††††† 907 KAR 3:210. Acquired brain injury long-term care waiver services and reimbursement.

 

††††† RELATES TO: KRS 17.165, 202A.011, 205.5605, 205.5607, 205.8451, 205.8477, 314.011, 319.010(8), 319A.010, 319.056, 327.010, 334A.020, 335.300(2), 335.500(3), 620.030, 42 C.F.R. 441 Subpart G, 455 Subpart B, 42 U.S.C. 1396a, 1396b, 1396d, 1396n

††††† STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), 205.5606(1).

††††† 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, by administrative regulation, to comply with a requirement that may be imposed, or opportunity presented, by federal law for the provision of medical assistance to Kentuckyís indigent citizenry. KRS 205.5606(1) requires the cabinet to promulgate administrative regulations to establish a consumer-directed services program to provide an option for the home and community-based services waivers. This administrative regulation establishes the coverage provisions relating to home- and community-based waiver services provided to an individual with an acquired brain injury as an alternative to nursing facility services and including a consumer-directed services program pursuant to KRS 205.5606. The purpose of acquired brain injury long term care waiver services is to provide an alternative to institutional care to individuals with acquired brain injury who require maintenance services.

 

††††† Section 1. Definitions. (1) "ABI" means an acquired brain injury.

††††† (2) "ABI provider" means an entity that meets the criteria established in Section 2 of this administrative regulation.

††††† (3) "ABI recipient" means an individual who meets the criteria established in Section 3 of this administrative regulation.

††††† (4) "ABIB" means the Acquired Brain Injury Branch in the Division of Community Alternatives, in the Cabinet for Health and Family Services.

††††† (5) "Acquired brain injury long term care waiver service" means a home and community based waiver service for an individual who requires long term maintenance and has acquired a brain injury involving the central nervous system that resulted from:

††††† (a) An injury from a physical trauma;

††††† (b) Anoxia or a hypoxic episode; or

††††† (c) Allergic condition, toxic substance, or another acute medical incident.

††††† (6) "ADHC services" means adult day health care services provided on a regularly scheduled basis that ensure optimal functioning of an ABI recipient who does not require twenty-four (24) hour care in an institutional setting.

††††† (7) "Assessment" or "reassessment" means a comprehensive evaluation of abilities, needs, and services that is:

††††† (a) Completed on a MAP 351; and

††††† (b) Submitted to the department:

††††† 1. For a level of care determination; and

††††† 2. No less than every twelve (12) months.

††††† (8) "Axis I diagnosis" means a clinical disorder or other condition which may be a focus of clinical attention.

††††† (9) "Behavior intervention committee" or "BIC" means a group of individuals established to evaluate the technical adequacy of a proposed behavior intervention for an ABI recipient.

††††† (10) "Blended services" means a nonduplicative combination of ABI waiver services identified in Section 4 of this administrative regulation and consumer directed option services identified in Section 8 of this administrative regulation provided in accordance with the recipient's approved plan of care.

††††† (11) "Board certified behavior analyst" means an independent practitioner who is certified by the Behavior Analyst Certification Board, Inc.

††††† (12) "Case manager" means an individual who manages the overall development and monitoring of a recipientís plan of care.

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

††††† (14) "Consumer directed option" or "CDO" means an option established by KRS 205.5606 within the home and community based services waiver that allows a recipient to:

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

††††† (b) Choose a provider of services; and

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

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

††††† (16) "Crisis prevention and response plan" means a plan developed to identify any potential risk to a recipient and to detail a strategy to minimize the risk.

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

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

††††† (19) "Family training" means providing to the family or other responsible person:

††††† (a) Interpretation or explanation of medical examinations and procedures;

††††† (b) Treatment regimens;

††††† (c) Use of equipment specified in the plan of care; or

††††† (d) Advising the family how to assist the participant.

††††† (20) "Good cause" means a circumstance beyond the control of an individual which affects the individualís ability to access funding or services, including:

††††† (a) Illness or hospitalization of the individual which is expected to last sixty (60) days or less;

††††† (b) Death or incapacitation of the primary caregiver;

††††† (c) Required paperwork and documentation for processing in accordance with Section 3 of this administrative regulation that has not been completed but is expected to be completed in two (2) weeks or less; or

††††† (d) The individual not having been accepted for services or placement by a potential provider despite the individual or individualís legal representative having made diligent contact with the potential provider to secure placement or access services within sixty (60) days.

††††† (21) "Human rights committee" means a group of individuals established to protect the rights and welfare of an ABI recipient.

††††† (22) "Human rights restriction" means the denial of a basic right or freedom to which all humans are entitled, including the right to life and physical safety, civil and political rights, freedom of expression, equality before the law, social and cultural justice, the right to participate in culture, the right to food and water, the right to work, and the right to education.

††††† (23) "Interdisciplinary team" means a group of individuals that assist in the development and implementation of an ABI recipientís plan of care consisting of:

††††† (a) The ABI recipient and legal representative if appointed;

††††† (b) A chosen ABI service provider;

††††† (c) A case manager; and

††††† (d) Others as designated by the ABI recipient.

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

††††† (25) "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.

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

††††† (27) "Medically necessary" or "medical necessity" means that a covered benefit is determined to be needed in accordance with 907 KAR 3:130.

††††† (28) "Nursing supports" means training and monitoring of services by a registered nurse or a licensed practical nurse.

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

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

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

††††† (32) "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.

††††† (33) "Pro re nata" or "PRN" means as needed.

††††† (34) "Psychologist" is defined by KRS 319.010(8).

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

††††† (36) "Qualified mental health professional" is defined by KRS 202A.011(12).

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

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

††††† (b) Has one (1) year or more experience as a professional nurse.

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

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

††††† (40) "Support broker" means an individual 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.

††††† Section 2. Non-CDO Provider Participation. (1) In order to provide an ABI waiver service in accordance with Section 4 of this administrative regulation, excluding a consumer-directed option service, an ABI provider shall be:

††††† (a) Enrolled as a Medicaid provider in accordance with 907 KAR 1:671;

††††† (b) Located within an office in the Commonwealth of Kentucky; and

††††† (c)1. A licensed provider in accordance with:

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

††††† b. 902 KAR 20:081, if a home health service provider; or

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

††††† 2. Certified by the department in accordance with 907 KAR 1:145, Section 3, or 907 KAR 3:090, Section 2, if a provider type is not listed in subparagraph 1. of this paragraph.

††††† (2) An ABI provider shall comply with:

††††† (a) 907 KAR 1:672; and

††††† (b) 907 KAR 1:673.

††††† (3) An ABI provider shall have a governing body that shall be:

††††† (a) A legally-constituted entity within the Commonwealth of Kentucky; and

††††† (b) Responsible for the overall operation of the organization including establishing policy that complies with this administrative regulation concerning the operation of the agency and the health, safety, and welfare of an ABI recipient served by the agency.

††††† (4) An ABI provider shall:

††††† (a) Unless participating in the CDO program, ensure that an ABI waiver service is not provided to an ABI recipient by a staff member of the ABI provider who has one (1) of the following blood relationships to the ABI recipient:

††††† 1. Child;

††††† 2. Parent;

††††† 3. Sibling; or

††††† 4. Spouse;

††††† (b) Not enroll an ABI recipient for whom the ABI provider cannot meet the service needs; and

††††† (c) Have and follow written criteria in accordance with this administrative regulation for determining the eligibility of an individual for admission to services.

††††† (5) An ABI provider shall comply with the requirements of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 pursuant to 42 U.S.C. 1320d to 1320d-8.

††††† (6) An ABI provider shall meet the following requirements if responsible for the management of an ABI recipient's funds:

††††† (a) Separate accounting shall be maintained for each ABI recipient or for the recipientís interest in a common trust or special account;

††††† (b) Account balance and records of transactions shall be provided to the ABI recipient or legal representative on a quarterly basis; and

††††† (c) The ABI recipient or legal representative shall be notified if a large balance is accrued that may affect Medicaid eligibility.

††††† (7) An ABI provider shall have a written statement of its mission and values.

††††† (8) An ABI provider shall have written policies and procedures for communication and interaction with a family and legal representative of an ABI recipient which shall:

††††† (a) Require a timely response to an inquiry;

††††† (b) Require the opportunity for interaction with direct care staff;

††††† (c) Require prompt notification of any unusual incident;

††††† (d) Permit visitation with the ABI recipient at a reasonable time and with due regard for the ABI recipient's right of privacy;

††††† (e) Require involvement of the legal representative in decision-making regarding the selection and direction of the service provided; and

††††† (f) Consider the cultural, educational, language, and socioeconomic characteristics of the ABI recipient.

††††† (9) An ABI provider shall ensure the rights of an ABI recipient by:

††††† (a) Making available a description of the rights and the means by which the rights may be exercised, including the right:

††††† 1. To time, space, and opportunity for personal privacy;

††††† 2. To retain and use personal possessions; and

††††† 3. For a supervised residential care, personal care, companion, or respite provider to communicate, associate and meet privately with a person of the ABI recipientís choice, including:

††††† a. The right to send and receive unopened mail; and

††††† b. The right to private, accessible use of the telephone;

††††† (b) Maintaining a grievance and appeals system;

††††† (c) Complying with the Americans with Disabilities Act pursuant to 28 C.F.R. Part 35; and

††††† (d) Prohibiting the use of:

††††† 1. Prone or supine restraint;

††††† 2. Corporal punishment;

††††† 3. Seclusion;

††††† 4. Verbal abuse; or

††††† 5. Any procedure which denies private communication, requisite sleep, shelter, bedding, food, drink, or use of a bathroom facility.

††††† (10) An ABI provider shall maintain fiscal and service records and incident reports for a minimum of six (6) years from the date that a covered service was provided and all records and reports shall be made available to the:

††††† (a) Department;

††††† (b) ABI recipientís selected case manager;

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

††††† (d) General Accounting Office or its designee;

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

††††† (f) Office of the Attorney General or its designee; and

††††† (g) Centers for Medicare and Medicaid Services.

††††† (11) An ABI provider shall cooperate with monitoring visits from monitoring agents.

††††† (12) An ABI provider shall maintain a record for each ABI recipient served that shall:

††††† (a) Be recorded in permanent ink;

††††† (b) Be free from correction fluid;

††††† (c) Have a strike through for each error which is initialed and dated; and

††††† (d) Contain no blank lines between each entry.

††††† (13) A record of each ABI recipient who is served shall:

††††† (a) Be cumulative;

††††† (b) Be readily available;

††††† (c) Contain a legend that identifies any symbol or abbreviation used in making a record entry;

††††† (d) Contain the following specific information:

††††† 1. The ABI recipient's name and Medical Assistance Identification Number (MAID);

††††† 2. An assessment summary relevant to the service area;

††††† 3. The plan of care, MAP 109;

††††† 4. The crisis prevention and response plan that shall include:

††††† a. A list containing emergency contact telephone numbers; and

††††† b. The ABI recipientís history of any allergies with appropriate allergy alerts for severe allergies;

††††† 5. The training objective for any service which provides skills training to the ABI recipient;

††††† 6. The ABI recipient's medication record, including a copy of the prescription or the signed physicianís order and the medication log if medication is administered at the service site;

††††† 7. Legally-adequate consent for the provision of services or other treatment including consent for emergency attention which shall be located at each service site;

††††† 8. The Long Term Care Facilities and Home and Community Based Program Certification form, MAP-350, updated at recertification; and

††††† 9. Current level of care certification;

††††† (e) Be maintained by the provider in a manner to ensure the confidentiality of the ABI recipient's record and other personal information and to allow the ABI recipient or legal representative to determine when to share the information;

††††† (f) Be secured against loss, destruction, or use by an unauthorized person ensured by the provider; and

††††† (g) Be available to the ABI recipient or legal guardian according to the provider's written policy and procedures which shall address the availability of the record.

††††† (14) An ABI provider shall:

††††† (a) Ensure that each new staff person or volunteer performing direct care or a supervisory function has had a tuberculosis (TB) risk assessment performed by a licensed medical professional and, if indicated, a TB skin test with a negative result within the past twelve (12) months as documented on test results received by the provider;

††††† (b) Maintain documentation of the annual TB risk assessment or negative TB test result described in paragraph (a) of this subsection for:

††††† 1. Existing staff; or

††††† 2. A volunteer, if the volunteer performs direct care or a supervisory function;

††††† (c) Ensure that an employee or volunteer who tests positive for TB, or has a history of a positive TB skin test, shall be assessed annually by a licensed medical professional for signs or symptoms of active disease;

††††† (d) If it is determined that signs and symptoms of active TB are present, ensure that the employee or volunteer has follow-up testing administered by the employeeís or volunteerís physician and that the follow-up test results indicate the employee or volunteer does not have active TB disease;

††††† (e) Not permit an individual to work for or volunteer for the provider if the individual has TB or symptoms of active TB;

††††† (f) Maintain documentation for an employee or volunteer with a positive TB test to ensure that active disease or symptoms of active disease are not present;

††††† (g) Prior to the employeeís date of hire or the volunteerís date of service, obtain results of a criminal record check from:

††††† 1. The Administrative Office of the Courts; or

††††† 2. The equivalent out-of-state agency if the individual resided, worked, or volunteered outside Kentucky during the year prior to employment or volunteer service in Kentucky;

††††† (h) Obtain the result of a nurse aide abuse registry check as described in 906 KAR 1:100;

††††† (i) Annually, for twenty-five (25) percent of employees randomly selected, obtain the results of a criminal record check from:

††††† 1. The Kentucky Administrative Office of the Courts; or

††††† 2. The equivalent out-of-state agency, if the individual resided or worked outside of Kentucky during the year prior to employment;

††††† (j) Within thirty (30) days of the date of hire or service as a volunteer, obtain the results of a central registry check as described in 922 KAR 1:470;

††††† (k) Evaluate and document the performance of each employee upon completion of the agencyís designated probationary period, and at a minimum, annually thereafter;

††††† (l) Conduct and document periodic and regularly scheduled supervisory visits of all professional and paraprofessional direct service staff at the service site in order to ensure that high quality, appropriate services are provided to the ABI recipient;

††††† (m) Not employ or permit an individual to serve as a volunteer performing direct care or a supervisory function, if the individual has a prior conviction of an offense delineated in KRS 17.165(1) through (3) or prior felony conviction;

††††† (n) Not permit an employee or volunteer to transport an ABI recipient, if the employee or volunteer has a conviction of Driving under the Influence (DUI) during the past year;

††††† (o) Not employ or permit an individual to serve as a volunteer performing direct care or a supervisory function, if the individual has a conviction of abuse or sale of illegal drugs during the past five (5) years;

††††† (p) Not employ or permit an individual to serve as a volunteer performing direct care or a supervisory function, if the individual has a conviction of abuse, neglect, or exploitation;

††††† (q) Not employ or permit an individual to serve as a volunteer performing direct care or a supervisory function, if the individual has a Cabinet for Health and Family Services finding of child abuse or neglect pursuant to the central registry; and

††††† (r) Not employ or permit an individual to serve as a volunteer performing direct care or a supervisory function, if the individual is listed on the nurse aide abuse registry.

††††† (15) An ABI provider shall:

††††† (a) Have an executive director who:

††††† 1. Is qualified with a bachelorís degree from an accredited institution in administration or a human services field; and

††††† 2. Has a minimum of one (1) year of administrative responsibility in an organization which served an individual with a disability; and

††††† (b) Have adequate direct contact staff who:

††††† 1. Is eighteen (18) years of age or older and has a high school diploma or GED; and

††††† 2. Has a minimum of two (2) years experience in providing a service to an individual with a disability or has successfully completed a formalized training program approved by the department.

††††† (16) An ABI provider shall establish written guidelines which:

††††† (a) Ensure the health, safety, and welfare of the ABI recipient;

††††† (b) Address maintenance of sanitary conditions;

††††† (c) Ensure each site operated by the provider is equipped with:

††††† 1. Operational smoke detectors placed in strategic locations; and

††††† 2. A minimum of two (2) correctly charged fire extinguishers placed in strategic locations, one (1) of which shall be capable of extinguishing a grease fire and with a rating of 1A10BC;

††††† (d) Ensure the availability of a supply of hot and cold running water with the water temperature at a tap, for water used by the ABI recipient, not exceeding 120 degrees Fahrenheit, for a Supervised Residential Care, Adult Day Training, or Adult Day Health provider;

††††† (e) Ensure that the nutritional needs of the ABI recipient are met in accordance with the current recommended dietary allowance of the Food and Nutrition Board of the National Research Council or as specified by a physician;

††††† (f) Ensure that staff who supervise waiver participants in medication administration;

††††† 1. Unless the employee is a licensed or registered nurse, have been provided specific training by a licensed medical professional and competency has been documented on cause and effect and proper administration and storage of medication. The training shall be provided by a nurse, pharmacist, or medical doctor; and

††††† 2. Document on a medication log all medication administered, including:

††††† a. Self-administered and over-the-counter drugs; and

††††† b. The date, time, and initials of the person who administered the medication;

††††† (g) Ensure that the medication shall be:

††††† 1. Kept in a locked container;

††††† 2. Kept under double lock, if it is a controlled substance;

††††† 3. Carried in a proper container labeled with medication, dosage, and time of administration, if administered to the ABI recipient or self-administered at a program site other than the recipientís residence;

††††† 4. Documented on a medication administration form; and

††††† 5. Properly disposed of if it is discontinued; and

††††† (h) Establish policy and procedures for monitoring of medication administration, which shall be approved by the department before services begin to ensure that medication administration will be properly monitored under the policies and procedures as approved by the department.

††††† (17) An ABI provider shall establish and follow written guidelines for handling an emergency or a disaster which shall:

††††† (a) Be readily accessible on site;

††††† (b) Include an evacuation drill:

††††† 1. To be conducted and documented at least quarterly; and

††††† 2. For a residential setting, scheduled to include a time when an ABI recipient is asleep;

††††† (c) Mandate:

††††† 1. That the result of an evacuation drill be evaluated and modified as needed; and

††††† 2. That results of the prior years' evacuation drills be maintained on site.

††††† (18) An ABI provider shall:

††††† (a) Provide orientation for each new employee which shall include the agency's:

††††† 1. Mission;

††††† 2. Goals;

††††† 3. Organization; and

††††† 4. Policies and procedures;

††††† (b) Require documentation of all training provided which shall include the:

††††† 1. Type of training;

††††† 2. Name and title of the trainer;

††††† 3. Length of the training;

††††† 4. Date of completion; and

††††† 5. Signature of the trainee verifying completion;

††††† (c) Ensure that each employee completes ABI training consistent with the curriculum that has been approved by the department, prior to working independently with an ABI recipient, which shall include:

††††† 1. Required orientation in brain injury;

††††† 2. Identifying and reporting:

††††† a. Abuse;

††††† b. Neglect; and

††††† c. Exploitation;

††††† 3. Unless the employee is a licensed or registered nurse, first aid provided by an individual certified as a trainer by:

††††† a. The American Red Cross; or

††††† b. Other nationally accredited organization; and

††††† 4. Coronary pulmonary resuscitation provided by an individual certified as a trainer by:

††††† a The American Red Cross; or

††††† b. Other nationally accredited organization;

††††† (d) Ensure that each employee completes six (6) hours of continuing education in brain injury annually, following the first year of service;

††††† (e) Not be required to receive the training specified in paragraph (c)1 of this subsection if the provider is a professional who has, within the prior five (5) years, attained 2,000 hours of experience providing services to a person with a primary diagnosis of a brain injury including:

††††† 1. An occupational therapist or occupational therapy assistant providing occupational therapy;

††††† 2. A psychologist or psychologist with autonomous functioning providing psychological services;

††††† 3. A speech-language pathologist providing speech therapy;

††††† 4. A board certified behavior analyst; or

††††† 5. A physical therapist or physical therapist assistant providing physical therapy; and

††††† (f) Ensure that prior to the date of service as a volunteer, an individual receives training which shall include:

††††† 1. Required orientation in brain injury as specified in paragraph (c)1, 2, 3, and 4 of this subsection;

††††† 2. Orientation to the agency;

††††† 3. A confidentiality statement; and

††††† 4. Individualized instruction on the needs of the ABI recipient to whom the volunteer shall provide services.

††††† (19) An ABI provider shall provide information to a case manager necessary for completion of a Mayo-Portland Adaptability Inventory-4 for each ABI recipient served by the provider.

††††† (20) A case management provider shall:

††††† (a) Establish a human rights committee which shall:

††††† 1. Include an individual:

††††† a. With a brain injury or a family member of an individual with a brain injury;

††††† b. Not affiliated with the ABI provider; and

††††† c. Who has knowledge and experience in human rights issues;

††††† 2. Review and approve each plan of care with human rights restrictions at a minimum of every six (6) months;

††††† 3. Review and approve, in conjunction with the ABI recipientís team, behavior intervention plans that contain human rights restrictions; and

††††† 4. Review the use of a psychotropic medication by an ABI recipient without an Axis I diagnosis;

††††† (b) Establish a behavior intervention committee which shall:

††††† 1. Include one (1) individual who has expertise in behavior intervention and is not the behavior specialist who wrote the behavior intervention plan;

††††† 2. Be separate from the human rights committee; and

††††† 3. Review and approve, prior to implementation and at a minimum of every six (6) months in conjunction with the ABI recipient's team, an intervention plan that contain human rights restrictions; and

††††† (c) Complete and submit a Mayo-Portland Adaptability Inventory-4 to the department for each ABI recipient:

††††† 1. Within thirty (30) days of the recipient's admission into the ABI program;

††††† 2. Annually thereafter; and

††††† 3. Upon discharge from the ABI Waiver program.

 

††††† Section 3. ABI Recipient Eligibility, Enrollment and Termination. (1) To be eligible to receive a service in the ABI long term care waiver program, and individual shall:

††††† (a) Be at least eighteen (18) years of age;

††††† (b) Have an ABI which necessitates:

††††† 1. Supervision;

††††† 2. Rehabilitative services; and

††††† 3. Long term supports; and

††††† (c) Have an ABI that involves:

††††† 1. Cognition;

††††† 2. Behavior; or

††††† 3. Physical function;

††††† (2) From inception of the ABI long term care waiver through June 30, 2009, the department shall enroll an individual on a first priority basis, if the individual:

††††† (a) Is currently being served in the ABI waiver as established in 907 KAR 3:090 and has reached maximum rehabilitation potential; or

††††† (b) Has previously received ABI waiver services as established in 907 KAR 3:090 and is currently in a nursing facility or ICF/MR/DD and meets the eligibility criteria established in this section.

††††† (3) From inception through June 30, 2009, after all first priority basis individuals outlined in subsection (2)(a) and (b) of this Section have been enrolled, the department shall enroll the remaining ABI rehabilitation waiver waiting list individuals as described in 907 KAR 3:090, Section 7, who meet the eligibility criteria established in this section.

††††† (4) After all individuals have been enrolled pursuant to subsections (2)(a), (2)(b), and (3) of this section, the department shall utilize a first come, first serve priority basis to enroll an individual who meets the eligibility criteria established in this section.

††††† (5) If funding is not available, an individual shall be placed on the ABI long term care waiver waiting list in accordance with Section 7 of this administrative regulation.

††††† (6) A certification packet shall be submitted to the department by a case manager or support broker on behalf of the applicant. The packet shall contain:

††††† (a) A copy of the allocation letter sent to the applicant at the time funding was allocated for the applicant's participation in the ABI Long Term Care Waiver program;

††††† (b) An Assessment form, MAP-351;

††††† (c) A statement of the need for ABI long term care waiver services which shall be signed and dated by a physician on a MAP 10, Waiver Services Physician's Recommendation form;

††††† (d) A Long Term Care Facilities and Home and Community Based Program Certification form, MAP-350;

††††† (e) A Plan of Care form, MAP 109; and

††††† (f) The ABI recipient's MAP-24C, Admittance, Discharge or Transfer of an Individual in the ABI/SCL Program form.

††††† (7) An individual shall receive notification of potential funding allocated for the ABI long term care waiver services for the individual in accordance with this section.

††††† (8) An individual shall meet the patient status criteria for nursing facility services established in 907 KAR 1:022, including nursing facility services for a brain injury.

††††† (9) An individual shall:

††††† (a) Have a primary diagnosis that indicates an ABI with structural, non-degenerative brain injury;

††††† (b) Be medically stable;

††††† (c) Meet Medicaid eligibility requirements established in 907 KAR 1:605;

††††† (d) Exhibit:

††††† 1. Cognitive damage;

††††† 2. Behavioral damage;

††††† 3. Motor damage; or

††††† 4. Sensory damage;

††††† (e) Have a rating of at least four (4) or above on the Rancho Levels of Cognitive Functioning, The Revised Levels - Third Edition; and

††††† (f) Receive notification of approval from the department.

††††† (10) The basis of an eligibility determination for participation in the ABI long term care waiver program shall be the:

††††† (a) Presenting problem;

††††† (b) Plan of care goal;

††††† (c) Expected benefit of the admission;

††††† (d) Expected outcome;

††††† (e) Service required; and

††††† (f) Cost effectiveness of service delivery as an alternative to nursing facility and nursing facility brain injury services.

††††† (11) An ABI long term care waiver service shall not be furnished to an individual if the individual is:

††††† (a) An inpatient of a hospital, nursing facility, or an intermediate care facility for individuals with mental retardation or a developmental disability; or

††††† (b) Receiving a service in another home and community based waiver program.

††††† (12) The department shall make:

††††† (a) An initial evaluation to determine if an individual meets the nursing facility level of care criteria established in 907 KAR 1:022; and

††††† (b) A determination of whether to admit an individual into the ABI long term care waiver program.

††††† (13) To maintain eligibility as an ABI recipient:

††††† (a) An individual shall maintain Medicaid eligibility requirements established in 907 KAR 1:605;

††††† (b) A reevaluation shall be conducted at least once every twelve (12) months to determine if the individual continues to meet the patient status criteria for nursing facility services established in 907 KAR 1:022; and

††††† (c) Progress toward outcomes identified in the approved plan of care shall not be required.

††††† (14) An ABI case manager or support broker provider shall notify the local DCBS office and the department using a MAP-24C, Admittance, Discharge or Transfer of an Individual in the ABI/SCL Program form, if the ABI recipient is:

††††† (a) Admitted to the ABI long term care waiver program;

††††† (b) Discharged from the ABI long term care waiver program;

††††† (c) Temporarily discharged from the ABI long term care waiver program;

††††† (d) Admitted to a nursing facility;

††††† (e) Changing the primary provider; or

††††† (f) Changing the case management agency.

††††† (15) The department shall exclude an individual from receiving an ABI long term care waiver service for whom the average cost of ABI waiver service is reasonably expected to exceed the cost of a nursing facility service.

††††† (16) Involuntary termination and loss of an ABI long term care waiver program placement shall be in accordance with 907 KAR 1:563 and shall be initiated if:

††††† (a) An individual fails to initiate an ABI long term care waiver service within sixty (60) days of notification of potential funding without good cause shown. The individual or legal representative shall have the burden of providing documentation of good cause, including:

††††† 1. A statement signed by the recipient or legal representative;

††††† 2. Copies of letters to providers; and

††††† 3. Copies of letters from providers;

††††† (b) An ABI recipient or legal representative fails to access the required service as outlined in the plan of care for a period greater than sixty (60) consecutive days without good cause shown.

††††† 1. The recipient or legal representative shall have the burden of providing documentation of good cause including:

††††† a. A statement signed by the recipient or legal representative;

††††† b. Copies of letters to providers; and

††††† c. Copies of letters from providers.

††††† 2. Upon receipt of documentation of good cause, the department shall grant one (1) extension period, which shall not exceed sixty (60) days, to the ABI recipient during which time period the recipient shall initiate the ABI long term care waiver services or access the required services as outlined in the plan of care. The extension shall be in writing;

††††† (c) An ABI recipient changes residence outside the Commonwealth of Kentucky;

††††† (d) An ABI recipient does not meet the patient status criteria for nursing facility services established in 907 KAR 1:022;

††††† (e) An ABI recipient is no longer able to be safely served in the community; or

††††† (f) An ABI recipient is no longer actively participating in services within the approved plan of care as determined by the Interdisciplinary Team.

††††† (17) Involuntary termination of a service to an ABI recipient by an ABI provider shall require:

††††† (a) Simultaneous notice, which shall:

††††† 1. Be sent at least thirty (30) days prior to the effective date of the action, to the:

††††† a. Department;

††††† b. ABI recipient or legal representative; and

††††† c. Case manager; and

††††† 2. Include:

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

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

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

††††† c. The ABI recipientís right to appeal the intended action through the providerís appeal or grievance process; and

††††† (b) The case manager in conjunction with the provider to:

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

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

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

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

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

††††† 6. Continue to provide supports until alternative services or another placement is secured; and

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

††††† (18) Voluntary termination and loss of an ABI long term care waiver program placement shall be initiated if an ABI recipient or legal representative submits a written notice of intent to discontinue services to the service provider and to the department.

††††† (a) An action to terminate services shall not be initiated until thirty (30) calendar days from the date of the notice; and

††††† (b) The ABI recipient or legal representative may reconsider and revoke the notice in writing during the thirty (30) calendar day period.

 

††††† Section 4. Covered Services. (1) An ABI waiver service shall be:

††††† (a) Prior-authorized by the department; and

††††† (b) Provided pursuant to the plan of care.

††††† (2) An ABI waiver provider shall provide the following services to an ABI recipient:

††††† (a) Case management services which shall:

††††† 1. Include initiation, coordination, implementation, monitoring of the assessment and reassessment, and intake and eligibility process;

††††† 2. Assist an ABI recipient in the identification, coordination, and facilitation of the interdisciplinary team and interdisciplinary team meetings;

††††† 3. Assist an ABI recipient and the interdisciplinary team with the development of an individualized plan of care and with updating the plan of care as necessary based on changes in the recipient's medical condition and supports;

††††† 4. Include monitoring the delivery of services and the effectiveness of the plan of care, which shall:

††††† a. Be initially developed with the ABI recipient and legal representative, if appointed prior to the level of care determination;

††††† b. Be updated within the first thirty (30) days of service and as changes or recertification occurs; and

††††† c. Include sending the ABI Plan of Care form, MAP 109, to the department or its designee prior to the implementation of the effective date the change occurs with the ABI recipient;

††††† 5. Assist an ABI recipient in obtaining a needed service outside those available by the ABI long term care waiver;

††††† 6. Be provided by a case manager who:

††††† a. Is a registered nurse;

††††† b. Is a licensed practical nurse;

††††† c. Has a bachelorís or masterís degree in a human services field and meets all applicable requirements of the individualís particular field, including a degree in:

††††† (i) Psychology;

††††† (ii) Sociology;

††††† (iii) Social work;

††††† (iv) Rehabilitation counseling; or

††††† (v) Occupational therapy;

††††† d. Is an independent case manager; or

††††† e. Is employed by a free-standing case management agency;

††††† 7. Be provided by a case manager who:

††††† a. Has completed case management training that is consistent with the curriculum that has been approved by the department prior to providing case management services;

††††† b. Shall provide an ABI recipient and legal representative with a listing of each available ABI provider in the service area;

††††† c. Shall maintain documentation signed by an ABI recipient or legal representative of informed choice of an ABI provider and of any change to the selection of an ABI provider and the reason for the change;

††††† d. Shall, within the first thirty (30) days of the service and as information is updated, provide to the chosen ABI service provider a distribution of the:

††††† (i) Crisis prevention and response plan;

††††† (ii) Transition plan;

††††† (iii) Plan of care; and

††††† (iv) Other pertinent documents;

††††† e. Shall provide twenty-four (24) hour telephone access to the ABI recipient and chosen ABI provider;

††††† f. Shall work in conjunction with an ABI provider selected by an ABI recipient to develop a crisis prevention and response plan which shall be:

††††† (i) Individual-specific; and

††††† (ii) Updated as a change occurs and at each recertification;

††††† g. Shall assist an ABI recipient in planning resource use and assuring protection of resources;

††††† h. Shall conduct one (1) face-to-face meeting with an ABI recipient within a calendar month occurring at a covered service site, with one (1) visit quarterly occurring at the ABI recipientís residence;

††††† i. Shall ensure twenty-four (24) hour availability of services; and

††††† j. Shall ensure that the ABI recipientís health, welfare, and safety needs are met; and

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

††††† a. A quarterly summary including documentation of:

††††† (i) Monthly contact with each chosen ABI provider;

††††† (ii) Evidence of monitoring of the delivery of services approved in the recipientís plan of care; and

††††† (iii) Effectiveness of the plan of care;

††††† b. A description of the ABI recipientís health, safety, and welfare;

††††† c. Progress toward outcomes identified in the approved plan of care;

††††† d. The date of the service;

††††† e. Beginning and ending time; and

††††† f. The signature and title of the individual providing the service;

††††† (b) Behavioral services which shall:

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

††††† 2. Include a functional analysis of the ABI recipient's behavior including:

††††† a. An evaluation of the impact of an ABI on:

††††† (i) Cognition; and

††††† (ii) Behavior;

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

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

††††† d. Critical variables that precede the behavior;

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

††††† f. A hypothesis regarding the:

††††† (i) Motivation;

††††† (ii) Purpose; and

††††† (iii) Factors which maintain the behavior;

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

††††† a. Be developed by the behavioral specialist;

††††† b. Not be implemented by the behavior specialist who wrote the plan;

††††† c. Be revised as necessary;

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

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

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

††††† g. Prohibit the use of:

††††† (i) Prone or supine restraint;

††††† (ii) Corporal punishment;

††††† (iii) Seclusion;

††††† (iv) Verbal abuse; and

††††† (v) Any procedure which denies private communication, requisite sleep, shelter, bedding, food, drink, or use of a bathroom facility;

††††† 4. Include the provision of training to other ABI providers concerning implementation of the behavioral intervention plan;

††††† 5. Include the monitoring of an ABI recipient's progress which shall be accomplished through:

††††† a. The analysis of data concerning the:

††††† (i) Frequency;

††††† (ii) Intensity; and

††††† (iii) Duration of a behavior; and

††††† b. Reports involved in implementing the behavioral service plan;

††††† 6. Be provided by a behavior specialist who shall:

††††† a. Be:

††††† (i) A psychologist;

††††† (ii) A psychologist with autonomous functioning;

††††† (iii) A licensed psychological associate;

††††† (iv) A psychiatrist;

††††† (v) A licensed clinical social worker;

††††† (vi) A clinical nurse specialist with a masterís degree in psychiatric nursing or rehabilitation nursing;

††††† (vii) An advanced registered nurse practitioner (ARNP);

††††† (viii) A board certified behavior analyst; or

††††† (ix) A licensed professional clinical counselor; and

††††† b. Have at least one (1) year of behavior specialist experience or provide documentation of completed coursework regarding learning and behavior principles and techniques; and

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

††††† a. The date of the service;

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

††††† c. The signature and title of the behavioral specialist; and

††††† d. A summary of data analysis and progress of the individual related to the approved plan of care;

††††† (c) Community living supports, which shall:

††††† 1. Be provided in accordance with the recipientís plan of care, including:

††††† a. A nonmedical service;

††††† b. Supervision; or

††††† c. Socialization;

††††† 2. Include assistance, prompting, observing, or training in activities of daily living;

††††† 3. Include activities of daily living which shall include:

††††† a. Bathing;

††††† b. Eating;

††††† c. Dressing;

††††† d. Personal hygiene;

††††† e. Shopping; and

††††† f. Money management;

††††† 4. Include prompting, observing, and monitoring of medications and nonmedical care not requiring a nurse or physician intervention;

††††† 5. Include socialization, relationship building, and participation in community activities according to the approved plan of care which are therapeutic and not diversional in nature;

††††† 6. Accompany and assist an ABI recipient while utilizing transportation services;

††††† 7. Include documentation in a detailed staff note which shall include the:

††††† a. Progress toward goals and objectives identified in the approved plan of care;

††††† b. Date of the service;

††††† c. Beginning and ending time; and

††††† d. Signature and title of the individual providing the service;

††††† 8. Not be provided to an ABI recipient who receives community residential services; and

††††† 9. Be provided by a:

††††† a. Home health agency licensed and operating in accordance with 902 KAR 20:081;

††††† b. Community mental health center licensed and operating in accordance with 902 KAR 20:091;

††††† c. Community habilitation program certified at least annually by the department; or

††††† d. Supervised Residential Care setting certified at least annually by the department;

††††† (d) Supervised residential care level I, which:

††††† 1. Shall be provided by:

††††† a. A community mental health center licensed and operating in accordance with 902 KAR 20:091 and certified at least annually by the department; or

††††† b. An approved waiver provider certified at least annually by the department;

††††† 2. Shall not be provided to an ABI recipient unless the recipient has been authorized to receive residential care by the departmentís residential review committee which shall:

††††† a. Consider applications for residential care in the order in which the applications are received;

††††† b. Base residential care decisions on the following factors:

††††† (i) Whether the applicant resides with a caregiver or not;

††††† (ii) Whether the applicant resides with a caregiver but demonstrates maladaptive behavior which places the applicant at significant risk of injury or jeopardy if the caregiver is unable to effectively manage the applicantís behavior or the risk it poses, resulting in the need for removal from the home to a more structured setting; or

††††† (iii) Whether the applicant demonstrates behavior which may result in potential legal problems if not ameliorated;

††††† c. Be comprised of three (3) Cabinet for Health and Family Services employees:

††††† (i) With professional or personal experience with brain injury or other cognitive disabilities; and

††††† (ii) Two (2) of whom shall not be supervised by the manager of the acquired brain injury branch; and

††††† d. Only consider applications for a monthly committee meeting which were received no later than the close of business the day before the committee convenes;

††††† 3. Shall not have more than three (3) ABI recipients simultaneously in a home rented or owned by the ABI provider;

††††† 4. Shall provide nineteen (19) to twenty-four (24) hours of supervision daily unless the provider implements, pursuant to subparagraph 5. of this paragraph, an individualized plan allowing for up to five (5) unsupervised hours per day;

††††† 5. May include the provision of up to five (5) unsupervised hours per day per recipient if the provider develops an individualized plan for the recipient to promote increased independence which shall:

††††† a. Contain provisions necessary to ensure the recipientís health, safety, and welfare;

††††† b. Be approved by the recipientís treatment team, with the approval documented by the provider; and

††††† c. Contain periodic reviews and updates based on changes, if any, in the recipientís status;

††††† 6. Shall include assistance and training with daily living skills including:

††††† a. Ambulating;

††††† b. Dressing;

††††† c. Grooming;

††††† d. Eating;

††††† e. Toileting;

††††† f. Bathing;

††††† g. Meal planning;

††††† h. Grocery shopping;

††††† i. Meal preparation;

††††† j. Laundry;

††††† k. Budgeting and financial matters;

††††† l. Home care and cleaning;

††††† m. Leisure skill instruction; or

††††† n. Self-medication instruction;

††††† 7. Shall include social skills training including the reduction or elimination of maladaptive behaviors in accordance with the individualís plan of care;

††††† 8. Shall include provision or arrangement of transportation to services, activities, or medical appointments as needed;

††††† 9. Shall include accompanying or assisting an ABI recipient while the recipient utilizes transportation services as specified in the recipientís plan of care;

††††† 10. Shall include participation in medical appointments or follow-up care as directed by the medical staff;

††††† 11. Shall be documented by a detailed staff note which shall document:

††††† a. Progress toward goals and objectives identified in the approved plan of care;

††††† b. The date of the service;

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

††††† d. The signature and title of the individual providing the service;

††††† 12. Shall not include the cost of room and board;

††††† 13. Shall be provided to an ABI recipient who:

††††† a. Does not reside with a caregiver;

††††† b. Is residing with a caregiver but demonstrates maladaptive behavior that places him or her at significant risk of injury or jeopardy if the caregiver is unable to effectively manage the behavior or the risk it presents, resulting in the need for removal from the home to a more structured setting; or

††††† c. Demonstrates behavior that may result in potential legal problems if not ameliorated;

††††† 14. May utilize a modular home only if the:

††††† a. Wheels are removed;

††††† b. Home is anchored to a permanent foundation; and

††††† c. Windows are of adequate size for an adult to use as an exit in an emergency;

††††† 15. Shall not utilize a motor home;

††††† 16. Shall provide a sleeping room which ensures that an ABI recipient:

††††† a. Does not share a room with an individual of the opposite gender who is not the ABI recipient's spouse;

††††† b. Does not share a room with an individual who presents a potential threat; and

††††† c. Has a separate bed equipped with substantial springs, a clean and comfortable mattress, and clean bed linens as required for the ABI recipient's health and comfort; and

††††† 17. Shall provide service and training to obtain the outcomes for the ABI recipient as identified in the approved plan of care;

††††† (e) Supervised residential care level II, which:

††††† 1. Shall be provided by:

††††† a. A community mental health center licensed and operating in accordance with 902 KAR 20:091 and certified at least annually by the department; or

††††† b. An approved waiver provider certified at least annually by the department;

††††† 2. Shall not be provided to an ABI recipient unless the recipient has been authorized to receive residential care by the departmentís residential review committee which shall:

††††† a. Consider applications for residential care in the order in which the applications are received;

††††† b. Base residential care decisions on the following factors:

††††† (i) Whether the applicant resides with a caregiver or not;

††††† (ii) Whether the applicant resides with a caregiver but demonstrates maladaptive behavior which places the applicant at significant risk of injury or jeopardy if the caregiver is unable to effectively manage the applicantís behavior or the risk it poses, resulting in the need for removal from the home to a more structured setting; or

††††† (iii) Whether the applicant demonstrates behavior which may result in potential legal problems if not ameliorated;

††††† c. Be comprised of three (3) Cabinet for Health and Family Services employees:

††††† (i) With professional or personal experience with brain injury or other cognitive disabilities; and

††††† (ii) Two (2) of whom shall not be supervised by the manager of the acquired brain injury branch; and

††††† d. Only consider applications for a monthly committee meeting which were received no later than the close of business the day before the committee convenes;

††††† 3. Shall not have more than three (3) ABI recipients simultaneously in a home rented or owned by the ABI provider;

††††† 4. Shall provide twelve (12) to eighteen (18) hours of daily supervision, the amount of which shall:

††††† a. Be based on the recipientís needs;

††††† b. Be approved by the recipientís treatment team; and

††††† c. Be documented in the recipientís plan of care which shall also contain periodic reviews and updates based on changes, if any, in the recipientís status;

††††† 5. Shall include assistance and training with daily living skills including:

††††† a. Ambulating;

††††† b. Dressing;

††††† c. Grooming;

††††† d. Eating;

††††† e. Toileting;

††††† f. Bathing;

††††† g. Meal planning;

††††† h. Grocery shopping;

††††† i. Meal preparation;

††††† j. Laundry;

††††† k. Budgeting and financial matters;

††††† l. Home care and cleaning;

††††† m. Leisure skill instruction; or

††††† n. Self-medication instruction;

††††† 6. Shall include social skills training including the reduction or elimination of maladaptive behaviors in accordance with the individualís plan of care;

††††† 7. Shall include provision or arrangement of transportation to services, activities, or medical appointments as needed;

††††† 8. Shall include accompanying or assisting an ABI recipient while the recipient utilizes transportation services as specified in the recipientís plan of care;

††††† 9. Shall include participation in medical appointments or follow-up care as directed by the medical staff;

††††† 10. Shall include provision of twenty-four (24) hour on-call support;

††††† 11. Shall be documented by a detailed staff note which shall document:

††††† a. Progress toward goals and objectives identified in the approved plan of care;

††††† b. The date of the service;

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

††††† d. The signature and title of the individual providing the service;

††††† 12. Shall not include the cost of room and board;

††††† 13. Shall be provided to an ABI recipient who:

††††† a. Does not reside with a caregiver;

††††† b. Is residing with a caregiver but demonstrates maladaptive behavior that places him or her at significant risk of injury or jeopardy if the caregiver is unable to effectively manage the behavior or the risk it presents, resulting in the need for removal from the home to a more structured setting; or

††††† c. Demonstrates behavior that may result in potential legal problems if not ameliorated;

††††† 14. May utilize a modular home only if the:

††††† a. Wheels are removed;

††††† b. Home is anchored to a permanent foundation; and

††††† c. Windows are of adequate size for an adult to use as an exit in an emergency;

††††† 15. Shall not utilize a motor home;

††††† 16. Shall provide a sleeping room which ensures that an ABI recipient:

††††† a. Does not share a room with an individual of the opposite gender who is not the ABI recipient's spouse;

††††† b. Does not share a room with an individual who presents a potential threat; and

††††† c. Has a separate bed equipped with substantial springs, a clean and comfortable mattress, and clean bed linens as required for the ABI recipient's health and comfort; and

††††† 17. Shall provide service and training to obtain the outcomes for the ABI recipient as identified in the approved plan of care;

††††† (f) Supervised residential care level III, which:

††††† 1. Shall be provided by:

††††† a. A community mental health center licensed and operating in accordance with 902 KAR 20:091 and certified at least annually by the department; or

††††† b. An approved waiver provider certified at least annually by the department;

††††† 2. Shall not be provided to an ABI recipient unless the recipient has been authorized to receive residential care by the departmentís residential review committee which shall:

††††† a. Consider applications for residential care in the order in which the applications are received;

††††† b. Base residential care decisions on the following factors:

††††† (i) Whether the applicant resides with a caregiver or not;

††††† (ii) Whether the applicant resides with a caregiver but demonstrates maladaptive behavior which places the applicant at significant risk of injury or jeopardy if the caregiver is unable to effectively manage the applicantís behavior or the risk it poses, resulting in the need for removal from the home to a more structured setting; or

††††† (iii) Whether the applicant demonstrates behavior which may result in potential legal problems if not ameliorated;

††††† c. Be comprised of three (3) Cabinet for Health and Family Services employees:

††††† (i) With professional or personal experience with brain injury or other cognitive disabilities; and

††††† (ii) Two (2) of whom shall not be supervised by the manager of the acquired brain injury branch; and

††††† d. Only consider applications for a monthly committee meeting which were received no later than the close of business the day before the committee convenes;

††††† 3. May be provided in a single family home, duplex or apartment building to an ABI recipient who lives alone or with an unrelated roommate;

††††† 4. Shall not be provided to more than two (2) ABI recipients simultaneously in one (1) apartment or home;

††††† 5. Shall not be provided in more than two (2) apartments in one (1) building;

††††† 6. Shall, if provided in an apartment building, have staff:

††††† a. Available twenty-four (24) hours per day and seven (7) days per week; and

††††† b. Who do not reside in a dwelling occupied by an ABI recipient;

††††† 7. Shall provide less than twelve (12) hours of supervision or support in the home based on an individualized plan developed by the provider to promote increased independence which shall:

††††† a. Contain provisions necessary to ensure the recipientís health, safety, and welfare;

††††† b. Be approved by the recipientís treatment team, with the approval documented by the provider; and

††††† c. Contain periodic reviews and updates based on changes, if any, in the recipientís status;

††††† 8. Shall include assistance and training with daily living skills including:

††††† a. Ambulating;

††††† b. Dressing;

††††† c. Grooming;

††††† d. Eating;

††††† e. Toileting;

††††† f. Bathing;

††††† g. Meal planning;

††††† h. Grocery shopping;

††††† i. Meal preparation;

††††† j. Laundry;

††††† k. Budgeting and financial matters;

††††† l. Home care and cleaning;

††††† m. Leisure skill instruction; or

††††† n. Self-medication instruction;

††††† 9. Shall include social skills training including the reduction or elimination of maladaptive behaviors in accordance with the individualís plan of care;

††††† 10. Shall include provision or arrangement of transportation to services, activities, or medical appointments as needed;

††††† 11. Shall include accompanying or assisting an ABI recipient while the recipient utilizes transportation services as specified in the recipientís plan of care;

††††† 12. Shall include participation in medical appointments or follow-up care as directed by the medical staff;

††††† 13. Shall be documented by a detailed staff note which shall document:

††††† a. Progress toward goals and objectives identified in the approved plan of care;

††††† b. The date of the service;

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

††††† d. The signature and title of the individual providing the service; and

††††† e. Evidence of at least one (1) daily face-to-face contact with the ABI recipient;

††††† 14. Shall not include the cost of room and board;

††††† 15. Shall be provided to an ABI recipient who:

††††† a. Does not reside with a caregiver;

††††† b. Is residing with a caregiver but demonstrates maladaptive behavior that places him or her at significant risk of injury or jeopardy if the caregiver is unable to effectively manage the behavior or the risk it presents, resulting in the need for removal from the home to a more structured setting; or

††††† c. Demonstrates behavior that may result in potential legal problems if not ameliorated;

††††† 16. May utilize a modular home only if the:

††††† a. Wheels are removed;

††††† b. Home is anchored to a permanent foundation; and

††††† c. Windows are of adequate size for an adult to use as an exit in an emergency;

††††† 17. Shall not utilize a motor home;

††††† 18. Shall provide a sleeping room which ensures that an ABI recipient:

††††† a. Does not share a room with an individual of the opposite gender who is not the ABI recipient's spouse;

††††† b. Does not share a room with an individual who presents a potential threat; and

††††† c. Has a separate bed equipped with substantial springs, a clean and comfortable mattress, and clean bed linens as required for the ABI recipient's health and comfort; and

††††† 19. Shall provide service and training to obtain the outcomes for the ABI recipient as identified in the approved plan of care;

††††† (g) Counseling services which:†† 1. Shall be designed to help an ABI long term care waiver recipient resolve personal issues or interpersonal problems resulting from the recipientís ABI;

††††† 2. Shall assist a family member in implementing an ABI long term care waiver recipientís approved plan of care;

††††† 3. In a severe case, shall be provided as an adjunct to behavioral programming;

††††† 4. Shall include substance abuse or chemical dependency treatment, if needed;

††††† 5. Shall include building and maintaining healthy relationships;

††††† 6. Shall develop social skills or the skills to cope with and adjust to the brain injury;

††††† 7. Shall increase knowledge and awareness of the effects of an ABI;

††††† 8. May include group counseling if the service is:

††††† a. Provided to a maximum of twelve (12) ABI recipients; and

††††† b. Included in the recipientís approved plan of care for:

††††† (i) Substance abuse or chemical dependency treatment;

††††† (ii) Building and maintaining healthy relationships;

††††† (iii) Developing social skills;

††††† (iv) Developing skills to cope with and adjust to a brain injury, including the use of cognitive remediation strategies consisting of the development of compensatory memory and problem solving strategies, and the management of impulsivity; and

††††† (v) Increasing knowledge and awareness of the effects of the acquired brain injury upon the ABI recipientís functioning and social interactions;

††††† 9. Shall be provided by:

††††† a. A psychiatrist;

††††† b. A psychologist;

††††† c. A psychologist with autonomous functioning;

††††† d. A licensed psychological associate;

††††† e. A licensed clinical social worker;

††††† f. A clinical nurse specialist with a masterís degree in psychiatric nursing;

††††† g. An advanced registered nurse practitioner (ARNP);

††††† h. A certified alcohol and drug counselor;

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

††††† j. A licensed professional clinical counselor; and

††††† 10. Shall be documented by a detailed staff note which shall include:

††††† a. Progress toward the goals and objectives established in the plan of care;

††††† b. The date of the service;

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

††††† d. The signature and title of the individual providing the service;

††††† (h) Family training which shall:††† 1. Provide training and counseling services for the families of individuals served in the ABI long term care waiver. Training to family or other responsible persons shall include:

††††† a. Interpretation or explanation of medical examinations and procedures;

††††† b. Treatment regimens;

††††† c. Use of equipment specified in the plan of care; or

††††† d. Advising how to assist the participant;

††††† 2. Include updates as needed to safely maintain the participant at home;

††††† 3. Include specified goals in the ABI recipientís plan of care;

††††† 4. Be training provided to family that may include a person who:

††††† a. Lives with, or provides care to, and ABI long term care waiver recipient; and

††††† b. Is a:

††††† (i) Parent;

††††† (ii) Spouse;

††††† (iii) Child;

††††† (iv) Relative;

††††† (v) Foster family; or

††††† (vi) In-law;

††††† 5. Not include an individual who is employed to care for the consumer;

††††† 6. Be provided by an approved ABI waiver provider that is certified at least annually and which may include:

††††† a. An occupational therapist;

††††† b. A certified occupational therapy assistant;

††††† c. A licensed practical nurse;

††††† d. A physical therapist;

††††† e. A physical therapist assistant;

††††† f. A registered nurse;

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

††††† h. A psychiatrist;

††††† i. A psychologist;

††††† j. A psychologist with autonomous functioning;

††††† k. A licensed psychological associate;

††††† l. A clinical nurse specialist with a masterís degree in:

††††† (i) Psychiatric nursing; or

††††† (ii) Rehabilitative nursing;

††††† m. An advanced registered nurse practitioner (ARNP);

††††† n. A certified alcohol and drug counselor;

††††† o. A licensed professional clinical counselor;

††††† p. A board certified behavior analyst;

††††† q. A licensed clinical social worker; or

††††† r. A licensed marriage and family therapist; and

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

††††† a. Progress toward the goals and objectives established in the plan of care;

††††† b. The date of the service;

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

††††† d. The signature and title of the individual providing the service;

††††† (i) Nursing supports which shall include:

††††† 1.a. A physician order to monitor medical conditions; or

††††† b. A physician order for training and oversight of medical procedures;

††††† 2. The monitoring of specific medical conditions;

††††† 3. Services that shall be provided by:

††††† a. A registered nurse who meets the definition established in KRS 314.011(5); or

††††† b. A licensed practical nurse as defined by KRS 314.011(9) who works under the supervision of a registered nurse; and

††††† 4. Documentation by a detailed staff note which shall include:

††††† a. Progress toward the goals and objectives established in the plan of care;

††††† b. The date of the service;

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

††††† d. The signature and title of the individual providing the service;

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

††††† 1. A physician-ordered evaluation of an ABI recipientís level of functioning by applying diagnostic and prognostic tests;

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

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

††††† 4. Documented by a detailed staff note which shall include:

a. Progress toward goals and objectives identified in the approved plan of care;

††††† b. The date of the service;

††††† c. Beginning and ending time; and

††††† d. The signature and title of the individual providing the service;

††††† (k) A physical therapy service which shall be:

††††† 1. A physician-ordered evaluation of an ABI recipient by applying muscle, joint, and functional ability tests;

††††† 2. Physician-ordered treatment in a specified amount and duration to assist an ABI recipient in obtaining the highest possible level of functioning;

††††† 3. Training of another ABI provider to improve the level of functioning of the recipient in that providerís service setting;

††††† 4. 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 22:020; and

††††† 5. Documented by a detailed staff note which shall include:

††††† a. Progress made toward outcomes identified in the plan of care;

††††† b. The date of the service;

††††† c. Beginning and ending time of the service; and

††††† d. The signature and title of the individual providing the service;

††††† (l) A respite service which shall:

††††† 1. Be provided only to an ABI long term care waiver recipient unable to administer self-care;

††††† 2. Be provided by a:

††††† a. Nursing facility;

††††† b. Community mental health center;

††††† c. Home health agency;

††††† d. Supervised residential care provider;

††††† e. Adult day training provider; or

††††† f. Adult day health care provider;

††††† 3. Be provided on a short-term basis due to the absence or need for relief of an individual providing care to an ABI long term care waiver recipient;

††††† 4. Be limited to 5,760 fifteen (15) minute units per calendar year unless an individual's usual caregiver is unable to provide care due to a:

††††† a. Death in the family;

††††† b. Serious illness; or

††††† c. Hospitalization;

††††† 5. Not be provided to an ABI long term care waiver recipient who receives supervised residential care;

††††† 6. Not include the cost of room and board if provided in a nursing facility; and

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

††††† a. Progress toward goals and objectives identified in the approved plan of care;

††††† b. The date of the service;

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

††††† d. The signature and title of the individual providing the service;

††††† (m) Speech therapy services which shall be:

††††† 1. A physician-ordered evaluation of an ABI recipient with a speech, hearing, or language disorder;

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

††††† 3. Provided by a speech language pathologist; and

††††† 4. Documented by a detailed staff note which shall include:

††††† a. Progress toward goals and objectives identified in the approved plan of care;

††††† b. The date of the service;

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

††††† d. The signature and title of the individual providing the service;

††††† (n) Adult day training services which shall:

††††† 1. Be provided by:

††††† a. An adult day training center which is certified at least annually by the department;

††††† b. An outpatient rehabilitation facility which is licensed and operating in accordance with 902 KAR 20:190; or

††††† c. A community mental health center licensed and operating in accordance with 902 KAR 20:091;

††††† 2. Focus on enabling the individual to attain or maintain the individualís maximum functional level and reintegrate the individual into the community;

††††† 3. Not exceed a staffing ratio of five (5) ABI recipients per one (1) staff person unless an ABI recipient requires individualized special service;

††††† 4. Include the following services:

††††† a. Social skills training related to problematic behaviors identified in the recipient's plan of care;

††††† b. Sensory or motor development;

††††† c. Reduction or elimination of a maladaptive behavior;

††††† d. Prevocational; or

††††† e. Teaching concepts and skills to promote independence including:

††††† (i) Following instructions;

††††† (ii) Attendance and punctuality;

††††† (iii) Task completion;

††††† (iv) Budgeting and money management;

††††† (v) Problem solving; or

††††† (vi) Safety;

††††† 5. Be provided in a nonresidential setting;

††††† 6. Be developed in accordance with an ABI waiver service recipientís overall approved plan of care;

††††† 7. Reflect the recommendations of an ABI waiver service recipientís interdisciplinary team;

††††† 8. Be appropriate:

††††† a. Given an ABI waiver service recipientís:

††††† (i) Age;

††††† (ii) Level of cognitive and behavioral function; and

††††† (iii) Interest;

††††† b. Given an ABI waiver service recipientís ability prior to and after the recipientís injury; and

††††† c. According to the approved plan of care and be therapeutic in nature and not diversional;

††††† 9. Be coordinated with the occupational, speech, or other rehabilitation therapy included in an ABI long term care waiver recipientís plan of care;

††††† 10. Provide an ABI long term care waiver recipient with an organized framework within which to function in the recipientís daily activities;

††††† 11. Entail frequent assessments of an ABI long term care waiver recipientís progress and be appropriately revised as necessary; and

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

††††† a. Progress toward goals and objectives identified in the approved plan of care;

††††† b. The date of the service;

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

††††† d. The signature and title of the individual providing the service;

††††† (o) Adult day health care services which shall:

††††† 1. Be provided by an adult day health care center that is licensed and operating in accordance with 902 KAR 20:066; and

††††† 2. Include the following basic services and necessities provided to a Medicaid ABI long term care waiver recipient during the posted hours of operation:

††††† a. Skilled nursing services provided by a registered nurse or licensed practical nurse, including:

††††† (i) Ostomy care;

††††† (ii) Urinary catheter care;

††††† (iii) Decubitus care;

††††† (iv) Tube feeding;

††††† (v) Venipuncture;

††††† (vi) Insulin injections;

††††† (vii) Tracheotomy care; or

††††† (viii) 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 a registered nurse;

††††† e. Daily activities that are appropriate, given an ABI long term care waiver recipientís:

††††† (i) Age;

††††† (ii) Level of cognitive and behavioral function;

††††† (iii) Interest; and

††††† f. Routine services that meet the daily personal and health care needs of an ABI long term care 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 an ABI long term care waiver recipient;

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

††††† 4. Focus on enabling the individual to attain or maintain the individualís maximum functional level and reintegrate an individual into the community by providing the following training;

††††† a. Social skills training related to problematic behaviors identified in the ABI long term care waiver recipient's plan of care;

††††† b. Sensory or motor development;

††††† c. Reduction or elimination of a maladaptive behavior per the ABI long term care waiver recipientís plan of care;

††††† d. Prevocational services; or

††††† e. Teaching concepts and skills to promote independence including:

††††† (i) Following instructions;

††††† (ii) Attendance and punctuality;

††††† (iii) Task completion;

††††† (iv) Budgeting and money management;

††††† (v) Problem solving; or

††††† (vi) Safety;

††††† 5. Be provided in a nonresidential setting;

††††† 6. Be developed in accordance with an ABI long term care waiver recipientís overall approved plan of care, therapeutic in nature and not diversional;

††††† 7. Reflect the recommendations of an ABI long term care waiver recipientís interdisciplinary team;

††††† 8. Include ancillary services in accordance with 907 KAR 1:023 if ordered by a physician, physician assistant, or advanced registered nurse practitioner in an ABI long term care waiver recipientís adult day health care plan of treatment. Ancillary services shall:

††††† a. Consist of evaluations or reevaluations for the purpose of developing a plan which shall be carried out by the ABI long term care waiver recipient or adult day health care center staff;

††††† b. Be reasonable and necessary for the ABI long term care waiver recipientís condition;

††††† c. Be rehabilitative in nature;

††††† d. Include:

††††† (i) Physical therapy provided by a physical therapist or physical therapist assistant;

††††† (ii) Occupational therapy provided by an occupational therapist or occupational therapy assistant; or

††††† (iii) Speech therapy provided by a speech-language pathologist; and

††††† e. Comply with the physical, occupational, and speech therapy requirements established in Technical Criteria for Reviewing Ancillary Services for Adults in accordance with 907 KAR 1:030, Sections 3 and 6;

††††† 9. Be provided to an ABI long term care waiver recipient by the health team in an adult day health care center which may include:

††††† a. A physician;

††††† b. A physician assistant;

††††† c. An advanced registered nurse practitioner (ARNP);

††††† d. A registered nurse;

††††† e. A licensed practical nurse;

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

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

††††† r. A licensed psychological associate;

††††† 10. Be provided pursuant to a plan of treatment and developed annually in accordance with 902 KAR 20:066 and from information in the MAP 351 and revised as needed; and

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

††††† a. Progress toward goals and objectives identified in the approved plan of care;

††††† b. The date of the service;

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

††††† d. The signature and title of the individual providing the service; and

††††† e. A monthly summary that assesses the participantís status related to the approved plan of care;

††††† (p) Supported employment which shall be:

††††† 1. Intensive, ongoing services for an ABI long term care waiver recipient to maintain paid employment in an environment in which an individual without a disability is employed;

††††† 2. Provided by a:

††††† a. Supported employment provider;

††††† b. Sheltered employment provider; or

††††† c. Structured day program provider;

††††† 3. Provided one-on-one;

††††† 4. Unavailable under a program funded by either the Rehabilitation Act of 1973 (29 U.S.C. Chapter 16) or Pub.L. 99-457 (34 C.F.R. Parts 300 to 399), proof of which shall be documented in the ABI long term care waiver recipient's file;

††††† 5. Limited to forty (40) hours per week alone or in combination with adult day training or adult day health services;

††††† 6. An activity needed to sustain paid work by an ABI long term care waiver recipient receiving waiver services, including:

††††† a. Supervision; and

††††† b. Training;

††††† 7. Exclusive of work performed directly for the supported employment provider; and

††††† 8. Documented by a time and attendance record which shall include:

††††† a. Progress toward the goals and objectives identified in the plan of care;

††††† b. The date of service;

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

††††† d. The signature and title of the individual providing the service;

††††† (q) Specialized medical equipment and supplies which shall:

††††† 1. Include durable and nondurable medical equipment, devices, controls, appliances, or ancillary supplies;

††††† 2. Enable an ABI recipient to increase his or her ability to perform daily living activities or to perceive, control, or communicate with the environment;

††††† 3. Be ordered by a physician and submitted on a Request for Equipment Form, MAP 95, and include three (3) estimates for vision and hearing;

††††† 4. Include equipment necessary for the proper functioning of specialized items;

††††† 5. Not be available through the departmentís durable medical equipment, vision, or hearing programs;

††††† 6. Not be necessary for life support;

††††† 7. Meet applicable standards of manufacture, design, and installation; and

††††† 8. Exclude those items which are not of direct medical or remedial benefit to an ABI recipient;

††††† (r) Environmental and minor home adaptations which shall:

††††† 1. Be provided in accordance with applicable state and local building codes;

††††† 2. Be provided to an ABI recipient if:

††††† a. Ordered by a physician;

††††† b. Prior-authorized by the ABIB;

††††† c. Submitted on a Request for Equipment Form, MAP 95, by a case manager or support broker;

††††† d. Specified in an ABI long term care waiver recipientís approved plan of care;

††††† e. Necessary to enable an ABI recipient to function with greater independence within the recipientís home; and

††††† f. Without the modification, the ABI recipient requires institutionalization;

††††† 3. Not include a vehicle modification;

††††† 4. Be limited to no more than $2,000 for an ABI recipient in a twelve (12) month period; and

††††† 5. If entailing:

††††† a. Electrical work, be provided by a licensed electrician; or

††††† b. Plumbing work, be provided by a licensed plumber;

††††† (s) Assessment services which shall:

††††† 1. Be a comprehensive assessment which shall identify an ABI long term care waiver recipientís needs and the services that the recipientís family cannot manage or arrange for the recipient;

††††† 2. Evaluate an ABI long term care waiver recipientís physical health, mental health, social supports, and environment;

††††† 3. Be requested by an individual requesting ABI services or a family or legal representative of the individual;

††††† 4. Be conducted by an ABI case manager or support broker;

††††† 5. Be conducted within seven (7) calendar days of receipt of the request for assessment;

††††† 6. Include at least one (1) face-to-face contact with the ABI long term care waiver recipient and, if appropriate, the recipientís family by the assessor in the ABI long term care waiver recipientís home; and

††††† 7. Not be reimbursable if the individual does not receive a level of care certification; or

††††† (t) Reassessment services which shall:

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

††††† 2. Be conducted using the same procedures as for an assessment service;

††††† 3. Be conducted by an ABI case manager or support broker and submitted to the department no more than three (3) weeks prior to the expiration of the current level of care certification to ensure that certification is consecutive;

††††† 4. Not be reimbursable if conducted during a period that the ABI long term care waiver recipient is not covered by a valid level of care certification; and

††††† 5. Not be retroactive.

 

††††† Section 5. Exclusions of the Acquired Brain Injury Waiver Program. A condition included in the following list shall not be considered an acquired brain injury requiring specialized rehabilitation:

††††† (1) A stroke treatable in a nursing facility providing routine rehabilitation services;

††††† (2) A spinal cord injury for which there is no known or obvious injury to the intracranial central nervous system;

††††† (3) Progressive dementia or another condition related to mental impairment that is of a chronic degenerative nature, including:

††††† (a) Senile dementia;

††††† (b) Organic brain disorder;

††††† (c) Alzheimerís disease;

††††† (d) Alcoholism; or

††††† (e) Another addiction;

††††† (4) A depression or a psychiatric disorder in which there is no known or obvious central nervous system damage;

††††† (5) A birth defect;

††††† (6) Mental retardation without an etiology to an acquired brain injury; or

††††† (7) A condition which causes an individual to pose a level of danger or an aggression which is unable to be managed and treated in a community.

 

††††† Section 6. Incident Reporting Process. (1) An incident shall be documented on an Incident Report form, MAP-045.

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

††††† (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 within twenty-four (24) hours to the:

††††† a. Case manager; or

††††† b. Support broker;

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

††††† 5. Be retained on file at the:

††††† a. Provider and case management agency; or

††††† b. Support brokerage agency;

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

††††† 1.a. Be serious in nature;

††††† b. Include a medication error; or

††††† c. Involve the use of a physical or chemical restraint;

††††† 2. Require an investigation which shall:

††††† a. Be initiated by the provider agency within twenty-four (24) hours of discovery; and

††††† b. Involve the case manager or support broker; and

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

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

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

††††† c. ABIB within twenty-four (24) hours of discovery followed by:

††††† (i) A complete written report of the incident investigation; and

††††† (ii) Follow-up within ten (10) calendar days of discovery; and

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

††††† 1.a. Be grave in nature;

††††† b. Involve suspected:

††††† (i) Abuse;

††††† (ii) Neglect; or

††††† (iii) 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;

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

††††† d. ABIB within eight (8) hours of discovery followed by:

††††† (i) A complete written report of the incident investigation; and

††††† (ii) Follow-up within seven (7) calendar days of discovery. If an incident occurs after 5 p.m. EST on a weekday or occurs on a weekend or holiday, notification to ABIB shall occur on the following business day.

††††† (3) The following documentation with a complete written report shall be submitted for a death:

††††† (a) A current plan of care;

††††† (b) A current list of prescribed medications including PRN medications;

††††† (c) A current crisis plan;

††††† (d) Medication administration documentation 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;

††††† (g) A coroner's report; and

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

 

††††† Section 7. ABI Long Term Care Waiver Waiting List. (1) An individual eighteen (18) years of age or older applying for an ABI long term care waiver service shall be placed on a statewide ABI long term care waiver waiting list which shall be maintained by the department.

††††† (2) In order to be placed on the ABI long term care waiver waiting list, an individual shall submit to the department a completed:

††††† (a) MAP-26, Program Application Kentucky Medicaid Program Acquired Brain Injury (ABI) Waiver Services Program; and

††††† (b) MAP 10, Waiver Services Physician's Recommendation form.

††††† (3) The order of placement on the ABI long term care waiver waiting list shall be determined by:

††††† (a) Chronological date of receipt of the MAP 10, Waiver Services Physician's Recommendation form;

††††† (b) Category of need of the individual as follows:

††††† 1. Emergency. An emergency shall exist if an immediate service is indicated as determined by:

††††† a. The individual currently is demonstrating behavior related to the individualís acquired brain injury that places the recipient, caregiver, or others at risk of significant harm; or

††††† b. The individual is demonstrating behavior related to the individualís acquired brain injury which has resulted in the individualís arrest; or

††††† 2. Nonemergency; and

††††† (c) The Emergency Committee which shall consider applications for the Acquired Brain Injury long term care waiver program for emergency placement. The Emergency Committee meetings shall regularly occur during the fourth week of each month. To be considered at the monthly committee meeting, an application shall be received by the department no later than three (3) business days before the scheduled committee meeting.

††††† 1. The Emergency Review Committee shall be comprised of three (3) program staff of the cabinet.

††††† a. Each member shall have professional or personal experience with brain injuries or other cognitive disabilities.

††††† b. At least two (2) members shall not be supervised by the branch manager of the Acquired Brain Injury Branch.

††††† (4) In determining chronological status, the original date of receipt of the MAP-26, Program Application Kentucky Medicaid Program Acquired Brain Injury (ABI) Waiver Services Program form, and the MAP 10, Waiver Services Physician's Recommendation form, shall be maintained and not changed if an individual is moved from one (1) category of need to another.

††††† (5) A written statement by a physician or other qualified mental health professional shall be required to support the validation of risk of significant harm to an individual or caregiver, or the nature of the individualís medical need.

††††† (6) Written documentation by law enforcement or court personnel shall be required to support the validation of a history of arrest.

††††† (7) If multiple applications are received on the same date, a lottery shall be held to determine placement on the waiting list within each category of need.

††††† (8) A written notification of placement on the waiting list shall be mailed to the individual or the individualís legal representative and case management provider if identified.

††††† (9) Maintenance of the ABI long term care waiver waiting list shall occur as follows:

††††† (a) The department shall, at a minimum, update the waiting list annually;

††††† (b) If an individual is removed from the ABI long term care waiver waiting list, written notification shall be mailed by the department to the:

††††† 1. Individual;

††††† 2. Individualís legal representative; and

††††† 3. ABI case manager.

††††† (10) Reassignment of category of need shall be completed based on the updated information and validation process.

††††† (11) An individual or legal representative may submit a request for consideration of movement from one (1) category of need to another at any time an individualís status changes.

††††† (12) An individual shall be removed from the ABI long term care waiver waiting list if:

††††† (a) After a documented attempt, the department is unable to locate the individual or the individualís legal representative;

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

††††† (c) The individual or individualís legal representative refuses the offer of ABI long term care waiver services and does not request to be maintained on the ABI long term care waiver waiting list.

††††† (13) If an individual is removed from the ABI long term care waiver waiting list, written notification shall be mailed by the department to the:

††††† (a) Individual or to the individualís legal representative; and

††††† (b) ABI case manager.

††††† (14) The removal of an individual from the ABI long term care waiver waiting list shall not prevent the submittal of a new application at a later date.

††††† (15) Potential funding allocated for services for an individual shall be based upon:

††††† (a) The individualís category of need; and

††††† (b) The individualís chronological date of placement on the ABI long term care waiver waiting list.

 

††††† Section 8. Consumer Directed Option. (1) Covered services and supports provided to an ABI long term care waiver recipient participating in CDO shall 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 by a non-CDO acquired brain injury service; and

††††† 5.a. Be respite for the primary caregiver; or

††††† b. Be supports and assistance related to chosen outcomes to facilitate independence and promote integration into the community for an individual residing in the individualís own home or the home of a family member and may include:

††††† (i) Routine household tasks and maintenance;

††††† (ii) Activities of daily living;

††††† (iii) Personal hygiene;

††††† (iv) Shopping;

††††† (v) Money management;

††††† (vi) Medication management;

††††† (vii) Socialization;

††††† (viii) Relationship building;

††††† (ix) Meal planning;

††††† (x) Meal preparation;

††††† (xi) Grocery shopping; or

††††† (xii) Participation in 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; and

††††† (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:

††††† a. Work or community activities;

††††† b. Socialization; and

††††† c. 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 by a non-CDO acquired brain injury service.

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

††††† (3) Reimbursement for a CDO service shall not exceed the departmentís allowed reimbursement for the same or a similar service provided in a non-CDO ABI setting.

††††† (4) A consumer, including a married consumer, shall choose a provider and the choice of CDO provider shall be documented in the consumerís 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 consumerís plan of care indicates the consumer requires more hours of service than the program can provide, jeopardizing the consumerís safety and welfare due to being left alone without a caregiver present; or

††††† (d) The consumer, 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 the department determines that the consumerís CDO provider has not adhered to the plan of care.

††††† (9) Except as provided in 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 form 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 ABI 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) Except if the consumer failed to pay patient liability, inform the consumer of the right to appeal the departmentís decision in accordance with Section 11 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 conducted by:

††††† 1. The Administrative Office of the Courts if the individual is a Kentucky resident; or

††††† 2. An equivalent out-of-state agency if the individual resided or worked outside Kentucky during the year prior to selection as a provider of CDO services;

††††† (i) Submit to a check of the central registry maintained in accordance with 922 KAR 1:470 and not be found on the registry.

††††† 1. A consumer may employ a provider prior to a central registry check result being obtained for up to thirty (30) days.

††††† 2. If a consumer does not obtain a central registry check result within thirty (30) days of employing a provider, the consumer shall cease employment of the provider until a favorable result is obtained;

††††† (j) 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;

††††† (k) Not have pled guilty or been convicted of committing a sex crime or violent crime as defined in KRS 17.165(1) through (3);

††††† (l) 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;

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

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

††††† (o) 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 family members who receive waiver services.

††††† (13)(a) The department shall establish a budget for a consumer based on the individualís historical costs in any Medicaid waiver program minus five (5) percent to cover costs associated with administering the consumer directed option. If no historical cost exists for the consumer, the consumer's budget shall equal the average per capita historical costs of an ABI waiver recipient participating in the ABI waiver program established by 907 KAR 3:090 minus five (5) percent.

††††† (b) Cost of services authorized by the department for the individual's prior year plan of care but not utilized may be added to the budget if necessary to meet the individual's needs.

††††† (c) The department may adjust a consumer's budget based on the consumer's needs and in accordance with paragraphs (d) and (e) of this subsection.

††††† (d) A consumer's budget shall not be adjusted to a level higher than established in paragraph (a) of this subsection unless:

††††† 1. The consumer's support broker requests an adjustment to a level higher than established in paragraph (a) of this subsection; and

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

††††† (e) The department shall consider the following factors in determining whether to allow for a 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 consumer's health, safety, and welfare; or

††††† 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.

††††† (f) A consumerís budget shall not exceed the average per capita cost of services provided to individuals with a brain injury in a nursing facility.

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

††††† (15) A support broker shall:

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

††††† (b) Be available by phone or in person to a consumer twenty-four (24) hours per day, seven (7) days per week to assist the consumer in obtaining community resources as needed;

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

††††† (d) Continually monitor a consumer's health, safety, and welfare; and

††††† (e) Complete or revise a plan of care using person-centered planning principles.

††††† (16) For a CDO participant, a support broker may conduct an assessment or reassessment.

††††† (17) Financial Management Services shall:

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

††††† (b) Include payroll processing associated with an individual hired by a consumer or the consumerís representative;

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

††††† (d) Be performed by an entity:

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

††††† 2. With at least two (2) years of experience working with acquired brain injury; and

††††† (e) Include preparing fiscal accounting and expenditure reports for:

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

††††† 2. The department.

 

††††† Section 9. Reimbursement and Coverage. (1) The department shall reimburse a participating provider for a service provided to a Medicaid eligible person who meets the ABI long term care waiver program requirements as established in this administrative regulation.

††††† (2) The department shall reimburse an ABI participating long term waiver provider for a prior-authorized ABI long term waiver service, if the service is:

††††† (a) Included in the plan of care and is medically necessary; and

††††† (b) Essential to provide an alternative to institutional care to an individual with acquired brain injury that requires maintenance services.

††††† (3) Exclusions to acquired brain injury long term care waiver program. Under the ABI long term care waiver program, the department shall not reimburse a provider for a service provided:

††††† (a) To an individual who does not meet the criteria established in Section 3 of this administrative regulation; or

††††† (b) Which has not been prior authorized as a part of the plan of care.

††††† (4) Payment Amounts.

††††† (a) A participating ABI long term care waiver service provider shall be reimbursed a fixed rate for reasonable and medically necessary services for a prior-authorized unit of service provided to a recipient.

††††† (b) A participating ABI long term care waiver service provider certified in accordance with this administrative regulation shall be reimbursed at the lesser of:

††††† 1. The providerís usual and customary charge; or

††††† 2. The Medicaid fixed upper payment limit per unit of service as established in subsection (5) of this section.

††††† (5) Fixed upper payment limits.

††††† (a) The rates established in this subsection shall be the fixed upper payment limits, in effect on November 10, 2008, for ABI long term care waiver services in conjunction with the corresponding units of service:

Service

Unit of Service

Upper Payment Limit

Case Management

1 month

$375.00 - limited to one (1) unit per member per month

Community Living Supports

15 minutes

 

$5.56 - limited to 160 units per member, per calendar week.

Respite Care

5 minutes

$4.00 - limited to 5760 units, equal to 1440 hours, per member, per calendar year, except as provided in paragraph (c) of this subsection

Adult Day Health Care

15 minutes

$3.19 - limited to 160 units per member, per calendar week.

Adult Day Training

15 minutes

$4.03 - limited to 160 units per member, per calendar week alone or in combination with supported employment services.

Supported

Employment

15 minutes

$7.98 - limited to 160 units per member, per calendar week alone or in combination with adult day training.

Behavior Programming

15 minutes

$33.61 - limited to 80 units per member, per calendar month for the first three (3) months; after initial three (3) months limited to forty-eight (48) units per member, per month.

Counseling Ė Individual

 

 

Counseling Ė Group

15 minutes

 

 

 

15 minutes

$23.84 - limited to 52 units per member, per month.

 

$5.75 - limited to 48 units per member, per calendar month.

Occupational Therapy

15 minutes

$25.90 - limited to 52 units per member, per calendar month.

Speech Therapy

15 minutes

$28.41 - limited to 52 units per member, per calendar month

Specialized Medical Equipment and Supplies (see paragraph (b) of this subsection)

Per Item

As negotiated by the department

Environmental

Modification

Per Modification

Actual cost not to exceed $2000 per member, per calendar year.

Supervised Residential Care Level I

(1) calendar day

$200.00 - Limited to one (1) unit per member, per calendar day

Supervised Residential Care Level II

(1) calendar day

$150.00 - Limited to one (1) unit per member, per calendar day

Supervised Residential Care Level III

(1) calendar day

$75.00 - Limited to one (1) unit per member, per calendar day

Nursing Supports

15 minutes

$25.00 - Limited to 28 units per member, per calendar week

Family Training

15 minutes

$25.00 - Limited to 8 units per member, per calendar week

Physical Therapy

15 minutes

$25.00 - Limited to 52 units per member, per calendar month.

Assessment

One (1) unit equals entire process

$100.00

Assessment or Reassessment

One (1) unit equals entire process

$100.00

Consumer Directed Options:

 

 

Home and Community Supports

 

Service limited by dollar amount prior authorized by QIO based on DMS approved consumer budget

Community Day Supports

 

Service limited by dollar amount prior authorized by QIO based on DMS approved consumer budget

Goods and Services

 

Service limited by dollar amount prior authorized by DMS based on DMS approved consumer budget

Support Broker

One (1) unit equal to one (1) calendar month

$375.00 - Limited to one (1) unit per member, per calendar month

Financial

Management

Services

Fifteen (15) minutes

$12.50 Limited to eight (8) units per member, per calendar month

††††† (b) Specialized medical equipment and supplies shall be reimbursed on a per item basis based on a reasonable cost as negotiated by the department if they meet the following criteria:

††††† 1. They are not covered through the Medicaid durable medical equipment program established in 907 KAR 1:479; and

††††† 2. They are provided to an individual participating in the ABI waiver program.

††††† (c) Respite care may exceed 1440 hours in a twelve (12) month period if an individualís usual caregiver is unable to provide care due to a:

††††† 1. Death in the family;

††††† 2. Serious illness; or

††††† 3. Hospitalization.

††††† (d) If supported employment services are provided at a work site in which persons without disabilities are employed, payment shall be made only for the supervision and training required as the result of the ABI recipientís disabilities and shall not include payment for supervisory activities normally rendered.

††††† (e) The department shall only pay for supported employment services for an individual if supported employment services are unavailable under a program funded by either the Rehabilitation Act of 1973 (29 U.S.C. Chapter 16) or Pub.L. 94-142 (34 C.F.R. Subtitle B, Chapter III). For an individual receiving supported employment services, documentation shall be maintained in the individualís record demonstrating that the services are not currently available under a program funded by either the Rehabilitation Act of 1973 (29 U.S.C. Chapter 16) or Pub.L. 94-142 (34 C.F.R. Subtitle B, Chapter III).

††††† (6) Payment Exclusions. Payment shall not include:

††††† (a) The cost of room and board, unless provided as part of respite care in a Medicaid certified nursing facility. If an ABI recipient is placed in a nursing facility to receive respite care, the department shall pay the nursing facility its per diem rate for that individual;

††††† (b) The cost of maintenance, upkeep, an improvement, or an environmental modification to a group home or other licensed facility;

††††† (c) The cost of a service that is not listed in the approved plan of care; or

††††† (d) A service provided by a family member unless provided under an approved service through consumer directed option.

††††† (7) Records Maintenance. A participating provider shall:

††††† (a) Maintain fiscal and service records for a period of at least six (6) years; and

††††† (b) Provide, as requested by the department, a copy of, and access to, each record of the ABI Waiver Program retained by the provider pursuant to paragraph (a) of this subsection or 907 KAR 1:672, Sections 2, 3, and 4; and

††††† (c) Upon request, make available service and financial records to a representative or designee of the:

††††† 1. Commonwealth of Kentucky, Cabinet for Health and Family Services;

††††† 2. United States Department for Health and Human Services, Comptroller General;

††††† 3. United States Department for Health and Human Services, Centers for Medicare and Medicaid Services (CMS);

††††† 4. General Accounting Office;

††††† 5. Commonwealth of Kentucky, Office of the Auditor of Public Accounts; or

††††† 6. Commonwealth of Kentucky, Office of the Attorney General.

 

††††† Section 10. Electronic Signature Usage. (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) An ABI long term care waiver provider which chooses to use electronic signatures shall:

††††† (a) Develop and implement a written security policy which 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 which 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 with:

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

††††† 2. The signed consent form; and

††††† 3. The original filed signature immediately upon request.

 

††††† Section 11. Appeal Rights. (1) An appeal of a department decision regarding a Medicaid beneficiary based upon an application of this administrative regulation shall be in accordance with 907 KAR 1:563.

††††† (2) An appeal of a department decision regarding Medicaid eligibility of an individual based upon an application of this administrative regulation shall be in accordance with 907 KAR 1:560.

††††† (3) An appeal of a department decision regarding a provider based upon an application of this administrative regulation:

††††† (a) Regarding a providerís reimbursement shall be in accordance with 907 KAR 1:671, Sections 8 and 9; or

††††† (b) Not regarding a providerís reimbursement shall be in accordance with 907 KAR 1:671.

 

††††† Section 12. Incorporation by Reference. (1) The following material is incorporated by reference:

††††† (a) "MAP 10, Waiver Services Physician's Recommendation", July 2008 edition;

††††† (b) "MAP-24C, Admittance, Discharge or Transfer of an Individual in the ABI/SCL Program", July 2008 edition;

††††† (c) "MAP-26, Program Application Kentucky Medicaid Program Acquired Brain Injury (ABI) Waiver Services Program", July 2008 edition;

††††† (d) "MAP-045, Incident Report", July 2008 edition;

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

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

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

††††† (h) "MAP 351, Medicaid Waiver Assessment", July 2008 edition;

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

††††† (j) "Mayo-Portland Adaptability Inventory-4", March 2003 edition;

††††† (k) "The Rancho Levels of Cognitive Functioning, The Revised Levels - Third Edition", 1998; and

††††† (l) "Kentucky Consumer Directed Option Employee Provider Contract", revised April 19, 2007.

††††† (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. 1675; 2096; 2267; eff. 5-1-2009.)