August 11 2021 Heightened Scrutiny Settings Evidentiary Package

August 11, 2021 Heightened Scrutiny Settings: Evidentiary Package Training

Dr. Lisa A. Mills, Lead Subject Matter Expert for Econ. Sys Shannon Webb, Subject Matter Expert for Econ. Sys (Lead SME for Heightened Scrutiny Settings) Presenters and Hosts Heidi Bechard, OADS Manager for HCBS Settings Rule Initiative Derek Fales, Waiver Director, OADS

Summary of Heightened Scrutiny Settings Type of Setting # Determined Isolating 6+ Gr Home 13 3 -5 Gr Home 24 1 -2 Gr Home 30 FCH 5 SL-Unrelated 15 SL-Related Family Member 7 Community Supports 82 TOTAL 176 10% of All Settings with Findings Report Issued

Heightened Scrutiny Settings • 5 settings fully remediated as of 7/1/21 • 171 settings require Evidentiary Package

Why is Evidentiary Package (EP) Required? • Settings that are determined to isolate must go through federal “Heightened Scrutiny” review § 441. 301(c)(5)(v): Any setting that has the effect of isolating individuals receiving Medicaid HCBS from the broader community of individuals not receiving Medicaid HCBS will be presumed to be a setting that has the qualities of an institution (and, therefore, cannot be used for HCBS) unless the DHHS Secretary determines through heightened scrutiny review based on information presented by the State or other parties that the setting does not have the qualities of an institution and that the setting does have the qualities of home and community-based settings. • What is submitted for review is called the “Evidentiary Package”

Evidentiary Package (EP) Cover Letter • All HS settings receive a cover letter that explains the EP: • With 7/1/21 Compliance Determination email notice (if setting was trying to fully remediate by 7/1/21); OR With approved Transition to Compliance Plan email notice (for settings with remediation target dates after 7/1/21) • • You have 60 -days from the date of the cover letter to complete/upload the EP template and any supporting documents not already uploaded to portal • Only exception: If you receive an approved TTCP anytime after 8/31/21, the EP is still due by no later than 10/31/21. A small number of settings may have less than 60 days. • Cover letter provides instructions for uploading EP. Instructions are also included in the EP template itself.

8/31/21: Provider receives approved Transition-to-Compliance Plan for setting. EP Process and Timeframes Note: Submitting semiannual progress reports on implementing Transition-to-Compliance Plan (TTCP) for the setting is separate process. 10/31/21: Provider uploads draft EP and attachments to HCBS Compliance Portal 11/30/21: SME feedback on draft EP sent to Provider 12/31/21: Provider uploads final EP and any additional attachments to HCBS Compliance Portal 1/31/22: State reviews narrative for all final EPs and decides which will be posted for public comment with the Maine Final Statewide Transition Plan 2/28/22 to 3/30/22: EPs posted for public comment with Maine Final Statewide Transition Plan 4/1/22 -4/30/22: State reviews public comments on EPs and makes final decision on EPs to submit to CMS for federal Heightened Scrutiny review/decision 5/1/22: State submits EPs to CMS for federal Heightened Scrutiny review and decision [Note: Timeframe for CMS issuing decision has been requested from CMS but not yet received. ]

Evidentiary Package (EP) Blank Template • Find it on the HCBS Compliance Portal: https: //maine. hcbscompliance. com/Heightened%20 Scrutiny%20 Ev identiary%20 Package%20 Template%20 FINAL%20 CMS%20 Revie wed-7 -15 -21 Locked. docx After today, this slide deck, the recording of the training, and 2 tools we will introduce during this training will be posted at: https: //maine. hcbscompliance. com/training_materials

How to Download the EP Template For settings trying to remediate before 7/1/21: EP template was attached to the 7/1/21 Compliance Determination Notice For all other HS settings: EP template is attached to the approved Transition to Compliance Plan notice EP template can also be downloaded from the portal by going to the setting’s Profile Page

EP Template Sections I. Contact Information (Page 1)

EP Template Sections II. Instructions (Pages 1 -2)

EP Template Sections II. Instructions (Pages 1 -2): Continued

EP Template Sections II. Instructions (Pages 1 -2): Continued

EP Template Sections II. Instructions (Pages 1 -2): What Not To Include in Your EP

EP Template Sections III. Evidence Package (Pages 3 -12) • 18 Questions that require narrative response and listing of supporting evidence (Each question deals with different rule requirement) • Shared Living-Related Family Member Settings only required to address the first 12 questions. • All other residential settings must address all 18 questions. • Non-Residential Settings only required to address the first 16 questions.

Evidentiary Package Example (Question 3)

Evidentiary Package (EP) Narrative Responses Narrative response is most critical. Narratives will be the most consistently read portion of the EP.

Evidentiary Package (EP) Narrative Responses (continued) • Narrative to Demonstrate Two Things: 1. The setting’s current compliance with HCBS Rule requirements 2. A clear picture of how, after remediation (as described in approved TTCP) is done, the experience of HCBS participants served in the setting will not be isolating and will reflect all HCBS Rule requirements. • Full implementation of your approved TTCP, based on the target dates in the Plan, is required in addition to the EP.

Evidentiary Package (EP) Narrative Responses (continued-2) Narrative PART ONE: Addressing Current Compliance: 1. This includes ALL of the Self-Assessment areas (questions) which were NOT listed in the setting’s Findings Report because the setting was determined compliant on these areas (questions). See Tools to Assist You: Residential-Evidentiary Package-Statements for Compliant Areas Non-Residential-Evidentiary Package-Statements for Compliant Areas § § Supporting documents are used to verify this narrative; not substitute for the narrative. BOTH narrative and supporting documents are necessary to demonstrate the setting’s current compliance.

Tool: “Residential-Evidentiary Package-Statements for Compliant Areas” Self-Assessment Question Statement to Include in EP if this Question IS NOT Listed in Findings Report Include Statement As Part of Response to Which Evidentiary Package (EP) Question? Note: The statement of compliance in column B may also be relevant for other EP questions. Q 1: Is the setting adjacent to or under the same roof as a building that houses a publicly or privately-operated setting which provides The setting is not adjacent to or under the same roof as a building that houses a publicly or privatelyinpatient institutional care: skilled nursing setting (SNF), immediate operated setting which provides inpatient institutional care setting for individuals with intellectual disabilities (ICF/IID), institute for mental disease (IMD), or hospital? 1 Q 2: Is the setting located on the grounds of, or immediately adjacent to, a building that is a public institution which provides inpatient The setting is not located on the grounds of, or immediately adjacent to, a building that is a public institutional care (Skilled Nursing Setting (SNF), Intermediate Care which provides inpatient institutional care. Setting for Individuals with Intellectual (ICF/IID), Institute for Mental Disease (IMD), or hospital)? 1 Q 7: Are there gates, fences, locked doors, or other barriers that would There are no gates, fences, locked doors, or other barriers that would prevent a person’s entrance to or exit from the setting? from the setting. 2 Q 8: Is a telephone available to people for personal use? 2 A telephone is available to people for personal use.

Evidentiary Package Example (Question 3)

Evidentiary Package (EP) Supporting Information • 1. Supporting Documents to Demonstrate One Thing: The setting’s current compliance with HCBS Rule requirements Because you are in the process of remediation, the only supporting documents you should submit with the EP are those documents demonstrating current compliance that was confirmed through validation process.

Examples of Supporting Evidence 2 Community Inclusion Uploaded 6/28/21 to Provider Page 2 Employment First Policy Uploaded 6/28/21 to Provider Page 2 Transportation Policy Uploaded 6/28/21 to Provider Page 2 Person-Centered Planning Policy Uploaded 6/28/21 to Provider Page Positive Personal Profile Attached Skills Assessment Attached Relationship Map Attached Interest Inventory Attached ISP Template Attached Transportation Planning Form Attached Daily Documentation Template Attached Quarterly Progress Reporting Form Attached Staff Training Plan for Community Inclusion Attached

Evidentiary Package Narrative Describing Full Compliance After Remediation Narrative PART TWO: Describing Future (Full) Compliance: • Narrative painting a clear picture of how, after remediation (as described in approved TTCP) is done, the experience of HCBS participants served in the setting will not be isolating and will reflect all HCBS Rule requirements. • Address how remediation will change the setting and the experience of people receiving services in the setting. • This narrative is future tense. There is no supporting documentation at this point.

Developing a Strong EP Narrative: Suggestions/Tips • Ensure concise, clear use of language that is understandable • Provide enough details and information for each Question to convince the reader of: 1. The setting’s current level of compliance (as supported by validation and findings report); and 2. The setting’s ability to become fully compliant after implementation of remediation as required in the Transition-to. Compliance-Plan (TTCP)

Developing a Strong EP Narrative: Suggestions/Tips (continued) • Use statements of compliance in tools provided by Econ. Sys • Use bullets and group information based on similar content • Read thorough the written information, is it through, is it clear, is there enough detail? • Have another person read through thoroughly for spelling, punctuation and alignment with content requirements

Example Narrative: Question #2 Describe how the setting will support HCBS waiver members to have full and person-centered access to community places and opportunities for involvement with members of the broader community, beyond family, who do not receive HCBS and who are not paid staff.

Unacceptable Example People in this setting already access the community. Staff provide transportation upon request because the guardians do not want the people in this setting to take any other form of transportation. During the PCP we discuss community goals, including employment, and choices of activities the person prefers. This is implemented into the service plan. Staff have begun asking people if they want to be employed. We have uploaded the redacted PCP, transportation log, and daily documentation to the portal describing this remediation.

Acceptable Example ABC, Inc. current provides supports to members to access their communities for shopping and medical appointments. The setting has a wheelchair accessible van and staffing ratios adequate enough to provide transportation for these activities as well as transportation to community supports programs and employment. ABC, Inc. has submitted and received approval for policies related to community inclusion, employment, transportation and person-centered planning. We have an established practice of being part of person-centered planning teams, engaging members in preplanning and providing regular progress updates. Additionally, our Service Coordinators conduct monthly conversations with members about their plans and goals, adjusting the plans as needed and informing staff of changes. All of our staff are trained in Person-Centered Planning using the CDS modules as well as supplemental training on positive supports and person-centered strategies developed and provided by ABC, Inc.

To fully align with the HCBS Settings Rule, ABC, Inc. will begin to utilize four primary personcentered planning tools with each member served to determine their interests, preferences, and goals: 1) Positive Personal Profile, 2) relationship mapping tool from the Friends manual, 3) skills assessment form and 4) interest inventory based on opportunity mapping that ABC, Inc. has done in the local community. These tools will be used to engage members (and key informants from the team if appropriate) in exploratory discussions to develop Individualized Service Plans (ISPs), along with information provided from the Person. Centered Plan. ABC, Inc. will encourage each member to develop at least one goal related to community connection and contribution (going beyond shopping, economic exchange and medical appointments) such as employment, volunteering, joining a club/interest group, taking a class, taking up a new hobby that involves interacting with others in meaningful ways, etc. We will provide the support necessary for the member to feel comfortable pursuing this goal, at the pace they determine. With the member (and team as appropriate) a we will generate a preliminary list of ideas based on the four tools and create a schedule for the month, which will be flexible and individualized. ABC, Inc. will not “make” members to do things they do not want to do, however, our staff will be trained on motivational interviewing and other positive support techniques in order to engage members and their guardians in conversations to explore possibilities, identify and address concerns, and expand members’ horizons.

As members explore and connect to their communities, ABC Inc. staff will document the person’s discovery journey, their preferences, emerging interests, and connections. The service coordinator will review this documentation monthly, meet with each member to review and update their Positive Personal Profile and discuss/adjust/create their plan for the next month, after which staff will be notified of the plan. Staff will be trained on facilitating community relationships through the training provided by Dr. Angela Amado as well as modules from Open Future Learning. The Service Coordinator will meet with staff every month to discuss progress members are making as well as guide and trouble shoot with staff to ensure they are using best practices when supporting people in the community. On a quarterly basis, Service Coordinators will meet with each member to update their Positive Personal Profile and develop a progress report, both which will be shared with the team. The ISP will be updated accordingly with the member/guardian’s consent.

ABC, Inc. will work with members to identify daily opportunities for community access, engagement and contribution through opportunities for learning, recreation, hobbies, giving back in small ways to neighbors and friends, or bigger ways such as formal volunteer experiences. Most adults contribute to their communities through employment. Therefore, ABC, Inc. will provide positive supports to all working-aged members to explore employment at least monthly but ideally more often that. For people who express a desire to work, ABC Inc. will actively work to connect the member to resources and supports to pursue employment. For people who are reluctant or disinterested, exploration will go beyond simple conversation between staff and member. ABC will learn about people’s skills and interests to support them develop valued social roles by pursuing those interests and using their skills. We will also identify concerns or barriers to employment and actively work to address those with the member and their team. ABC, Inc. will also arrange peer-to-peer conversations about work, support members to tour local businesses and arrange informational interviews about jobs and careers.

For members who are of retirement age, ABC Inc. will explore if they have the desire to (return) to work since sometimes retirees decide to go back to work and/or if they would like to find new or different ways to engage with their community through volunteer experiences, hobbies and recreation opportunities. To ensure that each member has the transportation and support necessary for planned and spontaneous access to the community, ABC Inc. will complete a transportation planning tool with members and identify members’ natural supports. The transportation planning tool will help ABC, Inc. determine members’ transportation barriers and possible accommodations. We will then work with members to try alternative transportation modes with staff support, provide mobility training and assist each member with budgeting for transportation needs. We will reach out to members’ natural supports to determine when they could be available for transportation and/or support, should transportation or staff support not be available at the time a member wants to do something. Details of this available support will be added to members’ plan and shared with staff. Staff will support members to connect with these natural supporters and alternative forms of transportation when needed.

Where to Upload the Completed EP Package Upload to the setting’s Profile Page: 1. The completed EP form 2. Supporting documents

Econ. Sys is Here to Help Shannon Webb, SME beoarith@gmail. com helpdesk@maine. hcbscompliance. com

Questions and Answers