††††† 907 KAR 1:835. Michelle P. waiver services and reimbursement.

 

††††† RELATES TO: KRS 205.520(3), 205.5605, 205.5606, 205.5607, 205.635, 42 C.F.R. 440.180

††††† STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), 205.5606, 42 C.F.R. 440.180, 42 U.S.C. 1396a, 1396b, 1396d, 1396n

††††† NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and Family Services, Department for Medicaid Services has responsibility to administer the Medicaid Program. KRS 205.520(3) authorizes the cabinet to comply with any requirement that may be imposed, or opportunity presented, by federal law to qualify for federal Medicaid funds. This administrative regulation establishes the coverage and reimbursement provisions for Michelle P. waiver services.

 

††††† Section 1. Definitions. (1) "ADHC" means adult day health care.

††††† (2) "ADHC center" means an adult day health care center licensed in accordance with 902 KAR 20:066.

††††† (3) "ADHC services" means health-related services provided on a regularly-scheduled basis that ensure optimal functioning of a Michelle P. waiver recipient who does not require twenty-four (24) hour care in an institutional setting.

††††† (4) "Advanced practice registered nurse" or "APRN" means a person who acts within his or her scope of practice and is licensed in accordance with KRS 314.042.

††††† (5) "Assessment team" means a team which:

††††† (a) Conducts assessment or reassessment services; and

††††† (b) Consists of:

††††† 1. Two (2) registered nurses; or

††††† 2. One (1) registered nurse and one (1) of the following:

††††† a. A social worker;

††††† b. A certified psychologist with autonomous functioning;

††††† c. A licensed psychological practitioner;

††††† d. A licensed marriage and family therapist; or

††††† e. A licensed professional clinical counselor.

††††† (6) "Behavior support specialist" means an individual who has:

††††† (a) A masterís degree from an accredited institution with formal graduate course work in a behavioral science; and

††††† (b) At least one (1) year of experience in behavioral programming.

††††† (7) "Blended services" means a nonduplicative combination of Michelle P. waiver services identified in Section 6 of this administrative regulation and consumer-directed option services identified in Section 7 of this administrative regulation provided pursuant to a recipient's approved plan of care.

††††† (8) "Budget allowance" is defined by KRS 205.5605(1).

††††† (9) "Certified psychologist" means an individual who is a certified psychologist in accordance with KRS 319.056.

††††† (10) "Consumer" is defined by KRS 205.5605(2).

††††† (11) "Consumer-directed option" or "CDO" means an option established by KRS 205.5606 within the home and community-based service waivers which allows recipients to:

††††† (a) Assist with the design of their programs;

††††† (b) Choose their providers of services; and

††††† (c) Direct the delivery of services to meet their needs.

††††† (12) "Covered services and supports" is defined by KRS 205.5605(3).

††††† (13) "DCBS" means the Department for Community Based Services.

††††† (14) "Department" means the Department for Medicaid Services or its designee.

††††† (15) "Developmental disability" means a severe, chronic disability that:

††††† (a) Is attributable to:

††††† 1. Cerebral palsy or epilepsy; or

††††† 2. Any other condition, excluding mental illness, closely related to an intellectual disability resulting in impairment of general intellectual functioning or adaptive behavior similar to that of an individual with an intellectual disability and which requires treatment or services similar to those required by persons with an intellectual disability;

††††† (b) Is manifested prior to the individualís 22nd birthday;

††††† (c) Is likely to continue indefinitely; and

††††† (d) Results in substantial functional limitations in three (3) or more of the following areas of major life activity:

††††† 1. Self-care;

††††† 2. Understanding and use of language;

††††† 3. Learning;

††††† 4. Mobility;

††††† 5. Self-direction; or

††††† 6. Capacity for independent living.

††††† (16) "Direct care staff" means an individual hired by a Michelle P. waiver provider to provide services to the recipient and who:

††††† (a)1.a. Is eighteen (18) years of age or older; and

††††† b. Has a high school diploma or GED; or

††††† 2.a. Is twenty-one (21) years of age or older; and

††††† b. Is able to communicate with a recipient in a manner that the recipient or recipient's legal representative or family member can understand;

††††† (b) Has a valid Social Security number or valid work permit if not a U.S. citizen;

††††† (c) Can understand and carry out simple instructions;

††††† (d) Has the ability to keep simple records; and

††††† (e) Is managed by the providerís supervisory staff.

††††† (17) "Electronic signature" is defined by KRS 369.102(8).

††††† (18) "Federal financial participation" is defined in 42 C.F.R. 400.203.

††††† (19) "Home health agency" means an agency that is:

††††† (a) Licensed in accordance with 902 KAR 20:081; and

††††† (b) Medicare and Medicaid certified.

††††† (20) "ICF-IID" means an intermediate care facility for individuals with an intellectual disability.

††††† (21) "Intellectual disability" means an individual has:

††††† (a) Significantly sub-average intellectual functioning;

††††† (b) An intelligence quotient of seventy (70) or below;

††††† (c) Concurrent deficits or impairments in present adaptive functioning in at least two (2) of the following areas:

††††† 1. Communication;

††††† 2. Self-care;

††††† 3. Home living;

††††† 4. Social or interpersonal skills;

††††† 5. Use of community resources;

††††† 6. Self-direction;

††††† 7. Functional academic skills;

††††† 8. Work;

††††† 9. Leisure; or

††††† 10. Health and safety; and

††††† (d) Had an onset prior to eighteen (18) years of age.

††††† (22) "Level of care determination" means a determination that an individual meets the Michelle P. waiver service level of care criteria established in Section 5 of this administrative regulation.

††††† (23) "Licensed marriage and family therapist" or "LMFT" is defined by KRS 335.300(2).

††††† (24) "Licensed practical nurse" or "LPN" means a person who:

††††† (a) Meets the definition of KRS 314.011(9); and

††††† (b) Works under the supervision of a registered nurse.

††††† (25) "Licensed professional clinical counselor" or "LPCC" is defined by KRS 335.500(3).

††††† (26) ďLicensed psychological associateĒ means an individual who meets the requirements established in KRS 319.064.

††††† (27) "Licensed psychological practitioner" means an individual who:

††††† (a) Meets the requirements established in KRS 319.053; or

††††† (b) Is a certified psychologist with autonomous functioning.

††††† (28) "Licensed psychologist" means an individual who:

††††† (a) Currently possesses a licensed psychologist license in accordance with KRS 319.010(6); and

††††† (b) Meets the licensed psychologist requirements established in 201 KAR Chapter 26.

††††† (29) "Michelle P. waiver recipient" means an individual who:

††††† (a) Is a recipient as defined by KRS 205.8451(9);

††††† (b) Meets the Michelle P. waiver service level of care criteria established in Section 5 of this administrative regulation; and

††††† (c) Meets the eligibility criteria for Michelle P. waiver services established in Section 4 of this administrative regulation.

††††† (30) "Normal babysitting" means general care provided to a child which includes custody, control, and supervision.

††††† (31) "Occupational therapist" is defined by KRS 319A.010(3).

††††† (32) "Occupational therapy assistant" is defined by KRS 319A.010(4).

††††† (33) "Patient liability" means the financial amount an individual is required to contribute toward cost of care in order to maintain Medicaid eligibility.

††††† (34) "Physical therapist" is defined by KRS 327.010(2).

††††† (35) "Physical therapist assistant" means a skilled health care worker who:

††††† (a) Is certified by the Kentucky Board of Physical Therapy; and

††††† (b) Performs physical therapy and related duties as assigned by the supervising physical therapist.

††††† (36) "Physician assistant" or "PA" is defined by KRS 311.840(3).

††††† (37) "Plan of care" or "POC" means a written individualized plan developed by:

††††† (a) A Michelle P. waiver recipient or a Michelle P. waiver recipientís legal representative;

††††† (b) The case manager or support broker; and

††††† (c) Any other person designated by the Michelle P. waiver recipient if the Michelle P. waiver recipient designates another person.

††††† (38)) "Plan of treatment" means a care plan used by an ADHC center.

††††† (39) "Psychologist with autonomous functioning" means an individual who is licensed in accordance with KRS 319.056.

††††† (40) "Qualified professional in the area of intellectual disabilities" is defined by KRS 202B.010(12).

††††† (41) "Registered nurse" or "RN" means a person who:

††††† (a) Meets the definition established in KRS 314.011(5); and

††††† (b) Has at least one (1) year of experience as a licensed practical nurse or a registered nurse.

††††† (42) "Representative" is defined by KRS 205.5605(6).

††††† (43) "SCL waiting list individual" means an individual on the Supports for Community Living (SCL) waiting list pursuant to 907 KAR 12:010, Section 7.

††††† (44) "Sex crime" is defined by KRS 17.165(1).

††††† (45) "Social worker" means a person with a bachelor's degree in social work, sociology, or a related field.

††††† (46) "Speech-language pathologist" is defined by KRS 334A.020(3).

††††† (47) "State plan" is defined by 42 C.F.R. 400.203.

††††† (48) "Supervisory staff" means an individual employed by the Michelle P. waiver provider who shall manage direct care staff and who:

††††† (a)1.a. Is eighteen (18) years of age or older; and

††††† b. Has a high school diploma or GED; or

††††† 2. Is twenty-one (21) years of age or older;

††††† (b) Has a minimum of one (1) year experience in providing services to individuals with an intellectual or developmental disability;

††††† (c) Is able to adequately communicate with the recipients, staff, and family members;

††††† (d) Has a valid Social Security number or valid work permit if not a U.S. citizen; and

††††† (e) Has the ability to perform required record keeping.

††††† (49) "Support broker" means an individual chosen by a consumer from an agency designated by the department to:

††††† (a) Provide training, technical assistance, and support to a consumer; and

††††† (b) Assist a consumer in any other aspects of CDO.

††††† (50) "Support spending plan" means a plan for a consumer that identifies the:

††††† (a) CDO services requested;

††††† (b) Employee name;

††††† (c) Hourly wage;

††††† (d) Hours per month;

††††† (e) Monthly pay;

††††† (f) Taxes;

††††† (g) Budget allowance; and

††††† (h) Six (6) month budget.

††††† (51) "Violent crime" is defined by KRS 17.165(3).

 

††††† Section 2. Non-CDO Provider Participation. (1) In order to provide Michelle P. waiver services, excluding consumer-directed option services, a provider shall be:

††††† (a) Licensed in accordance with:

††††† 1. 902 KAR 20:066 if an adult day health care provider;

††††† 2. 902 KAR 20:078 if a group home;

††††† 3. 902 KAR 20:081 if a home health agency; or

††††† 4. 902 KAR 20:091 if a community mental health center; or

††††† (b) Certified by the department in accordance with 907 KAR 12:010, Section 3, if the provider's type is not listed in paragraph (a) of this subsection.

††††† (2) A Michelle P. waiver provider shall:

††††† (a) Provide services to Michelle P. waiver recipients:

††††† 1. Directly; or

††††† 2. Indirectly through a subcontractor;

††††† (b) Comply with the following administrative regulations and program requirements:

††††† 1. 907 KAR 1:671;

††††† 2. 907 KAR 1:672; and

††††† 3. 907 KAR 1:673;

††††† (c) Not enroll a Michelle P. waiver recipient for whom the provider is unequipped or unable to provide Michelle P. waiver services; and

††††† (d) Be permitted to accept or not accept a Michelle P. waiver recipient.

 

††††† Section 3. Maintenance of Records. (1) A Michelle P. waiver provider shall maintain:

††††† (a) A clinical record for each Michelle P. waiver recipient that shall contain the following:

††††† 1. Pertinent medical, nursing, and social history;

††††† 2. A comprehensive assessment entered on form MAP 351 and signed by the:

††††† a. Assessment team; and

††††† b. Department;

††††† 3. A completed MAP 109;

††††† 4. A copy of the MAP-350 signed by the recipient or his or her legal representative at the time of application or reapplication and each recertification thereafter;

††††† 5. The name of the case manager;

††††† 6. Documentation of all level of care determinations;

††††† 7. All documentation related to prior authorizations, including requests, approvals, and denials;

††††† 8. Documentation of each contact with, or on behalf of, a Michelle P. waiver recipient;

††††† 9. Documentation that the Michelle P. waiver recipient receiving ADHC services or legal representative was provided a copy of the ADHC centerís posted hours of operation;

††††† 10. Documentation that the recipient or legal representative was informed of the procedure for reporting complaints; and

††††† 11. Documentation of each service provided. The documentation shall include:

††††† a. The date the service was provided;

††††† b. The duration of the service;

††††† c. The arrival and departure time of the provider, excluding travel time, if the service was provided at the Michelle P. waiver recipientís home;

††††† d. Itemization of each service delivered;

††††† e. The Michelle P. waiver recipient's arrival and departure time, excluding travel time, if the service was provided outside the recipientís home;

††††† f. Progress notes which shall include documentation of changes, responses, and treatments utilized to meet the Michelle P. waiver recipientís needs; and

††††† g. The signature of the service provider; and

††††† (b) Fiscal reports, service records, and incident reports regarding services provided. The reports and records shall be retained for the longer of:

††††† 1. At least six (6) years from the date that a covered service is provided; or

††††† 2. For a minor, three (3) years after the recipient reaches the age of majority under state law.

††††† (2) Upon request, a Michelle P. waiver provider shall make information regarding service and financial records available to the:

††††† (a) Department;

††††† (b) Kentucky Cabinet for Health and Family Services, Office of Inspector General or its designee;

††††† (c) United States Department for Health and Human Services or its designee;

††††† (d) United States Government Accountability Office or its designee;

††††† (e) Kentucky Office of the Auditor of Public Accounts or its designee; or

††††† (f) Kentucky Office of the Attorney General or its designee.

 

††††† Section 4. Michelle P. Waiver Recipient Eligibility Determinations and Redeterminations. (1) A Michelle P. waiver service shall be provided to a Medicaid-eligible Michelle P. waiver recipient who:

††††† (a) Is determined by the department to meet the Michelle P. waiver service level of care criteria in accordance with Section 5 of this administrative regulation; and

††††† (b) Would, without waiver services, be admitted to an ICF-IID or a nursing facility.

††††† (2) The department shall perform a Michelle P. waiver service level of care determination for each Michelle P. waiver recipient at least once every twelve (12) months or more often if necessary.

††††† (3) A Michelle P. waiver service shall not be provided to an individual who:

††††† (a) Does not require a service other than:

††††† 1. An environmental and minor home adaptation;

††††† 2. Case management; or

††††† 3. An environmental and minor home adaptation and case management;

††††† (b) Is an inpatient of:

††††† 1. A hospital;

††††† 2. A nursing facility; or

††††† 3. An ICF-IID;

††††† (c) Is a resident of a licensed personal care home; or

††††† (d) Is receiving services from another Medicaid home and community based services waiver program.

††††† (4) A Michelle P. waiver provider shall inform a Michelle P. waiver recipient or his legal representative of the choice to receive:

††††† (a) Michelle P. waiver services; or

††††† (b) Institutional services.

††††† (5) An eligible Michelle P. waiver recipient or the recipient's legal representative shall select a participating Michelle P. waiver provider from which the recipient wishes to receive Michelle P. waiver services.

††††† (6) A Michelle P. waiver provider shall use a MAP-24 to notify the department of a Michelle P. waiver recipient's:

††††† (a) Termination from the Michelle P. waiver program; or

††††† (b)1. Admission to an ICF-IID or nursing facility for less than sixty (60) consecutive days; or

††††† 2. Return to the Michelle P. waiver program from an ICF-IID or nursing facility within sixty (60) consecutive days;

††††† (c) Admission to a hospital; or

††††† (d) Transfer to another waiver program within the department.

††††† (7) Involuntary termination of a service to a Michelle P. waiver recipient by a Michelle P. waiver provider shall require:

††††† (a) Simultaneous notice to the recipient or legal representative, the case manager or support broker, and the department at least thirty (30) days prior to the effective date of the action, which shall include:

††††† 1. A statement of the intended action;

††††† 2. The basis for the intended action;

††††† 3. The authority by which the action is taken; and

††††† 4. The recipient's right to appeal the intended action through the provider's appeal or grievance process;

††††† (b) Submittal of a MAP-24 to the department at the time of the intended action; and

††††† (c) The case manager or support broker in conjunction with the provider to:

††††† 1. Provide the recipient with the name, address, and telephone number of each current provider in the state;

††††† 2. Provide assistance to the recipient in making contact with another provider;

††††† 3. Arrange transportation for a requested visit to a provider site;

††††† 4. Provide a copy of pertinent information to the recipient or legal representative;

††††† 5. Ensure the health, safety, and welfare of the recipient until an appropriate placement is secured;

††††† 6. Continue to provide supports until alternative services are secured; and

††††† 7. Provide assistance to ensure a safe and effective service transition.

 

††††† Section 5. Michelle P. Waiver Service Level of Care Criteria. (1) An individual shall be determined to have met the Michelle P. waiver service level of care criteria if the individual:

††††† (a) Requires physical or environmental management or rehabilitation and:

††††† 1. Has a developmental disability or significantly sub-average intellectual functioning;

††††† 2. Requires a protected environment while overcoming the effects of a developmental disability or sub-average intellectual functioning while:

††††† a. Learning fundamental living skills;

††††† b. Obtaining educational experiences which will be useful in self-supporting activities; or

††††† c. Increasing awareness of his or her environment; or

††††† 3. Has a primary psychiatric diagnosis if:

††††† a. The individual possesses care needs listed in subparagraph 1 or 2 of this paragraph;

††††† b. The individualís mental care needs are adequately handled in an ICF-IID; and

††††† c. The individual does not require psychiatric inpatient treatment; or

††††† (b) Has a developmental disability and meets the:

††††† 1. High-intensity nursing care patient status criteria pursuant to 907 KAR 1:022, Section 4(2); or

††††† 2. Low-intensity nursing care patient status criteria pursuant to 907 KAR 1:022, Section 4(3).

††††† (2) An individual who does not require a planned program of active treatment to attain or maintain an optimal level of functioning shall not meet the Michelle P. waiver service level of care criteria.

††††† (3) The department shall not determine that an individual fails to meet the Michelle P. waiver service level of care criteria solely due to the individualís age, length of stay in an institution, or history of previous institutionalization if the individual meets the criteria established in subsection (1) of this section.

 

††††† Section 6. Covered Services. (1) A Michelle P. waiver service shall:

††††† (a) Be prior authorized by the department to ensure that the service or modification of the service meets the needs of the Michelle P. waiver recipient;

††††† (b) Be provided pursuant to a plan of care or, for a CDO service, pursuant to a plan of care and support spending plan;

††††† (c) Except for a CDO service, not be provided by a member of the Michelle P. waiver recipientís family. A CDO service may be provided by a Michelle P. waiver recipient's family member; and

††††† (d) Be accessed within sixty (60) days of the date of prior authorization.

††††† (2) To request prior authorization, a provider shall submit a completed MAP 10, MAP 109, and MAP 351 to the department.

††††† (3) Covered Michelle P. waiver services shall include:

††††† (a) A comprehensive assessment which shall:

††††† 1. Be completed by the department;

††††† 2. Identify a Michelle P. waiver recipientís needs and the services the Michelle P. waiver recipient or the recipient's family cannot manage or arrange for on the recipient's behalf;

††††† 3. Evaluate a Michelle P. waiver recipientís physical health, mental health, social supports, and environment;

††††† 4. Be requested by an individual seeking Michelle P. waiver services or the individual's family, legal representative, physician, physician assistant, APRN, or another qualified professional in the area of intellectual disabilities;

††††† 5. Be conducted by an assessment team; and

††††† 6. Include at least one (1) face-to-face home visit by a member of the assessment team with the Michelle P. waiver recipient and, if appropriate, the recipient's family;

††††† (b) A reassessment service which shall:

††††† 1. Be completed by the department;

††††† 2. Determine the continuing need for Michelle P. waiver services and, if appropriate, CDO services;

††††† 3. Be performed at least every twelve (12) months;

††††† 4. Be conducted using the same procedures used in an assessment service; and

††††† 5. Not be retroactive;

††††† (c) A case management service which shall:

††††† 1. Consist of coordinating the delivery of direct and indirect services to a Michelle P. waiver recipient;

††††† 2. Be provided by a case manager who shall:

††††† a. Arrange for a service but not provide a service directly;

††††† b. Contact the Michelle P. waiver recipient monthly through a face-to-face visit at the Michelle P. waiver recipientís home, in the ADHC center, or the adult day training providerís location;

††††† c. Assure that service delivery is in accordance with a Michelle P. waiver recipientís plan of care; and

††††† d. Meet the requirements of subsection (4) of this section;

††††† 3. Not include a group conference;

††††† 4. Include development of a plan of care that shall:

††††† a. Be completed on the MAP 109 using Person Centered Planning: Guiding Principles;

††††† b. Reflect the needs of the Michelle P. waiver recipient;

††††† c. List goals, interventions, and outcomes;

††††† d. Specify services needed;

††††† e. Determine the amount, frequency, and duration of services;

††††† f. Provide for reassessment at least every twelve (12) months;

††††† g. Be developed and signed by the case manager and Michelle P. waiver recipient, family member, or legal representative; and

††††† h. Be submitted to the department no later than thirty (30) calendar days after receiving the department's approval of the Michelle P. waiver service level of care;

††††† 5. Include documentation with a detailed monthly summary note which includes:

††††† a. The month, day, and year for the time period each note covers;

††††† b. Progression, regression, and maintenance toward outcomes identified in the plan of care;

††††† c. The signature, date of signature, and title of the individual preparing the note; and

††††† d. Documentation of at least one (1) face-to-face meeting between the case manager and Michelle P. waiver recipient, family member, or legal representative;

††††† 6. Include requiring a Michelle P. waiver recipient or legal representative to sign a MAP-350 form at the time of application or reapplication and at each recertification to document that the individual was informed of the choice to receive Michelle P. waiver or institutional services; and

††††† 7. Not be provided to a recipient by an agency if the agency provides any other Michelle P. waiver service to the recipient;

††††† (d) A homemaker service which shall consist of general household activities and shall:

††††† 1. Be provided by direct care staff;

††††† 2. Be provided to a Michelle P. waiver recipient:

††††† a. Who is functionally unable, but would normally perform age-appropriate homemaker tasks; and

††††† b. If the caregiver regularly responsible for homemaker activities is temporarily absent or functionally unable to manage the homemaking activities; and

††††† 3. Include documentation with a detailed note which shall include:

††††† a. The month, day, and year for the time period each note covers;

††††† b. Progression, regression, and maintenance toward outcomes identified in the plan of care; and

††††† c. The signature, date of signature, and title of the individual preparing the note;

††††† (e) A personal care service which shall:

††††† 1. Be age appropriate;

††††† 2. Consist of assisting a recipient with eating, bathing, dressing, personal hygiene, or other activities of daily living;

††††† 3. Be provided by direct care staff;

††††† 4. Be provided to a Michelle P. waiver recipient:

††††† a. Who does not need highly skilled or technical care;

††††† b. For whom services are essential to the recipient's health and welfare and not for the recipient's family; and

††††† c. Who needs assistance with age-appropriate activities of daily living; and

††††† 5. Include documentation with a detailed note which shall include:

††††† a. The month, day, and year for the time period each note covers;

††††† b. Progression, regression, and maintenance toward outcomes identified in the plan of care;

††††† c. The signature, date of signature, and title of the individual preparing the note; and

††††† d. The beginning and ending time of service;

††††† (f) An attendant care service which shall consist of hands-on care that is:

††††† 1. Provided by direct care staff to a Michelle P. waiver recipient who:

††††† a. Is medically stable but functionally dependent and requires care or supervision twenty-four (24) hours per day; and

††††† b. Has a family member or other primary caretaker who is employed and not able to provide care during working hours;

††††† 2. Not of a general housekeeping nature;

††††† 3. Not provided to a Michelle P. waiver recipient who is receiving any of the following Michelle P. waiver services:

††††† a. Personal care;

††††† b. Homemaker;

††††† c. ADHC;

††††† d. Adult day training;

††††† e. Community living supports; or

††††† f. Supported employment; and

††††† 4. Include documentation with a detailed note which shall include:

††††† a. The month, day, and year for the time period each note covers;

††††† b. Progression, regression, and maintenance toward outcomes identified in the plan of care;

††††† c. The signature, date of signature, and title of the individual preparing the note; and

††††† d. Beginning and ending time of service;

††††† (g) A respite care service which shall be short term care based on the absence or need for relief of the primary caretaker and be:

††††† 1. Provided by direct care staff who provide services at a level which appropriately and safely meets the medical needs of the Michelle P. waiver recipient;

††††† 2. Provided to a Michelle P. waiver recipient who has care needs beyond normal babysitting;

††††† 3. Used no less than every six (6) months;

††††† 4. Provided in accordance with 902 KAR 20:066, Section 2(1)(b)10a through c, if provided to a child under age twenty-one (21) in an ADHC center; and

††††† 5. Include documentation with a detailed note which shall include:

††††† a. The month, day, and year for the time period each note covers;

††††† b. The signature, date of signature, and title of the individual preparing the note; and

††††† c. The beginning and ending time of service;

††††† (h) An environmental and minor home adaptation service which shall be a physical adaptation to a home that is necessary to ensure the health, welfare, and safety of a Michelle P. waiver recipient and which shall:

††††† 1. Meet all applicable safety and local building codes;

††††† 2. Relate strictly to the Michelle P. waiver recipientís disability and needs;

††††† 3. Exclude an adaptation or improvement to a home that has no direct medical or remedial benefit to the Michelle P. waiver recipient;

††††† 4. Be submitted on form MAP 95 for prior authorization; and

††††† 5. Include documentation with a detailed note which shall include:

††††† a. The month, day, and year for the time period each note covers; and

††††† b. The signature, date of signature, and title of the individual preparing the note;

††††† (i) Occupational therapy which shall be:

††††† 1. A physician ordered evaluation of a Michelle P. waiver recipientís level of functioning by applying diagnostic and prognostic tests;

††††† 2. Physician-ordered services in a specified amount and duration to guide a Michelle P. waiver recipient in the use of therapeutic, creative, and self-care activities to assist the recipient in obtaining the highest possible level of functioning;

††††† 3. Training of other Michelle P. waiver providers on improving the level of functioning;

††††† 4. Exclusive of maintenance or the prevention of regression;

††††† 5. Provided by an occupational therapist or an occupational therapy assistant supervised by an occupational therapist in accordance with 201 KAR 28:130; and

††††† 6. Documented with a detailed staff note which shall include:

††††† a. The month, day, and year for the time period each note covers;

††††† b. Progression, regression, and maintenance toward outcomes identified in the plan of care; and

††††† c. The signature, date of signature, and title of the individual preparing the note;

††††† (j) Physical therapy which shall:

††††† 1. Be a physician-ordered evaluation of a Michelle P. waiver recipient by applying muscle, joint, and functional ability tests;

††††† 2. Be physician-ordered treatment in a specified amount and duration to assist a Michelle P. waiver recipient in obtaining the highest possible level of functioning;

††††† 3. Include training of other Michelle P. waiver providers on improving the level of functioning;

††††† 4. Be exclusive of maintenance or the prevention of regression;

††††† 5. Be provided by a physical therapist or a physical therapist assistant supervised by a physical therapist in accordance with 201 KAR 22:001 and 201 KAR 22:053; and

††††† 6. Be documented with a detailed monthly summary note which shall include:

††††† a. The month, day, and year for the time period each note covers;

††††† b. Progression or lack of progression toward outcomes identified in the plan of care; and

††††† c. The signature, date of signature, and title of the individual preparing the note;

††††† (k) Speech therapy which shall:

††††† 1. Be a physician-ordered evaluation of a Michelle P. waiver recipient with a speech or language disorder;

††††† 2. Be a physician-ordered habilitative service in a specified amount and duration to assist a Michelle P. waiver recipient with a speech and language disability in obtaining the highest possible level of functioning;

††††† 3. Include training of other Michelle P. waiver providers on improving the level of functioning;

††††† 4. Be provided by a speech-language pathologist; and

††††† 5. Be documented with a detailed monthly summary note which shall include:

††††† a. The month, day, and year for the time period each note covers;

††††† b. Progression, regression, and maintenance toward outcomes identified in the plan of care; and

††††† c. The signature, date of signature, and title of the individual preparing the note;

††††† (l) An adult day training service which shall:

††††† 1. Support the Michelle P. waiver recipient in daily, meaningful routines in the community;

††††† 2. Stress training in:

††††† a. The activities of daily living;

††††† b. Self-advocacy;

††††† c. Adaptive and social skills; and

††††† d. Vocational skills;

††††† 3. Be provided in a community setting which may:

††††† a. Be a fixed location; or

††††† b. Occur in public venues;

††††† 4. Not be diversional in nature;

††††† 5. If provided on site:

††††† a. Include facility-based services provided on a regularly-scheduled basis;

††††† b. Lead to the acquisition of skills and abilities to prepare the recipient for work or community participation; or

††††† c. Prepare the recipient for transition from school to work or adult support services;

††††† 6. If provided off site:

††††† a. Include services provided in a variety of community settings;

††††† b. Provide access to community-based activities that cannot be provided by natural or other unpaid supports;

††††† c. Be designed to result in increased ability to access community resources without paid supports;

††††† d. Provide the opportunity for the recipient to be involved with other members of the general population; and

††††† e. Be provided as:

††††† (i) An enclave or group approach to training in which recipients work as a group or are dispersed individually throughout an integrated work setting with people without disabilities;

††††† (ii) A mobile crew performing work in a variety of community businesses or other community settings with supervision by the provider; or

††††† (iii) An entrepreneurial or group approach to training for participants to work in a small business created specifically by or for the recipient or recipients;

††††† 7. Ensure that any recipient performing productive work that benefits the organization is paid commensurate with compensation to members of the general work force doing similar work;

††††† 8. Require that an adult day training service provider conduct, at least annually, an orientation informing the recipient of supported employment and other competitive opportunities in the community;

††††† 9. Be provided at a time mutually agreed to by the recipient and Michelle P. waiver provider;

††††† 10.a. Be provided to recipients age twenty-two (22) or older; or

††††† b. Be provided to recipients age sixteen (16) to twenty-one (21) as a transition process from school to work or adult support services; and

††††† 11. Be documented with:

††††† a. A detailed monthly summary note which shall include:

††††† (i) The month, day, and year for the time period each note covers;

††††† (ii) Progression, regression, and maintenance toward outcomes identified in the plan of care; and

††††† (iii) The signature, date of signature, and title of the individual preparing the note; and

††††† b. A time and attendance record which shall include:

††††† (i) The date of service;

††††† (ii) The beginning and ending time of the service;

††††† (iii) The location of the service; and

††††† (iv) The signature, date of signature, and title of the individual providing the service;

††††† (m) A supported employment service which shall:

††††† 1. Be intensive, ongoing support for a Michelle P. waiver recipient to maintain paid employment in an environment in which an individual without a disability is employed;

††††† 2. Include attending to a recipientís personal care needs;

††††† 3. Be provided in a variety of settings;

††††† 4. Be provided on a one-to-one basis;

††††† 5. Be unavailable under a program funded by either 29 U.S.C. Chapter 16 or 34 C.F.R. Subtitle B, Chapter III (34 C.F.R. Parts 300 to 399), proof of which shall be documented in the Michelle P. waiver recipientís file;

††††† 6. Exclude work performed directly for the supported employment provider;

††††† 7. Be provided by a staff person who has completed a supported employment training curriculum conducted by staff of the cabinet or its designee;

††††† 8. Be documented by:

††††† a. A detailed monthly summary note which shall include:

††††† (i) The month, day, and year for the time period each note covers;

††††† (ii) Progression, regression, and maintenance toward outcomes identified in the plan of care; and

††††† (iii) The signature, date of signature, and title of the individual preparing the note; and

††††† b. A time and attendance record which shall include:

††††† (i) The date of service;

††††† (ii) The beginning and ending time of the service;

††††† (iii) The location of the service; and

††††† (iv) The signature, date of signature, and title of the individual providing the service;

††††† (n) A behavioral support service which shall:

††††† 1. Be the systematic application of techniques and methods to influence or change a behavior in a desired way;

††††† 2. Be provided to assist the Michelle P. waiver recipient to learn new behaviors that are directly related to existing challenging behaviors or functionally equivalent replacement behaviors for identified challenging behaviors;

††††† 3. Include a functional assessment of the Michelle P. waiver recipientís behavior which shall include:

††††† a. An analysis of the potential communicative intent of the behavior;

††††† b. The history of reinforcement for the behavior;

††††† c. Critical variables that preceded the behavior;

††††† d. Effects of different situations on the behavior; and

††††† e. A hypothesis regarding the motivation, purpose, and factors which maintain the behavior;

††††† 4. Include the development of a behavioral support plan which shall:

††††† a. Be developed by the behavior support specialist;

††††† b. Be implemented by Michelle P. waiver provider staff in all relevant environments and activities;

††††† c. Be revised as necessary;

††††† d. Define the techniques and procedures used;

††††† e. Be designed to equip the recipient to communicate his or her needs and to participate in age-appropriate activities;

††††† f. Include the hierarchy of behavior interventions ranging from the least to the most restrictive;

††††† g. Reflect the use of positive approaches; and

††††† h. Prohibit the use of restraints, seclusion, corporal punishment, verbal abuse, and any procedure which denies private communication, requisite sleep, shelter, bedding, food, drink, or use of a bathroom facility;

††††† 5. Include the provision of training to other Michelle P. waiver providers concerning implementation of the behavioral support plan;

††††† 6. Include the monitoring of a Michelle P. waiver recipientís progress which shall be accomplished by:

††††† a. The analysis of data concerning the frequency, intensity, and duration of a behavior; and

††††† b. The reports of a Michelle P. waiver provider involved in implementing the behavior support plan;

††††† 7. Provide for the design, implementation, and evaluation of systematic environmental modifications;

††††† 8. Be provided by a behavior support specialist; and

††††† 9. Be documented by a detailed staff note which shall include:

††††† a. The date of service;

††††† b. The beginning and ending time; and

††††† c. The signature, date of signature, and title of the behavior support specialist;

††††† (o) An ADHC service which shall:

††††† 1. Be provided to a Michelle P. waiver recipient who is at least twenty-one (21) years of age;

††††† 2. Include the following basic services and necessities provided to Michelle P. waiver recipients during the posted hours of operation:

††††† a. Skilled nursing services provided by an RN or LPN, including ostomy care, urinary catheter care, decubitus care, tube feeding, venipuncture, insulin injections, tracheotomy care, or medical monitoring;

††††† b. Meal service corresponding with hours of operation with a minimum of one (1) meal per day and therapeutic diets as required;

††††† c. Snacks;

††††† d. Supervision by an RN;

††††† e. Age and diagnosis appropriate daily activities; and

††††† f. Routine services that meet the daily personal and health care needs of a Michelle P. waiver recipient, including:

††††† (i) Monitoring of vital signs;

††††† (ii) Assistance with activities of daily living; and

††††† (iii) Monitoring and supervision of self-administered medications, therapeutic programs, and incidental supplies and equipment needed for use by a Michelle P. waiver recipient;

††††† 3. Include developing, implementing, and maintaining nursing policies for nursing or medical procedures performed in the ADHC center;

††††† 4. Include respite care services pursuant to paragraph (g) of this subsection;

††††† 5. Be provided to a Michelle P. waiver recipient by the health team in an ADHC center which may include:

††††† a. A physician;

††††† b. A physician assistant;

††††† c. An APRN;

††††† d. An RN;

††††† e. An LPN;

††††† f. An activities director;

††††† g. A physical therapist;

††††† h. A physical therapist assistant;

††††† i. An occupational therapist;

††††† j. An occupational therapy assistant;

††††† k. A speech-language pathologist;

††††† l. A social worker;

††††† m. A nutritionist;

††††† n. A health aide;

††††† o. An LPCC;

††††† p. An LMFT;

††††† q. A certified psychologist with autonomous functioning; or

††††† r. A licensed psychological practitioner; and

††††† 6. Be provided pursuant to a plan of treatment. The plan of treatment shall:

††††† a. Be developed and signed by each member of the plan of treatment team which shall include the recipient or a legal representative of the recipient;

††††† b. Include pertinent diagnoses, mental status, services required, frequency of visits to the ADHC center, prognosis, rehabilitation potential, functional limitation, activities permitted, nutritional requirements, medication, treatment, safety measures to protect against injury, instructions for timely discharge, and other pertinent information; and

††††† c. Be developed annually from information on the MAP 351 and revised as needed; and

††††† (p) Community living supports which shall:

††††† 1. Be provided to facilitate independence and promote integration into the community for an SCL recipient residing in his or her own home or in his or her family's home;

††††† 2. Be supports and assistance which shall be related to chosen outcomes and not be diversional in nature. This may include:

††††† a. Routine household tasks and maintenance;

††††† b. Activities of daily living;

††††† c. Personal hygiene;

††††† d. Shopping;

††††† e. Money management;

††††† f. Medication management;

††††† g. Socialization;

††††† h. Relationship building;

††††† i. Leisure choices;

††††† j. Participation in community activities;

††††† k. Therapeutic goals; or

††††† l. Nonmedical care not requiring nurse or physician intervention;

††††† 3. Not replace other work or day activities;

††††† 4. Be provided on a one-on-one basis;

††††† 5. Not be provided at an adult day-training or childrenís

†day habilitation site;

††††† 6. Be documented by:

††††† a. A time and attendance record which shall include:

††††† (i) The date of the service;

††††† (ii) The beginning and ending time of the service; and

††††† (iii) The signature, date of signature, and title of the individual providing the service; and

††††† b. A detailed monthly summary note which shall include:

††††† (i) The month, day, and year for the time period each note covers;

††††† (ii) Progression, regression, and maintenance toward outcomes identified in the plan of care; and

††††† (iii) The signature, date of signature, and title of the individual preparing the summary note; and

††††† 7. Be limited to sixteen (16) hours per day alone or in combination with adult day training and supported employment.

††††† (4) A case manager shall:

††††† (a) Have a bachelor's degree from an accredited institution in a human services field and be supervised by:

††††† 1. A qualified professional in the area of intellectual disabilities;

††††† 2. A registered nurse who has at least two (2) years of experience working with individuals with an intellectual or a development disability;

††††† 3. An individual with a bachelor's degree in a human service field who has at least two (2) years of experience working with individuals with an intellectual or a developmental disability;

††††† 4. A qualified social worker who has at least two (2) years of experience working with individuals with an intellectual or a developmental disability;

††††† 5. A licensed marriage and family therapist who has at least two (2) years of experience working with individuals with an intellectual or a developmental disability;

††††† 6. A licensed professional clinical counselor who has at least two (2) years of experience working with individuals with an intellectual or a developmental disability;

††††† 7. A certified psychologist or licensed psychological associate who has at least two (2) years of experience working with individuals with an intellectual or a developmental disability; or

††††† 8. A licensed psychological practitioner who has at least two (2) years of experience working with individuals with an intellectual or a developmental disability;

††††† (b) Be an RN;

††††† (c) Be an LPN;

††††† (d) Be a qualified social worker;

††††† (e) Be an LMFT;

††††† (f) Be an LPCC;

††††† (g) Be a licensed psychologist; or

††††† (h) Be a licensed psychological practitioner.

 

††††† Section 7. Consumer-Directed Option. (1) Covered services and supports provided to a Michelle P. waiver recipient participating in CDO shall be nonmedical and include:

††††† (a) A home and community support service which shall:

††††† 1. Be available only under the consumer-directed option;

††††† 2. Be provided in the consumerís home or in the community;

††††† 3. Be based upon therapeutic goals and not be diversional in nature;

††††† 4. Not be provided to an individual if the same or similar service is being provided to the individual via non-CDO Michelle P. waiver services; and

††††† 5. Include:

††††† a. Assistance, support, or training in activities including meal preparation, laundry, or routine household care or maintenance;

††††† b. Activities of daily living including bathing, eating, dressing, personal hygiene, shopping, or the use of money;

††††† c. Reminding, observing, or monitoring of medications;

††††† d. Nonmedical care which does not require a nurse or physician intervention;

††††† e. Respite; or

††††† f. Socialization, relationship building, leisure choice, or participation in generic community activities;

††††† (b) Goods and services which shall:

††††† 1. Be individualized;

††††† 2. Be utilized to reduce the need for personal care or to enhance independence within the home or community of the recipient;

††††† 3. Not include experimental goods or services; and

††††† 4. Not include chemical or physical restraints;

††††† (c) A community day support service which shall:

††††† 1. Be available only under the consumer-directed option;

††††† 2. Be provided in a community setting;

††††† 3. Be tailored to the consumerís specific personal outcomes related to the acquisition, improvement, and retention of skills and abilities to prepare and support the consumer for work or community activities, socialization, leisure, or retirement activities;

††††† 4. Be based upon therapeutic goals and not be diversional in nature; and

††††† 5. Not be provided to an individual if the same or similar service is being provided to the individual via non-CDO Michelle P. waiver services; or

††††† (d) Financial management which shall:

††††† 1. Include managing, directing, or dispersing a consumerís funds identified in the consumerís approved CDO budget;

††††† 2. Include payroll processing associated with the individuals hired by a consumer or consumerís representative;

††††† 3. Include withholding local, state, and federal taxes and making payments to appropriate tax authorities on behalf of a consumer;

††††† 4. Be performed by an entity:

††††† a. Enrolled as a Medicaid provider in accordance with 907 KAR 1:672; and

††††† b. With at least two (2) years of experience working with individuals possessing the same or similar level of care needs as those referenced in Section 5 of this administrative regulation;

††††† 5. Include preparing fiscal accounting and expenditure reports for:

††††† a. A consumer or consumerís representative; and

††††† b. The department.

††††† (2) To be covered, a CDO service shall be specified in a plan of care.

††††† (3) Reimbursement for a CDO service shall not exceed the departmentís allowed reimbursement for the same or similar service provided in a non-CDO Michelle P. waiver setting, except that respite may be provided in excess of the cap established in Section 12(2) of this administrative regulation if:

††††† (a) Necessary per the consumer's plan of care; and

††††† (b) Approved by the department in accordance with subsection (13) of this section.

††††† (4) A consumer, including a married consumer, shall choose providers and a consumerís choice shall be reflected or documented in the plan of care.

††††† (5) A consumer may designate a representative to act on the consumer's behalf. The CDO representative shall:

††††† (a) Be twenty-one (21) years of age or older;

††††† (b) Not be monetarily compensated for acting as the CDO representative or providing a CDO service; and

††††† (c) Be appointed by the consumer on a MAP-2000 form.

††††† (6) A consumer may voluntarily terminate CDO services by completing a MAP-2000 and submitting it to the support broker.

††††† (7) The department shall immediately terminate a consumer from CDO services if:

††††† (a) Imminent danger to the consumerís health, safety, or welfare exists;

††††† (b) The consumer fails to pay patient liability;

††††† (c) The recipientís plan of care indicates he or she requires more hours of service than the program can provide; thus, jeopardizing the recipientís safety and welfare due to being left alone without a caregiver present; or

††††† (d) The recipient, caregiver, family, or guardian threatens or intimidates a support broker or other CDO staff.

††††† (8) The department may terminate a consumer from CDO services if it determines that the consumerís CDO provider has not adhered to the plan of care.

††††† (9) Except for a termination required by subsection (7) of this section, prior to a consumerís termination from CDO services, the support broker shall:

††††† (a) Notify the assessment or reassessment service provider of potential termination;

††††† (b) Assist the consumer in developing a resolution and prevention plan;

††††† (c) Allow at least thirty (30) but no more than ninety (90) days for the consumer to resolve the issue, develop and implement a prevention plan, or designate a CDO representative;

††††† (d) Complete, and submit to the department, a MAP-2000 terminating the consumer from CDO services if the consumer fails to meet the requirements in paragraph (c) of this subsection; and

††††† (e) Assist the consumer in transitioning back to traditional Michelle P. waiver services.

††††† (10) Upon an involuntary termination of CDO services, the department shall:

††††† (a) Notify a consumer in writing of its decision to terminate the consumerís CDO participation; and

††††† (b) Inform the consumer of the right to appeal the departmentís decision in accordance with Section 14 of this administrative regulation.

††††† (11) A CDO provider shall:

††††† (a) Be selected by the consumer;

††††† (b) Submit a completed Kentucky Consumer Directed Option Employee/Provider Contract to the support broker;

††††† (c) Be eighteen (18) years of age or older;

††††† (d) Be a citizen of the United States with a valid Social Security number or possess a valid work permit if not a U.S. citizen;

††††† (e) Be able to communicate effectively with the consumer, consumer representative, or family;

††††† (f) Be able to understand and carry out instructions;

††††† (g) Be able to keep records as required by the consumer;

††††† (h) Submit to a criminal background check;

††††† (i) Submit to a check of the nurse aide abuse registry maintained in accordance with 906 KAR 1:100 and not be found on the registry;

††††† (j) Not have pled guilty or been convicted of committing a sex crime or violent crime;

††††† (k) Complete training on the reporting of abuse, neglect, or exploitation in accordance with KRS 209.030 or 620.030 and on the needs of the consumer;

††††† (l) Be approved by the department;

††††† (m) Maintain and submit timesheets documenting hours worked; and

††††† (n) Be a friend, spouse, parent, family member, other relative, employee of a provider agency, or other person hired by the consumer.

††††† (12) A parent, parents combined, or a spouse shall not provide more than forty (40) hours of services in a calendar week (Sunday through Saturday) regardless of the number of children who receive waiver services.

††††† (13)(a) The department shall establish a twelve (12) month budget for a consumer based on the consumerís plan of care.

††††† (b) A consumerís twelve (12) month budget shall not exceed $40,000 unless:

††††† 1. The consumerís support broker requests a budget adjustment to a level higher than $40,000; and

††††† 2. The department approves the adjustment.

††††† (c) The department shall consider the following factors in determining whether to grant a twelve (12) month budget adjustment:

††††† 1. If the proposed services are necessary to prevent imminent institutionalization;

††††† 2. The cost effectiveness of the proposed services;

††††† 3. Protection of the consumerís health, safety, and welfare; and

††††† 4. If a significant change has occurred in the recipientís:

††††† a. Physical condition, resulting in additional loss of function or limitations to activities of daily living and instrumental activities of daily living;

††††† b. Natural support system; or

††††† c. Environmental living arrangement, resulting in the recipientís relocation.

††††† (d) A consumer's twelve (12) month budget may encompass a service or any combination of services listed in subsection (1) of this section, if each service is established in the consumer's plan of care and approved by the department.

††††† (14) Unless approved by the department pursuant to subsection (13)(a) through (c) of this section, if a CDO service is expanded to a point in which expansion necessitates a twelve (12) month budget increase, the entire service shall only be covered via traditional (non-CDO) waiver services.

††††† (15) A support broker shall:

††††† (a) Provide needed assistance to a consumer with any aspect of CDO or blended services;

††††† (b) Be available to a consumer twenty-four (24) hours per day, seven (7) days per week;

††††† (c) Comply with all applicable federal and state laws and requirements;

††††† (d) Continually monitor a consumerís health, safety, and welfare; and

††††† (e) Complete or revise a plan of care using the Person Centered Planning: Guiding Principles.

††††† (16)(a) A support broker or case manager may conduct an assessment or reassessment for a CDO participant.

††††† (b) A CDO assessment or reassessment performed by a support broker shall comply with the assessment or reassessment provisions established in this administrative regulation.

 

††††† Section 8. Annual Expenditure Limit Per Individual. (1) The department shall have an annual expenditure limit per individual receiving services via this administrative regulation.

††††† (2) The limit referenced in subsection (1) of this section shall:

††††† (a) Be an overall limit applied to all services whether CDO services, Michelle P. waiver services not provided via CDO, or a combination of CDO and Michelle P. waiver services; and

††††† (b) Equal $63,000 per year.

 

††††† Section 9. Incident Reporting Process. (1) An incident shall be documented on a Michelle P. Waiver Incident Report Form.

††††† (2) There shall be three (3) classes of incidents including:

††††† (a) A class I incident which shall:

††††† 1. Be minor in nature and not create a serious consequence;

††††† 2. Not require an investigation by the provider agency;

††††† 3. Be reported to the case manager or support broker within twenty-four (24) hours;

††††† 4. Be reported to the guardian as directed by the guardian; and

††††† 5. Be retained on file at the provider and case management or support brokerage agency;

††††† (b) A class II incident which shall:

††††† 1. Be serious in nature;

††††† 2. Involve the use of physical or chemical restraints;

††††† 3. Require an investigation which shall be initiated by the provider agency within twenty-four (24) hours of discovery;

††††† 4. Be reported by the provider agency to:

††††† a. The case manager or support broker within twenty-four (24) hours;

††††† b. The guardian within twenty-four (24) hours;

††††† c. The department within ten (10) calendar days of discovery, and shall include a complete written report of the incident investigation and follow up; and

††††† (c) A class III incident which shall:

††††† 1.a. Be grave in nature;

††††† b. Involve suspected abuse, neglect, or exploitation;

††††† c. Involve a medication error which requires a medical intervention; or

††††† d. Be a death;

††††† 2. Be immediately investigated by the provider agency, and the investigation shall involve the case manager or support broker; and

††††† 3. Be reported by the provider agency to:

††††† a. The case manager or support broker within eight (8) hours of discovery;

††††† b. DCBS immediately upon discovery, if involving suspected abuse, neglect, or exploitation in accordance with KRS Chapter 209 or 620.030;

††††† c. The guardian within eight (8) hours of discovery; and

††††† d. The department within eight (8) hours of discovery and shall include a complete written report of the incident investigation and follow-up within seven (7) calendar days of discovery. If an incident occurs after 5 p.m. on a weekday or occurs on a weekend or holiday, notification to the department shall occur on the following business day.

††††† (3) Documentation with a complete written report for a death shall include:

††††† (a) The recipientís current plan of care;

††††† (b) The recipientís current list of prescribed medications including pro re nata (PRN) medications;

††††† (c) The recipientís current crisis plan;

††††† (d) Medication administration review forms for the current and previous month;

††††† (e) Staff notes from the current and previous month including details of physician and emergency room visits;

††††† (f) Any additional information requested by the department necessary to determine if a corrective action needs to be taken by the Cabinet for Health and Family Services against the provider;

††††† (g) A coronerís report when received; and

††††† (h) If performed, an autopsy report when received.

 

††††† Section 10. Michelle P. Waiver Program Waiting List. (1)(a) If a slot is not available for an individual to enroll in the Michelle P. Waiver Program at the time of applying for the program, the individual shall be placed on a statewide Michelle P. Waiver Program waiting list:

††††† 1. In accordance with subsection (2) of this section; and

††††† 2. Maintained by the department.

††††† (b) Each slot for the Michelle P. Waiver Program shall be contingent upon:

††††† 1. Biennium budget funding;

††††† 2. Federal financial participation; and

††††† 3. Centers for Medicare and Medicaid Services approval.

††††† (2)(a) For an individual to be placed on the Michelle P. Waiver Program waiting list, the individual shall submit to the department a completed Application for MPW Waiver Waiting List.

††††† (b)1. The department shall place the individual on the waiting list if the department confirms that the MAP-621, Application for MPW Waiver Waiting List, has been correctly completed.

††††† 2. If the department determines that a MAP-621, Application for MPW Waiver Waiting List, has not been completed correctly, the department shall return the form to the applicant notifying the applicant of the incorrectness or missing information.

††††† (3) Individuals shall be placed on the Michelle P. Waiver Program waiting list in the chronological order that each application is received and validated by the department.

††††† (4) The department shall send a written notice of placement on the Michelle P. Waiver Program waiting list to the:

††††† (a) Applicant; or

††††† (b) Applicantís legal representative.

††††† (5) At least annually, the department shall contact each individual, or individualís legal representative, on the Michelle P. Waiver Program waiting list to:

††††† (a) Verify the accuracy of the individualís information; and

††††† (b) Verify whether the individual wishes to continue to pursue enrollment in the Michelle P. Waiver Program.

††††† (6) The department shall remove an individual from the Michelle P. Waiver Program waiting list if:

††††† (a) The individual is deceased; or

††††† (b) The department notifies the individual or the individualís legal representative of potential funding approved to enroll the individual in the Michelle P. Waiver Program and the individual or individualís legal representative:

††††† 1. Declines the potential funding for enrollment in the program; and

††††† 2. Does not request to remain on the Michelle P. Waiver Program waiting list.

††††† (7) If, after being notified by the department of potential funding approved to enroll the individual in the Michelle P. Waiver Program, the individual or individualís legal representative declines the potential funding but requests to remain on the Michelle P. Waiver Program waiting list, the individual shall:

††††† (a) Lose his or her current position on the waiting list; and

††††† (b) Be moved to the bottom of the waiting list.

††††† (8) If the department removes an individual from the Michelle P. Waiver Program waiting list pursuant to this section, the department shall send written notice of the removal to:

††††† (a) The individual or the individualís legal representative; and

††††† (b) The individualís Michelle P. Waiver Program coordination provider if the individual has a Michelle P. Waiver Program coordination provider.

††††† (9) The removal of an individual from the Michelle P. Waiver Program waiting list shall not preclude the individual from applying for Michelle P. Waiver Program participation in the future.

††††† (10)(a) An individual who is placed on the Michelle P. Waiver Program waiting list shall be informed about and told how to apply for Medicaid state plan services for which the individual might qualify.

††††† (b) An individual who is under twenty-one (21) years of age and who is placed on the Michelle P. Waiver Program waiting list shall also be informed about Early and Periodic Screening, Diagnostic, and Treatment services.

 

††††† Section 11. Use of Electronic Signatures. (1) The creation, transmission, storage, and other use of electronic signatures and documents shall comply with the requirements established in KRS 369.101 to 369.120.

††††† (2) A provider that chooses to use electronic signatures shall:

††††† (a) Develop and implement a written security policy that shall:

††††† 1. Be adhered to by each of the provider's employees, officers, agents, and contractors;

††††† 2. Identify each electronic signature for which an individual has access; and

††††† 3. Ensure that each electronic signature is created, transmitted, and stored in a secure fashion;

††††† (b) Develop a consent form that shall:

††††† 1. Be completed and executed by each individual using an electronic signature;

††††† 2. Attest to the signature's authenticity; and

††††† 3. Include a statement indicating that the individual has been notified of his or her responsibility in allowing the use of the electronic signature; and

††††† (c) Provide the department, immediately upon request, with:

††††† 1. A copy of the provider's electronic signature policy;

††††† 2. The signed consent form; and

††††† 3. The original filed signature.

 

††††† Section 12. Reimbursement. (1) The following Michelle P. waiver services, alone or in any combination, shall be limited to forty (40) hours per calendar week:

††††† (a) Homemaker;

††††† (b) Personal care;

††††† (c) Attendant care;

††††† (d) Supported employment;

††††† (e) Adult day health care;

††††† (f) Adult day training;

††††† (g) Community living supports;

††††† (h) Physical therapy;

††††† (i) Occupational therapy;

††††† (j) Speech therapy; and

††††† (k) Behavior supports.

††††† (2) Respite services shall not exceed $4,000 per member, per calendar year.

††††† (3) Environmental and minor home adaptation services shall not exceed $500 per member, per calendar year.

††††† (4)(a) The department shall reimburse for a Michelle P. waiver service at the lesser of billed charges or the fixed upper payment rate for each unit of service.

††††† (b) The following rates shall be the fixed upper payment rate limits:

 

Service

Fixed Upper Payment Rate Limit

Unit of Service

Case Management

$50.00

15 minutes

Respite

$4,000 per calendar year

15 minutes

Homemaker

$6.50

15 minutes

Personal Care

$7.50

15 minutes

Attendant Care

$2.90

15 minutes

Supported Employment

$5.54

15 minutes

Adult Day Health Care

$2.75

15 minutes

Adult Day Training

$2.75

15 minutes

Community Living Supports

$5.54

15 minutes

Physical Therapy

$22.17

15 minutes

Occupational Therapy

$22.17

15 minutes

Speech Therapy

$22.17

15 minutes

Behavior Supports

$33.25

15 minutes

Environmental and Minor Home Adaptation

$500 per calendar year

Financial Management

$12.50 (not to exceed eight (8) units or $100.00 per month)

15 minutes

Support Broker

$265.00

One (1) month

 

††††† Section 13. Federal Financial Participation and Approval. The departmentís coverage and reimbursement for services pursuant to this administrative regulation shall be contingent upon:

††††† (1) Receipt of federal financial participation for the coverage and reimbursement; and

††††† (2) Centers for Medicare and Medicaid Servicesí approval of the coverage and reimbursement.

 

††††† Section 14. Appeal Rights. An appeal of a department determination regarding Michelle P. waiver service level of care or services to a Michelle P. waiver recipient or a consumer shall be in accordance with 907 KAR 1:563.

 

††††† Section 15. Incorporation by Reference. (1) The following material is incorporated by reference:

††††† (a) "Person Centered Planning: Guiding Principles", March 2005;

††††† (b) "MAP-24, Commonwealth of Kentucky, Cabinet for Health and Family Services, Department for Medicaid Services Memorandum", August 2008;

††††† (c) "MAP 95 Request for Equipment Form", June 2007;

††††† (d) "MAP 109, Plan of Care/Prior Authorization for Waiver Services", July 2008;

††††† (e) "MAP-350, Long Term Care Facilities and Home and Community Based Program Certification Form", July 2008;

††††† (f) "MAP 351, Department for Medicaid Services, Medicaid Waiver Assessment", July 2008;

††††† (g) "MAP-2000, Initiation/Termination of Consumer Directed Option (CDO)", July 2008;

††††† (h) "MAP 10, Waiver Services Physician's Recommendation", August 2014;

††††† (i) "Kentucky Consumer Directed Option Employee/Provider Contract", August 2010;

††††† (j) "Michelle P. Waiver Incident Report Form", May 2013; and

††††† (k) "MAP-621 Application for MPW Waiver Waiting List", February 2014.

††††† (2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Department for Medicaid Services, 275 East Main Street, Frankfort, Kentucky 40621, Monday through Friday, 8 a.m. to 4:30 p.m. (35 Ky.R. 688; Am. 1493; 1804; 1974; eff. 2-6-2009; TAm 7-16-2013; 40 Ky.R. 2899; 41 Ky.R. 516; 796; eff. 10-31-2014.)