSDS contact new waiver participants within 10 days of the prior authorization date to ensure that the services have begun and meet the participant's needs. The waiver provider is required to ensure prompt initiation of authorized services, not to exceed seven (7) days of the prior authorization date. When services are not initiated within the required time, the provider reports this information to DSDS. In addition to the 10 day follow-up by DSDS the waiver provider is required to monitor, at least monthly, the provision of services to ensure services are being delivered in accordance with the care plan. DSDS staff are to be contacted immediately regarding any critical issues identified during the monitoring. Service plan changes could be initiated as a result of these evaluations of the participant's status and service plan. Participants are advised of their right of provider choice, if service provision is an issue with the participant. (c) At least annually, direct contact is made with the participant. Information discussed and provided to participants annually during the assessment and reassessment process includes the following statement: "I agree to notify DSDS staff at ____________ (Regional Evaluation Team) any time there is a change in my circumstances that may affect the person centered care plan, when I am not satisfied with the services or treatment I received from the provider, I want to change providers, or when I have any unresolved issues with the aide." Once this is discussed with the participants and or their guardian, they acknowledge they understand by initialing this statement and signing the form. No less than annually DSDS conducts case record reviews on a statistically valid sample of participants to identify any issues related to the waiver assurances and sub-assurances including level of care, plan of care (including non-waiver referrals and supports), health and welfare, and provider choice. No less than annually DSDS will provide the Medicaid agency with reports related to the performance measures as specified in the quality section of Appendix D. The effectiveness of the back-up plan is reviewed with the participant as needed but no less than annually. The following requirements are applicable to all ADW participants regardless of the date of the last reassessment. The provider’s aides are required to report to their supervisor when the care needs of the participant changes. The providers, in turn, are required to report to DSDS anytime there is a change in the participant’s needs. DSDS then has further discussion with the participant to discuss any potential care plan changes. Also, during provider nurse visits, the nurse goes over the care plan to assure the adequacy of the care plan. Pursuant to state statute, at any time the provider owner, operator, or any employee is aware of, or suspects any abuse, neglect, or exploitation has occurred, the provider is required to immediately report that information to the Department of Health and Senior Services’ Central Registry Unit (CRU) for further investigation. In addition, DSDS conducts, no less than annually, case record reviews on a statistically valid sample of waiver participants. This includes reviewing the care plan and all supporting documentation in that participant's case record.

The state demonstrates it has designed and implemented an effective system for reviewing the adequacy of service plans for waiver participants.

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 the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

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 the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

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 the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

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 the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

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 the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

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

When an error is discovered during a DSDS case record review or one is identified in a DSDS report, a DSDS supervisor reviews the error, and works with the appropriate worker to address the error. The worker then documents the action taken. The DSDS supervisor reviews the action taken by worker to correct the error. General methods of remediation may include: service plan revisions, re-training staff, discussions during area and regional meetings and/or change in Division policy or procedure. If it is determined during the case record review that waiver services were not provided in accordance with the service plan, DSDS will request information from the provider as to why the services were not provided as specified in the care plan. General methods of remediation may include: provider training, service plan changes and, or a formal letter to the provider requiring a corrective action plan to ensure services are provided in accordance with the care plan.

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

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

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

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

Critical incidents include abuse (physical, sexual, or emotional; exploitation; and misappropriation of funds/property) and neglect (self, or by others). Missouri statutes include a universal mandated reporting, stating that any person having reasonable cause to suspect that an eligible adult is experiencing abuse or neglect and in need of protective services shall report such information to the Department of Health and Senior Services (DHSS). This universal mandate has no statutory penalties for not reporting and contains no immunity for those who do report. (660.255, RSMo) Missouri statutes also include specific language in certain sections that mandate various entities to report possible abuse and/or neglect or cause a report of possible abuse and/or neglect to be made to DHSS. The entities that are mandated to report are: adult day care worker; chiropractor; Christian Science practitioner; coroner; dentist; embalmer; employee of the Departments of Social Services, Mental Health, or Health and Senior Services; employee of a local area agency on aging or an organized area agency on aging program; funeral director; home health agency or home health agency employee; hospital and clinic personnel engaged in examination, care, or treatment of persons; in-home services owner, provider, operator, or employee; law enforcement officer; long-term care facility administrator or employee; medical examiner; medical resident or intern; mental health professional; minister; nurse; nurse practitioner; optometrist; other health practitioner; peace officer; pharmacist; physical therapist; physician; physician's assistant; podiatrist; probation or parole officer; psychologist; consumer-directed services provider (this covers IL Waiver providers); personal care attendant; or social worker. When any of these entities has reasonable cause to believe that a participant has been abused or neglected they are to immediately report or cause a report to be made to the department. These mandated reporters who fail to report or cause a report to be made to DHSS immediately after the act of abuse or neglect are guilty of a Class A misdemeanor (198.070 and 660.300, RSMo). The methods of reporting include calling DHSS staff or the Central Registry Unit 800# (this number is promoted on DHSS public information, brochure, posters, and website), written correspondence with DHSS or through the 'Ask Us' function on DHSS' website. All reports are logged in the Mo CaseCompass system, regardless of the method utilized to report, in order to track all reports.

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

DSDS and waiver providers provide participants with information (verbally and in written format) about reporting policy and procedures for incidents at the time of enrollment, annually, and any time the waiver participant perceives that his/her rights and/or responsibilities have been violated. DHSS staff, DSDS, and its designee, etc., instruct the waiver participant, legally responsible parties, and any informal caregivers about the types of critical incidents and all the methods/options for reporting incidents of abuse, neglect, or exploitation to DHSS. The 'Home and Community Based Services Care Plan and Participant Choice Statement' document that participants sign includes the sentence, "I understand I can call the toll-free hotline at 1-800-392-0210 to report abuse, neglect, or exploitation." This document is gone over thoroughly with waiver participants at time of entry into the waiver and at least annually thereafter.

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 Department of Health and Senior Services (DHSS) is the mandated adult protective services agency in Missouri. Statute 660.260, RSMo defines the investigatory authority of DHSS as limited to eligible adults with a protective service need. DHSS/DSDS staff shall investigate and offer protective services to all eligible adults when deemed appropriate. This shall include: 1) adults age 60 years or older who are unable to protect their own interests or adequately perform or obtain services which are necessary to meet their essential human needs, and 2) adults with disabilities between the ages of 18 and 59 who are unable to protect their own interests or adequately perform or obtain services which are necessary to meet their essential human needs. Reports may be received that would not fall within the scope of DHSS' authority but may be appropriately referred to another agency for assistance. All reports are registered by DSDS Home and Community Services or Central Registry Unit (CRU) staff into the states reporting data base system, Mo CaseCompass. The following is applicable to waiver participants receiving services in their own home: Preliminary classification of reports is based on information received from the reporter at the point of intake. Classification is based on the level of harm or risk to the reported adult, combined with the reported need to gather evidence. Class 1 reports contain allegations, which if true, present either an imminent danger to the health, safety, or welfare of an eligible adult or a substantial probability that death or serious physical harm will result. Class I reports involve situations of a crisis or acute nature which are currently occurring and require immediate intervention and/or investigation to gather critical evidence. (Reporters are directed to contact the local law enforcement agency on reports involving allegations of homicide or suicidal threats). Class II reports contain allegations of some form of abuse, neglect, or exploitation of an eligible adult but do not allege or imply a substantial probability of immediate harm or danger. Situations described in a Class II report do not require an immediate response, but must be initiated within set timeframes. DHSS staff are responsible for the investigative process. Mo CaseCompass develops a baseline investigation plan to which the investigator can add additional activities/tasks as appropriate to each case and is completed in the Mo CaseCompass system. Depending on the report, the investigation plan may include a combination of Activities/Tasks to address: 1) Review of the report and conducting background checks of the subjects of the report. 2) Development of an investigative plan, outlining the actions to be taken in accordance with the reported information. The investigative plan will include the assessed need to involve medical professionals; the order of the interviews to be conducted, i.e., reporter, reported adult, witnesses and the alleged perpetrator; determination of which records or documents need to be obtained to (dis)prove the allegations in the report; evidence suggested in the report to be immediately obtainable which will assist in (dis)proving the allegations and determination of which agency or entity (if any) that needs to be contacted to co-investigate or provide support. 3) A thorough investigation is conducted obtaining all information necessary to determine whether the alleged abuse, neglect or exploitation actually occurred (or is occurring). The information is gathered and memorialized through documentation to properly preserve the evidence. 4) Evaluation, analysis, organizing and reviewing the information to determine if legal intervention or protective services is warranted. This shall include further follow-up and resolution when there are discrepancies or inconsistencies, evaluating the risk of harm or injury to the reported adult and assessing the capacity of the reported adult and providing necessary interventions. 5) Completion of a summary and determining the investigative conclusion according to the information obtained during the investigation. This will include recording all contacts and activities related to the investigation in the case record. It will also include submitting a copy of the investigation and findings to the local police and local prosecutor when the information gathered substantiates the allegation. A copy of the report is also sent to the DHSS Employee Disqualification List staff when a referral to this list warrants consideration. 6) Policy requires that investigations are conducted and completed and findings/results entered into the Mo CaseCompass system within a sixty (60) day period. Class I reports are to be forwarded to investigative staff immediately; Class II reports are to be forwarded within 3 hours of receipt. In response to Class I reports, a face-to-face must be made as soon as necessary or possible with the 24 hours following receipt of a report to ensure the safety and well being of a reported adult. The 24-hour period will begin at the time the information was received by DSDS. Investigations of Class II reports shall be initiated within a period not to exceed 48 hours after receipt of the report or by close of business the first working day after a weekend or holiday. Investigators shall conduct a face-to-face interview as soon as possible within a period not to exceed 7 calendar days from the receipt of the report. A waiver participant for whom an investigation is being conducted is involved in the investigation and the subsequent intervention process or plan on an ongoing basis. State statutes specifically, 660.263, 660.320 and 660.321, RSMo prohibit DHSS from disclosing the investigative results/reports to anyone other than the participant/legal representative upon request, the Attorney General's office to perform that office's constitutional or statutory duties, the Department of Mental Health for residents placed through that Department to perform its constitutional or statutory duties, the appropriate law enforcement agency to perform its constitutional or statutory duties, or the Department of Social Services for individuals who receive MHD benefits to perform its constitutional or statutory duties. During the initial visit all DSDS participants receive a notice regarding 42 CFR 160-164. This informs the participant that they may inspect and receive a copy of their information which could include a copy of their abuse/neglect/exploitation investigation report, if applicable. DSDS does provide report information if the participant asks. The participant also may request a copy of their APS case record at the conclusion of an investigation. In those cases, a letter is sent within 3 working days notifying them of the receipt of their request. The case will be sent within 45 days of this notification letter.

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

DSDS is responsible for overseeing the operation of the incident management system. DSDS supervisors are required to complete a full review on all reports in which: reports of abuse, neglect or exploitation by a third party perpetrator has been found reason to believe; suspicious death reports; cases found reason to believe that would be appropriate for review for potential Employee Disqualification List (EDL) referral; reports completed by any probationary Worker; and, any report that the supervisor or division management deems necessary. In addition, the Supervisor shall periodically review all other reports. The supervisory review determines if the staff person conducting the investigation has followed policy and procedure during the investigation, has communicated with all the necessary parties, and has documented the investigation correctly. This oversight is conducted on an ongoing basis. The Supervisor, in an effort to assist in ensuring the on-going quality of the investigations, will conference with staff on reports, read on-going records, and possibly go on interviews with the investigator. This oversight is also conducted on an ongoing basis. The Mo CaseCompass system is utilized to collect information on alleged reports and to track occurrence/reoccurrence of ANE by reported adult, alleged perpetrator, and the allegation(s). This system is accessible to all investigating staff and can be utilized in the investigation process to track how past similar allegations were handled. DSDS is mandated to put in place protective services for eligible participants to help prevent future reports by reducing the cause of the abuse, neglect, or exploitation through a variety of activities: financial/economic interventions, education, local community supports, in-home or consumer-directed services, use of the resources of other agencies/entities, and the periodic contacts required when an individual is placed under 'protective service' status with DHSS. Waiver participants that have been placed under 'protective service' status are identified along with the level of protective service needed. These levels are: Indicative of a minimal but consistent need for protective intervention with the intent to reduce injury/harm by increasing support system and regular contacts to be made as needed to the support system and a minimum of one home visit every six months, or- Indicative of a moderate need for protective intervention with contacts to occur on a regular basis averaging at least twice per month and a minimum of one home visit every six months, or- Indicative of intense need for protective intervention with contacts to occur with and/or on the behalf of the participant weekly and a home visit monthly. Participant information is collected and compiled in the state reporting data base, Mo CaseCompass. The methods of reporting include calling DSDS staff or the Central Registry Unit 800# (this number is promoted on DHSS public information, brochure, posters and website), written correspondence with DHSS or through the 'Ask Us' function on DHSS' website. All reports are registered in the Mo CaseCompass system, regardless of the method utilized to report, in order to track all reports. Information gathered on abuse, neglect, and exploitation are used to prevent reoccurrence through education and changes in policy and procedures including but not limited to staff and provider training and public awareness. DSDS provides summary reports to the Medicaid Agency no less than annually.

Use of Restraints.(Select one): (For waiver actions submitted before March 2014, responses in Appendix G-2-a will displayinformation for both restraints and seclusion. For most waiver actions submitted afterMarch 2014, responses regarding seclusion appear in Appendix G-2-c.)

 The State does not permit or prohibits the use of restraints

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

 not selected

Safeguards Concerning the Use of Restraints. Specify the safeguards that the State has established concerningthe use of each type of restraint (i.e., personal restraints,drugs used as restraints, mechanical restraints).State laws, regulations, and policies that are referenced areavailable to CMS upon request through the Medicaid agency or the operating agency(if applicable).

Character Count: out of 12000

DHSS considers manual hold techniques and mechanical restraints to be a physical restraint. Manual hold techniques and mechanical restraints are designed to physically hold, immobilize and reduce the ability of an individual to move his or her arms, legs, body or head freely- therefore they should be considered to be a physical restraint. DHSS instructs inspectors that non-physical intervention techniques should always be the first course of action to assist in the de-escalation of behaviors, and potential interventions should be clearly delineated and easily understood by anyone who reads the residents care plan. Only as a last resort, when a resident has unanticipated violent or aggressive behavior that places him/her or others in imminent danger, does the program have the ability to contact the physician related to this change in status and to obtain an order for a physical restraints in order to assist the resident from harming his/herself. Physical restraints may not be used for the purpose of discipline or convenience. State regulations at 19 CSR 30-90 requires all Adult Day Care programs to ensure that each participant of the adult day care program be assured of the following rights- To be free of restraint, unless under physicians order as indicated in the individuals care plan. Facility Inspectors have been trained in the identification of physical, chemical, and mechanical restraints. State laws, regulations, and policies referenced in the specifications are available to CMS upon request through the Medicaid Agency or the Operating Agency. State laws, regulations, and policies that are referenced are available to CMS upon request through the Medicaid agency or the operating agency. The participant has the right to be free from any physical or chemical restraint except as follows: (A) When used to treat a specified medical symptom as a part of a total program of care to assist the resident to attain or maintain the highest practicable level of physical, mental, or psychosocial well-being. The use of restraints must be authorized in writing by a physician for a specified period of time; or (B) When necessary in an emergency to protect the resident from injury to himself or herself or to others, in which case restraints may be authorized by professional personnel so designated by the facility. The action taken shall be reported immediately to the residents physician and an order obtained which shall include the reason for the restraint, when the restraint may be removed, the type of restraint, and any other actions required. When restraints are indicated, only devices that are the least restrictive for the resident and consistent with the residents total plan of care may be used. Each participant has the right to be free from involuntary seclusion. Observation, interview and record review during inspections and complaint investigations to determine use and appropriateness of the use. Determine if the restraint was used only after a complete assessment and care planning. Ensure that only the least restrictive restraint has been used and appropriate for the individual resident to attain or maintain his or her highest practicable physical and psychosocial well-being. Monitor to ensure the program continues to assess the care plan and restraint use on an ongoing basis. Documentation of the use of restrictive interventions must be recorded in the participant record by the facility director or their designee. The Section for Long Term Care Regulation (SCLR) utilizes the interpretive guidance provided by the State Operation Manual (SOM), from the Centers for Medicare and Medicaid Services for Skilled Nursing Facilities as a guide to ensure a proper standard of practice is followed by providers. This guidance is commonly referred to as F221 and F222. Any restraint must be authorized by the resident/legal guardian and their physician and must be determined to part of the overall plan of care and monitoring. Determine if the facility follows a systematic process of evaluation and care planning prior to using restraints. Since continued restraint use is associated with a potential decline in functioning if the risk is not addressed, determine if the interdisciplinary team addressed the risk of decline at the time restraint use was initiated and that the care plan reflected measures to minimize a decline. Also determine if the plan of care was consistently implemented. Determine whether the decline can be attributed to a disease progression and/or inappropriate use of restraints. The adult day care provider would be required to provide evidence of a systematic process of evaluation and care planning prior to using restraints. The written individual plan of care for each participant is to be designed to maintain the participant at, or to restore to, optimal capability for self-care. The plan is based on a functional assessment and information obtained from the participant, participants family, physician and the person or agency referring the participant. The plan is to address the participants physical, social and psychological needs, goals and means of accomplishing goals to the degree that the program is designed and the staff are qualified to meet these goals. The plan identifies the positions of persons responsible for specific individualized activities provided for the participant that are not documented by the regularly scheduled plan of activities for the program. The plan of care is revised as frequently as warranted by the participants condition, but is minimally reviewed at least every six (6) months and updated as necessary. ADC must have staff trained and who are able to provide the appropriate care and services required to assist the participant in accomplishing their goals and carrying out the plan of care. Direct care paid staff shall be at least eighteen (18) years of age and qualified by education, training, experience or demonstrated competence in order to perform their duties. All medications are required to be received, controlled and administered by a licensed practical nurse or a registered nurse. Facility Inspectors are employees of the Department of Health and Senior Services who are trained to complete inspections and complaint investigations in Residential Care Facilities, Assisted Living Facilities, and Adult Day Care Programs. All adult day care staff, including non-direct care, direct care and volunteers are to be provided training related to all policies and procedures prior to performing job responsibilities. The orientation is to be an in depth training to enable staff to perform their assigned job responsibilities and meet the individual needs of participants. Staff are not allowed to perform job functions for which they are not trained and/or have the certification or license to provide. Any restraint must be applied by staff trained in its safe application, and must be authorized by a physician prior to its application and an order obtained containing specific criteria including the reason for the restraint, the type of restraint, when it may be removed and any other actions required. When the physician has determined a restraint is necessary, only devices that are the least restrictive for the resident and consistent with the residents total treatment program shall be used. It is never appropriate for the residents physician orders to contain standing or PRN (as needed) orders for the use of any type of restraint. This criteria is the same for any restraint- whether physical, chemical, mechanical or restrictive intervention. Non physical interventions are the first choice as an intervention when someone is beginning to lose control of his or her actions or behaviors. Early intervention crisis prevention techniques must be the first effort used to de-escalate conflict when possible. These techniques must be taught to all staff members, prior to their being placed in a situation where they must be used. ADC providers must ensure they are using the safest possible interventions for all residents. At least quarterly, or as needed based on participant's needs, in-service training is to be provided to staff, as appropriate to their job function or participant care needs. At a minimum, in-service training is to address: (A) Participant care needs, both general and individualized; (B) Participants rights; (C) Program policies; and (D) Specialized care needs, such as Alzheimers disease or related dementias, appropriate to the needs of participants, as follows: 1. For employees providing direct care to persons with Alzheimers disease or related dementia, the training shall include: A. An overview of Alzheimers disease and related dementia; B. Communicating with persons with dementia; C. Behavior management; D. Promoting independence in activities of daily living; E. Understanding and dealing with family issues; 2. For employees who do not provide direct care for, but may have daily contact with, persons with Alzheimers disease or related dementia, the training shall include. A. An overview of dementia; and B. Communicating with persons with dementia."

State Oversight Responsibility. Specify the State agency (or agencies) responsible for overseeingthe use of restraints and ensuring that State safeguardsconcerning their use are followed and how such oversight is conducted and its frequency:

Character Count: out of 12000

The Department of Health and Senior Services (DHSS), Division of Regulation and Licensure (DRL) is responsible for oversight related to statutory and regulatory requirements regarding Adult Day Care facilities. During relicensure DRL staff shall document the inspection process using the Adult Day Care Inspector Notes Worksheets. State regulations at 19 CSR 30-90 requires all Adult Day Care programs to ensure that each participant of the adult day care program be assured of the following rights- To be free of restraint, unless under physicians order as indicated in the individuals care plan. The State Medicaid Agency has access to ASPEN, the federal database that houses all inspection/survey activity in the state for all levels of long term care and adult day care programs. They are able to review Statements of Deficiency (SOD)s produced by SLCR at any time. MHD is also copied on all letters/licenses for new/existing/closed providers, and also are copied on all letters in regards to license denial or revocation. Observation, interview and record review during inspections and complaint investigations to determine use and appropriateness of the use. Determine if the restraint was used only after a complete assessment and care planning. Ensure that only the least restrictive restraint has been used and appropriate for the individual resident to attain or maintain his or her highest practicable physical and psychosocial well-being. Monitor to ensure the program continues to assess and care plan the restraint use on an ongoing basis. Section for Long Term Care Regulation (SLCR) prepares citation reports from ASPEN on an at least yearly basis to identify what citations are most frequently cited and uses the reports to provide training to adult day care providers on frequent citations. Full licensure inspections are completed at least upon initial licensing, every two years prior to the expiration of the program license and then as needed for onsite revisits, complaint investigations, participant capacity changes, etc. DHSS, the state licensing agency for Adult Day Care program, utilizes ASPEN, the federal database required by the Centers for Medicare and Medicaid Services (CMS) for Skilled Nursing Facility survey tracking, to also track their state licensed processes. Each inspection and any corresponding citations are entered into ASPEN. From this database, reports are run to determine the frequency of citations so that reports can be provided to the ADC providers on frequently cited citations and trends, and training programs can be tailored to address a particular area of concern. Reports can be run specifically on the incidence of restraints being cited.

Use of Restrictive Interventions.(Select one):

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

 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

Safeguards Concerning the Use of Restrictive Interventions. Specify the safeguards that the State has in effect concerning the use ofinterventions that restrict participant movement, participant access to otherindividuals, locations or activities, restrict participant rights or employ aversivemethods (not including restraints or seclusion) to modify behavior. State laws,regulations, and policies referenced in the specification are available to CMS uponrequest through the Medicaid agency or the operating agency.

Character Count: out of 20000

The waiver manual states that a restrictive intervention is "An action or procedure that limits an individual's movement, a person's access to other individuals, locations or activities, or restricts participant rights. DHSS does not utilize the phrase restrictive interventions in licensing regulations; however, they do address each piece of the definition in their regulations. DHSS views limiting an individuals movement to be a physical restraint. Restricting an individuals access to other individuals, locations or activities is considered to be seclusion. Participant rights may not be restricted by the program, and they include the following protections from these events. Each participant of the adult day care program is assured of the following rights: (A) To be treated as an adult, with respect and dignity regardless of race, color, sex or creed; (B) To participate in a program of services and activities which promotes positive attitudes regarding ones usefulness and capabilities; (C) To participate in a program of services designed to encourage learning, growth and awareness of constructive ways to develop ones interests and talents; (D) To maintain ones independence to the extent that conditions and circumstances permit, and to be involved in a program of services designed to promote personal independence; (E) To be encouraged to attain self-determination within the adult day care setting, including the opportunity to participate in developing ones plan for services; (F) To decide whether or not to participate in any given activity and to be involved in the extent possible in program planning and operation; (G) To be cared for in an atmosphere of sincere interest and concern in which needed support and services are provided; (H) To have access to a telephone to make or receive calls, unless necessary restrictions are indicated in the individuals care plan; (I) To have privacy and confidentiality; (J) To be free of mental or physical abuse; (K) To be free to choose whether or not to perform services for the program; (L) To be free of restraint, unless under physicians order as indicated in the individuals care plan; and (M) To be free of interference, coercion, discrimination or reprisal. DHSS monitors ADC providers during onsite inspections to ensure compliance with all ADC regulations, including those restrictive interventions including restraints, seclusion and restrictive interventions. State regulations at 19 CSR 30-90 requires all Adult Day Care programs to ensure that each participant of the adult day care program be assured of the following rights - To be free of restraint, unless under physicians order as indicated in the individuals care plan. Facility Inspectors have been trained in the identification of physical, chemical, and mechanical restraints. State laws, regulations, and policies referenced in the specifications are available to CMS upon request through the Medicaid Agency or the Operating Agency. State laws, regulations, and policies that are referenced are available to CMS upon request through the Medicaid agency or the operating agency. The participant has the right to be free from any physical or chemical restraint except as follows: (A) When used to treat a specified medical symptom as a part of a total program of care to assist the resident to attain or maintain the highest practicable level of physical, mental, or psychosocial well-being. The use of restraints must be authorized in writing by a physician for a specified period of time; or (B) When necessary in an emergency to protect the resident from injury to himself or herself or to others, in which case restraints may be authorized by professional personnel so designated by the facility. The action taken shall be reported immediately to the residents physician and an order obtained which shall include the reason for the restraint, when the restraint may be removed, the type of restraint, and any other actions required. When restraints are indicated, only devices that are the least restrictive for the resident and consistent with the residents total plan of care may be used. Each participant has the right to be free from involuntary seclusion. Observation, interview, and record review during inspections and complaint investigations to determine use and appropriateness of the use. Determine if the restraint was used only after a complete assessment and care planning. Ensure that only the least restrictive restraint has been used and appropriate for the individual resident to attain or maintain his or her highest practicable physical and psychosocial well-being. Monitor to ensure the program continues to assess and care plan the restraint use on an ongoing basis. Documentation of the use of restrictive interventions must be recorded in the participant record by the facility director or their designee. The Section for Long Term Care Regulation (SCLR) utilizes the interpretive guidance provided by the State Operation Manual (SOM), from the Centers for Medicare and Medicaid Services for Skilled Nursing Facilities as a guide to ensure a proper standard of practice is followed by providers. This guidance is commonly referred to as F221 and F222. Any restraint must be authorized by the resident/legal guardian and their physician and must be determined to part of the overall plan of care and monitoring. Determine if the facility follows a systematic process of evaluation and care planning prior to using restraints. Since continued restraint use is associated with a potential decline in functioning if the risk is not addressed, determine if the interdisciplinary team addressed the risk of decline at the time restraint use was initiated and that the care plan reflected measures to minimize a decline. Also determine if the plan of care was consistently implemented. Determine whether the decline can be attributed to a disease progression and/or inappropriate use of restraints. The adult day care provider would be required to provide evidence of a systematic process of evaluation and care planning prior to using restraints. The written individual plan of care for each participant is to be designed to maintain the participant at, or to restore to, optimal capability for self-care. The plan is based on a functional assessment and information obtained from the participant, participants family, physician and the person or agency referring the participant. The plan is to address the participants physical, social and psychological needs, goals and means of accomplishing goals to the degree that the program is designed and the staff are qualified to meet these goals. The plan identifies the positions of persons responsible for specific individualized activities provided for the participant that are not documented by the regularly scheduled plan of activities for the program. The plan of care is revised as frequently as warranted by the participants condition, but is minimally reviewed at least every six (6) months and updated as necessary. ADC must have staff trained and who are able to provide the appropriate care and services required to assist the participant in accomplishing their goals and carrying out the plan of care. Direct care paid staff shall be at least eighteen (18) years of age and qualified by education, training, experience or demonstrated competence in order to perform their duties. All medications are required to be received, controlled and administered by a licensed practical nurse or a registered nurse. Facility Inspectors are employees of the Department of Health and Senior Services who are trained to complete inspections and complaint investigations in Residential Care Facilities, Assisted Living Facilities, and Adult Day Care Programs. DHSS considers manual hold techniques and mechanical restraints to be a physical restraint. Manual hold techniques and mechanical restraints are designed to physically hold, immobilize and reduce the ability of an individual to move his or her arms, legs, body or head freely- therefore they should be considered to be a physical restraint. DHSS instructs inspectors that non-physical intervention techniques should always be the first course of action to assist in the de-escalation of behaviors, and potential interventions should be clearly delineated and easily understood by anyone who reads the residents care plan. Only as a last resort, when a resident has unanticipated violent or aggressive behavior that places him/her or others in imminent danger, does the program have the ability to contact the physician related to this change in status and to obtain an order for a physical restraints in order to assist the resident from harming his/herself. Physical restraints may not be used for the purpose of discipline or convenience. All adult day care staff, including non-direct care, direct care and volunteers are to be provided training related to all policies and procedures prior to performing job responsibilities. The orientation is to be an in depth training to enable staff to perform their assigned job responsibilities and meet the individual needs of participants. Staff are not allowed to perform job functions for which they are not trained and/or have the certification or license to provide. Any restraint must be applied by staff trained in its safe application, and must be authorized by a physician prior to its application and an order obtained containing specific criteria including the reason for the restraint, the type of restraint, when it may be removed and any other actions required. When the physician has determined a restraint is necessary, only devices that are the least restrictive for the resident and consistent with the residents total treatment program shall be used. It is never appropriate for the residents physician orders to contain standing or PRN (as needed) orders for the use of any type of restraint. This criteria is the same for any restraint- whether physical, chemical, mechanical or restrictive intervention." Since participants are encouraged to attain self-determination within the adult day care setting, including the opportunity to participate in developing ones plan for services, and since they have the right to decide whether or not to participate in any given activity and to be involved in the extent possible in program planning and operation, providers must ensure participants are not being secluded from other individuals or activities. DHSS documents findings on Facility Inspector Worksheets. Negative findings will be additionally documented in ASPEN, the federal database required by the Centers for Medicare and Medicaid Services (CMS) for Skilled Nursing Facility survey tracking- to also track citations and generate report findings (referred to as Statements of Deficiency). At least quarterly, or as needed based on participant's needs, in-service training is to be provided to staff, as appropriate to their job function or participant care needs. At a minimum, in-service training is to address: (A) Participant care needs, both general and individualized; (B) Participant's rights; (C) Program policies; and (D) Specialized care needs, such as Alzheimers disease or related dementias, appropriate to the needs of participants, as follows: 1. For employees providing direct care to persons with Alzheimers disease or related dementia, the training shall include: A. An overview of Alzheimers disease and related dementia; B. Communicating with persons with dementia; C. Behavior management; D. Promoting independence in activities of daily living; E. Understanding and dealing with family issues; 2. For employees who do not provide direct care for, but may have daily contact with, persons with Alzheimers disease or related dementia, the training shall include. A. An overview of dementia; and B. Communicating with persons with dementia.

State Oversight Responsibility. Specify the State agency (or agencies) responsible for monitoring and overseeingthe use of restrictive interventions and how this oversight is conducted and its frequency:

Character Count: out of 20000

DHSS, the state licensing agency for Adult Day Care programs, is responsible for overseeing ADC programs and ensuring that regulations pertaining to restraint, seclusion, and resident rights are adhered to and that participants are safe in their environment. DHSS complete onsite inspections and through observation, interview and record review ensure programs are following the regulations and providing services in accordance with the regulations. DHSS utilizes ASPEN, the federal database required by the Centers for Medicare and Medicaid Services (CMS) for Skilled Nursing Facility survey tracking, to also track their state licensed processes. Each inspection and any corresponding citations are entered into ASPEN. From this database, reports are run to determine the frequency of citations so that reports can be provided to the ADC providers on frequently cited citations and trends, and training programs can be tailored to address a particular area of concern. Reports can be run specifically on the incidence of restraints, and violations of resident rights being cited. Additionally, DHSS utilizes ACTS, the federal database required by the Centers for Medicare and Medicaid Services (CMS) for Skilled Nursing Facility complaint report tracking, to collect complaint allegations and to compile findings from investigations. DHSS is able to monitor complaints and corresponding statements of deficiency through ACTS and ASPEN in order to monitor current trends in citations- so that provider groups and DHSS can target industry training to ensure better understanding of regulations and compliance. State regulations at 19 CSR 30-90 requires all Adult Day Care programs to ensure that each participant of the adult day care program be assured of the following rights- To be free of restraint, unless under physicians order as indicated in the individuals care plan. MHD is copied on all letters/licenses for new/existing/closed providers, and also are copied on all letters in regards to license denial or revocation. ASPEN can be accessed as needed by the State Medicaid Agency. Observation, interview and record review during inspections and complaint investigations to determine use and appropriateness of the use. Determine if the restraint was used only after a complete assessment and care planning. Ensure that only the least restrictive restraint has been used and appropriate for the individual resident to attain or maintain his or her highest practicable physical and psychosocial well-being. Monitor to ensure the program continues to assess and care plan the restraint use on an ongoing basis. Section for Long Term Care Regulation (SLCR) prepares citation reports from ASPEN on an at least yearly basis to identify what citations are most frequently cited and uses the reports to provide training to adult day care providers on frequent citations. Full licensure inspections are completed at least upon initial licensing, every two years prior to the expiration of the program license and then as needed for onsite revisits, complaint investigations, participant capacity changes, etc. DHSS, the state licensing agency for Adult Day Care program, utilizes ASPEN, the federal database required by the Centers for Medicare and Medicaid Services (CMS) for Skilled Nursing Facility survey tracking, to also track their state licensed processes. Each inspection and any corresponding citations are entered into ASPEN. From this database, reports are run to determine the frequency of citations so that reports can be provided to the ADC providers on frequently cited citations and trends, and training programs can be tailored to address a particular area of concern. Reports can be run specifically on the incidence of restraints being cited.

Use of Seclusion.(Select one): (This section will be blank for waivers submitted before Appendix G-2-c was added to WMS in March 2014, andresponses for seclusion will display in Appendix G-2-a combined with information on restraints.)

 The State does not permit or prohibits the use of seclusion

 The use of seclusion is permitted during the course of the delivery of waiver services. Complete Items G-2-c-i and G-2-c-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 demonstrates it has designed and implemented an effective system for assuring waiver participant health and welfare. (For waiver actions submitted before June 1, 2014, this assurance read "The State, on an ongoing basis, identifies, addresses, and seeks to prevent the occurrence of abuse, neglect and exploitation.")

Sub-Assurances:

Sub-assurance: The state demonstrates on an ongoing basis that it identifies, addresses and seeks to prevent instancesof abuse, neglect, exploitation and unexplained death. (Performance measures in this sub-assurance include all Appendix G performance measures for waiver actions submitted before June 1, 2014.)

Performance Measures

For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

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 demonstrates that an incident management system is in place that effectively resolves those incidents and prevents further similar incidents to the extent possible.

Performance Measures

For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

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 policies and procedures for the use or prohibition of restrictive interventions (including restraints and seclusion) are followed.

Performance Measures

For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

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 establishes overall health care standards and monitors those standards based on the responsibility of the service provider as stated in the approved waiver.

Performance Measures

For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

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

When an error is discovered during a DSDS case record review or one is identified in a DSDS report, a DSDS supervisor reviews the error, and works with the appropriate worker to address the error. The worker then documents the action taken. The DSDS supervisor reviews the action taken by worker to correct the error. General methods of remediation may include: service plan revisions, re- training staff, discussions during area and regional meetings and/or change in Division policy or procedure. Problems related to timely investigation of hotlines are adressed through staffing and or staff training and or policy and or procedures as deemed appropriate.

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

No less than annually MHD Program Operation staff and DSDS Program Oversight staff meet to discuss the Quality Improvement Strategy described throughout the Adult Day Care, Aged and Disabled, and the Independent Living Waivers. At this time, DHSS Program Oversight staff and MHD Program Operations staff jointly review the performance measures and analyze corresponding reports generated by both agencies. MHD and DSDS review the outcome of the reports to ensure they are meeting the assurances specified throughout the application and what, if any, action may be necessary for remediation and or system improvement. Systemic errors and trends are identified by MHD and DSDS based on the reports for each performance measure using the number and percent of compliance. Recommendations for system change may come from either agency however MHD will approve any changes to the Quality Improvement Strategy specified in the waiver application. Any changes in the Quality Improvement Strategy in the waiver application are implemented and monitored, as appropriate. Any changes will be included on the next 372 report. System improvement activities related to participant health, welfare, and safety are the first priority for MHD and DSDS staff. Additional priorities are established based on the number and percent of compliance specified in the waiver reports for the Quality Improvement Strategy in the waiver. Although individual problems are remediated upon discovery, performance measures that are significantly lower than 100% may need to be addressed as a systemic issue. Implementation of system improvement will be a joint effort between DSDS and MHD. System change related to delegated activities will be the responsibility of DSDS and those activities that are not delegated will be the responsibility of MHD. Follow-up discussions related to system improvement activities may be discussed at quarterly meetings but will be discussed no less than annually. Systemic issues may require follow-up reports, policy and or procedure changes, as well as staff and/or provider training MHD and DSDS will analyze the effectiveness of system improvement activities through the Quality Improvement Strategy reports and or additional reports that may be recommended by DSDS and or MHD when significant areas of concern are identified. All reports are stratified by waiver.

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 State's targeted standards forsystems improvement.

Character Count: out of 12000

A quality improvement report is developed annually based on performance measure reports and at a minimum will identify the systemic issue, the proposed resolution, and the established time frame for implementation. Established timeframes from the annual report for remediation activities will be discussed and reviewed during quarterly meetings. The report will be updated as appropriate when systemic remediation activities have been completed. Effectiveness of system improvement activities will be monitored no less than annually at the QIS meeting based on new reports on the established performance measures. Significant systemic issues will be addressed by MHD and/or DSDS through increased reporting or monitoring as deemed necessary and appropriate. Results of the system improvement report will be available on the DSDS web site.

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

Character Count: out of 12000

The Home and Community Based Services Waiver Quality Management Strategy specified in the Adult Day Care Waiver (1021), Aged and Disabled Waiver (0026), and Independent Living Waiver (0346) are evaluated and updated no less than annually by MHD and DHSS. The process includes the review of performance measures, reports for performance measures and remediation activities resulting from discovery. Annually MHD and DSDS will determine if the QIS is providing the information and improvements necessary to meet the quality assurance performance measures as it relates to discovery, remediation and improvement activities. The committee will evaluate the QIS process annually to determine if the process is working. If it is determined additional input is necessary, DSDS and MHD will request input from individuals involved in the authorization and/or delivery of ADCW, ADW, and ILW services. This could include providers, other stakeholders and/or DSDS and MHD staff from other units within the Divisions.

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. (For waiver actions submitted before June 1, 2014, this assurance read "State financial oversight exists to assure that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver.")

Sub-Assurances:

Sub-assurance: The State provides evidence that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver and only for services rendered. (Performance measures in this sub-assurance include all Appendix I performance measures for waiver actions submitted before June 1, 2014.)

Performance Measures

For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

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 provides evidence that rates remain consistent with the approved rate methodology throughout the five year waiver cycle.

Performance Measures

For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

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

State financial oversight exists to ensure claims are coded and paid in accordance with the reimbursement methodology in the approved waiver. Claims payment issues are the responsibility of MHD. MHD works to resolve payment issues as they are identified by MHD or DHSS. When an overpayment or underpayment has occurred, MHD recycles claims to pay or recoup appropriate funds. MMAC is responsible for provider reviews and identifying incorrect billings due to inadequate documentation, coding or unit errors or other findings. Remediation occurs through changes in policy, procedure or MMIS system edits or through the finalization of audits. When payment issues are identified, MHD staff generate a System Problem Assistance Request to the state fiscal agent requesting information as to why a claim is not paying correctly. The state fiscal agent reviews the claims data to determine why a claim is not processing correctly. Once the problem is identified, the fiscal agent makes corrections to fix the problem. MHD staff review test documentation to ensure that the actions taken by the fiscal agent remedy the situation. Once the problem has been corrected, MHD staff monitor to ensure future claims pay correctly.

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

The reimbursement rates for services provided through the Aged and Disabled Waiver are subject to and determined by the State Legislature, through the State of MO annual budgeting/appropriation process. Participants and business entities are able to testify at annual appropriation hearings conducted by the State House of Representatives and State Senate appropriation committees to provide input on reimbursement rates. The rates established by the MO Legislature are statewide rates; it does not vary by provider. Current reimbursement rates can be found on MO HealthNet's website at http://dss.mo.gov/mhd/providers/pages/cptagree.htm. Information regarding payment rates is available upon request by the participant, through the MHD Participant Services Unit or online at the MHD website. Requests may be made in writing to the MHD or DHSS, by email to ASK MHD, or by phone call to the MHD Participant Services Unit. Rates for waiver services are historically based on four factors. These four factors are the Missouri hourly minimum wage, gas prices for the Midwest per gallon, the hourly amount for Aged and Disabled Waiver services, and the Consumer Price Index. Requests for funding are made to the General Assembly by MHD and DHSS. In addition to requests by the State, funding requests are made to the General Assembly by the provider industry. Missouri General Assembly appropriates the total funding based on a percent increase or a specific per unit increase. Both MHD and DSDS provide historical utilization data to the Governors’ budget office and the appropriation committee that is then used to apply a per unit increase to the waiver services. Waiver rate methodology for all services included in this Waiver includes occupational and wage estimates from the Missouri Department of Economic Development, Missouri Economic Research and Information Center (MERIC). Fringe benefits include payroll taxes (FICA, Medicare, SUTA, FUTA); health insurance; retirement funds; vacation, and sick time; paid holidays; life insurance; educational assistance as well as other employee benefits. DSDS used 49%, which is the amount used by Department of Health and Senior Services to estimate the fringe benefit costs for its employees. The estimated administrative cost of 22.5% of the Personal Services and Fringe Benefits total is based on the standard per FTE administrative costs the Department of Health and Senior Services utilizes in budget estimates. These costs include computer/software/network, travel, rent, utilities, cellular/connectivity and office supplies.

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

All services provided under this Waiver Program are prior authorized by Missouri Department of Health and Senior Services' (DHSS) staff. The prior authorization is forwarded to the MO HealthNet Fiscal Agent. Providers of services bill claims for services directly to the MO HealthNet Fiscal Agent for claims processing. All claims are processed through a MMIS. Claims are checked against services prior authorized. Only authorized services are paid. Payment is made directly to the provider of service.

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

DSDS staff determine participants' eligibility for waiver services and develop/finalize the service plan. Services are then prior authorized. This information is then transferred to the MMIS for establishment of a prior authorization against which all claims for payment from providers are compared. The MMIS system also incorporates an edit function that ensures services are only reimbursed to the provider for dates of service on which the participant is Medicaid eligible. The MMAC within the DSS conducts periodic compliance audits in which the documentation of services provided is reviewed to ensure that services billed to MHD were provided and documented as required (13 CSR 70.3). MMAC may arrange to conduct some interviews with waiver participants during monitoring; discussion of whether services were actually delivered is held during these interviews. When investigating a complaint, MMAC staff will also be verifying that services are delivered as reported. Providers have the responsibility of reviewing time sheets and meal delivery records and certifying their accuracy prior to the filing of claims to the MO HealthNet Division for reimbursement. Providers' procedures may include follow-up conversations with participants on actual service delivery.

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.

 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:

Answers provided in Appendix I-3-d indicate that you do not need to complete this section.

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:

Organized Health Care Delivery System.Select one:

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 Department of Health and Senior Services (DHSS) is appropriated the state funds for the Aged and Disabled Waiver. DHSS has filed an authorization letter with the Missouri Office of Administration indicating that MO HealthNet Division is approved to code the state portion of MO HealthNet expenditures for the Aged and Disabled Waiver against DHSS appropriations from the state's General Revenue 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

The average length of stay is 299 days and is based on the Aged and Disabled Waiver FY 11 CMS 372 report.

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 projections are based on actual service utilization data from the FY 11 CMS 372 report. This information was applied to the total slots available in the waiver renewal. The unit costs for each waiver service were projected forward using a 2.4% market basket rate increase for years 1-5 of the waiver application. The total projected expenditure was then divided by the unduplicated number of slots available.

Character Count: out of 12000

In order to estimate the Factor D' value, the FY 11 actual cost for ADW services was divided by the unduplicated number of participants. The amount was then projected forward using a 2.4% market basket rate increase. Part D drugs were no longer applicable to FY 11 actual expenditures.

Character Count: out of 12000

The factor G estimates are based on actual FY 11 paid claims for nursing facilities expenditures divided by the total unduplicated number of individuals who received nursing facility care. This resulted in the average aggregate cost per individual, for nursing facility care. This result was projected forward each year using a 2.4% market basket rate increase.

Character Count: out of 12000

The factor G’ estimates are based on FY 11 actual paid claims history for all other Medicaid covered services while the individuals were in a nursing facility, divided by the total unduplicated number of nursing facility residents. This resulted in the average aggregate cost per individual for all other services while the individuals were in the nursing facility. This result was projected forward each year using a 2.4% market basket rate increase.

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.