Home and CommunityBased Services HCBS Settings Rule The

Home- and Community-Based Services (HCBS) Settings Rule: The Individual Experience Assessment Process for Sections 18, 20, 21, and 29 Waivers Serena Lowe, Ph. D. , Econ. Sys and Representatives from the DHHS Office of Aging and Disability Services February 2020

Overview of the Federal HCBS Settings Rule and the State of Maine’s Requirements for HCBS Settings HCBS SETTINGS RULE – THE BASICS Maine Department of Health and Human Services 2

Federal HCBS Settings Rule What is the federal HCBS Settings Rule? • In January 2014, the federal Centers for Medicare & Medicaid Services (CMS) released a new rule regarding home- and community-based services (HCBS), which took effect March 17, 2014. • The rule requires that people who receive those home- and communitybased services and supports funded through Medicaid must receive those services and supports in settings that meet specific standards. • States have been given until March 17, 2022 to ensure their HCBS systems and settings are in full compliance with the rule. For more info: http: //www. maine. gov/dhhs/oads/hcbs/requirements. shtml Maine Department of Health and Human Services 3

Federal HCBS Settings Rule (cont. ) Why did CMS issue the federal HCBS Settings Rule? • To ensure people receiving HCBS have full access to benefits of community living and the opportunity to receive services in the most integrated setting. • To enhance the quality of HCBS and provide rights protections to participants. For more info: https: //www. medicaid. gov/medicaid/home-community-basedservices/guidance/home-community-based-services-final-regulation/index. html http: //www. maine. gov/dhhs/oads/hcbs/requirements. shtml Maine Department of Health and Human Services 4

What is the Vision of HCBS for People with Disabilities in the State of Maine? Why did CMS issue the federal HCBS Settings Rule? • Support people with disabilities to have lives like people without disabilities • Provide opportunities for true integration, independence, choice, and self-determination in all aspects of life – where people live, how they spend their days, and real community membership • Ensure quality services that meet people’s needs and help them achieve goals they have identified through real person-centered planning Maine Department of Health and Human Services 5

HCBS Settings Rule is an Important Opportunity to Work Towards This Vision The HCBS settings rule provides an opportunity to: • Expand the capacity of more integrated and individualized services and shift away from more segregated service models to meet the demand from people with disabilities • Ensure basic rights in all HCBS settings • Help states comply with the Americans with Disabilities Act and Olmstead Maine Department of Health and Human Services 6

General Requirements of ALL HCBS Settings The federal HCBS rule’s general requirements for ALL settings providing Medicaid-funded HCBS collectively outline an outcomeoriented definition that focuses on the nature and quality of individuals’ experiences. These requirements include that the setting: • Is integrated in and supports access to the greater community; • Provides opportunities to seek employment and work in competitive integrated settings, engage in community life, and control personal resources • Is selected by the individual from among setting options, including non-disability specific settings Maine Department of Health and Human Services 7

General Requirements of ALL HCBS Settings (2) • Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid HCBS • Ensures an individual’s rights of privacy, dignity, respect, and freedom from coercion and restraint • Optimizes individual initiative, autonomy, and independence in making life choices • Facilitates individual choice regarding services and supports, and who provides them There additional requirements for provider-owned and controlled residential (and non-residential) settings… Maine Department of Health and Human Services 8

HCBS Settings Rule is an Important Opportunity to Work Towards This Vision • For any provider-owned or controlled setting in the state of Maine (residential or non-residential), the setting must: – – Allow participants to control their own schedule Provide participants access to food at any time Afford participants the right to visitors of their choosing at any time Assure the setting is physical accessible • Residential provider-owned and controlled settings also must assure that participants have: – A lease or other legally enforceable agreement – Privacy and lockable doors for his or her unit (entry, bedroom and bathroom doors) – A choice of roommate – Freedom to furnish or decorate the unit as they wish Maine Department of Health and Human Services 9

HCBS Settings Rule & Modifications (1) • The Rule ensures basic human rights for people with disabilities in their own homes • There can be modifications based on health and safety (for example, someone with pica may not be able to have unlimited access to food) – But modifications must be based on individual needs determined through the person-centered planning process Maine Department of Health and Human Services 10

HCBS Settings Rule & Modifications (2) • Any modifications of provider owned and controlled (POC) requirements must be supported by a specific assessed need and justified in the person-centered plan. • Additionally, documentation must be included in the PCP that demonstrates that less-restrictive alternative strategies were attempted and were unsuccessful before modifications to the HCBS settings criteria were implemented. • The modifications must be reviewed periodically to determine whether they continue to be necessary. • This is important information for case managers to keep in mind as they complete the IEAs as well as conduct ongoing PCP reviews. Stay tuned – more training is coming. Maine Department of Health and Human Services 11

States Must Assess and Categorize All Settings • Meets all requirements of the Rule (or can with modifications) • Can never meet requirements of the Rule because it is an institution – Nursing home, ICF, hospital or IMD, PNMI – Settings in the same building as any public or private facility providing in-patient treatment – Settings on the grounds of or adjacent to a public institution • Is presumed institutional – Setting is unallowable unless a state can prove through a “heightened scrutiny” process that the setting overcomes the institutional presumption and meets the rule’s requirements Maine Department of Health and Human Services 12

Understanding the State of Maine’s Process for Independently Validating Setting Compliance with State & Federal HCBS Settings Criteria VALIDATING SETTINGS Maine Department of Health and Human Services 13

What is Validation? State must determine compliance of existing HCBS settings. Step One: Providers complete selfassessments for each setting Step Two: (required by CMS) state “validates” the provider selfassessment data Validation determines how compliant an existing setting is, and what must be done to bring that setting into full compliance in time for the March 17, 2022 deadline. Maine Department of Health and Human Services 14

HCBS Provider Validation Process Provider Self. Assessment Validation of the Self-Assessment Responses On-Site Reviews, Individual Experience Assessments, and/or Desk Reviews Notification to Providers and Implementation of Remediation Notification of Final Determination Ongoing Compliance Monitoring of Settings Maine Department of Health and Human Services 15

1 st Method: Onsite Validation of Provider Self-Assessments • Selection of Settings for Onsite Visits § 644 settings will receive onsite visits § 3 Non-Residential setting types: § Community Supports; Work Supports-Group; Clubhouse § 100% will get onsite visits § 6 Residential setting types: § Group Homes: (1 -2 person), (3 -5 person), (6+ person) § Family-Centered Homes § Shared Living-Related Family Member § Shared Living-Unrelated Provider § On average, 24% will get onsite visits • Selection Criteria § Proportional selection of settings by District § Random selection of settings for some of the residential setting types § Maximum number of distinct providers Maine Department of Health and Human Services 16

Provider Self-Assessments Residential Settings Submitted Self-Assessments Non-Residential Settings 2, 080 97% 180 Not submitted 68 3% - 0% Not reachable 6 0% - 0% 2, 154 100% Total Settings Provider Self-Assessments Residential Settings with >=1 individual served (as of 11/2019) Settings with 0 individual served (as of 11/2019) Total Self-Assessments Submitted 180 100% Non-Residential 1, 962 179 118 1 2, 080 180 Maine Department of Health and Human Services 17

Plan for On-Site Visits Contract in place with Disability Rights Maine (DRM) to conduct on-site validation Econ. Sys and DRM worked together to create validation tools and validator training. DRM has recruited a team of validators. They are training them, which includes coaching and mentoring in doing validation on-sites. On-site validation visits will occur on a rolling basis, between February 2020 and October 2020 If a provider has multiple settings selected for on-site validation, only the first validation visit will request/review agency policies, etc. Maine Department of Health and Human Services 18

Provider Self-Assessments and Validation Visits 1 -2 Person Group Home Onsite Visits 89 3 -5 Person Group Home 96 163 259 37% 6 -or More Person Group Home 36 0 36 100% Family-Centered Home 11 41 52 21% Shared Living - Related Family Member is Provider 63 585 648 10% 171 329 500 34% 466 1, 496 1, 962 24% Onsite Visits. DRM 165 Onsite Visits. OADS Total % Onsite Visits 165 100% 13 13 100% 1 1 100% 1, 496 179 100% Setting Type Residential Settings Shared Living - Unrelated Provider Grand Total Setting Type Non-Residential Settings Community Support Work Supports Group Clubhouse Grand Total 165 Maine Department of Health and Human Services Other Total 378 467 % Onsite Visits 19% 19

2 nd Method: Individual Experience Assessment (IEA) Survey • What is Included: All residential settings that do not receive an on-site visit • Support Coordinator/Care Coordinator/Case Manager conducts in-person IEA in the setting with each member (and guardian if one appointed) receiving services in the setting • Information will be compared with Provider Self-Assessment to determine current compliance with any areas of partial or noncompliance that need to be addressed • If concerns about lack of alignment between Provider Self-Assessment and IEAs, either on-site visit or desk review will also be used Maine Department of Health and Human Services 20

3 rd Method: Desk Level Review [NOTE: Settings selected for Desk Level Reviews are based on a trending in discrepancies identified between the Provider Self-Assessment and results of Individual Experience Assessments. Thus, a Desk-Level Review only occurs in the event that there is a substantial level of inconsistency between the findings from the IEAs and the provider self-assessment responses. ] • Provider will be contacted to submit information and documentation to support answers in Self-Assessment and to clear up areas of concern based upon feedback from IEAs previously completed by case managers. • OADS has identified staff who will conduct Desk Level Reviews • Econ. Sys is developing desk review process and procedures • Desk Reviews will occur on a rolling basis, between February 2020 and October 2020 • If Desk Reviews uncover additional inconsistencies/discrepancies with provider self-assessment responses, setting may be elevated to an onsite validation Maine Department of Health and Human Services 21

Detailed Overview of the IEA Process COMPLETING THE INDIVIDUAL EXPERIENCE ASSESSMENT (IEA) Maine Department of Health and Human Services 22

Completing the IEA: Key Principles • All IEAs must be conducted face-to-face. • All individuals residing in residential settings not chosen for an onsite validation will have the opportunity to complete an IEA with their case manager (not the provider). • The IEA should be conducted in a private space separate from staff and other participants so the individual’s responses remain confidential. • The IEA must be completed as a conflict-free assessment. Maine Department of Health and Human Services 23

Completing the IEA: Who should be involved? • The individual and who they choose in terms of natural supports. • Guardians may be present but this is not a requirement. • They may participate in person or via telephone (assuming they are available at the time the IEA is being completed). • Guardians who express concerns about the IEA should be educated on the importance of participant engagement in the IEA as part of HCBS service provision. • A Direct Support Professional working in the individual’s home cannot assist with the assessment. • An exception can be made only in the event that a non-traditional communication user relies on their DSP as a communications ally, and both the individual and individual’s guardian (if there is one) has made the request prior to the beginning of the IEA. Maine Department of Health and Human Services 24

Completing the IEA: Engaging the Individual • Spend some time initially helping them understand why you are there, what types of questions you are going to be asking them, and why you are asking them. • Use one-pager as needed to help explain the purpose of the federal HCBS rule and what it means for them. • In order to get them comfortable, talk to them a bit about things that you are aware of that they like/don’t like, and information you have about their goals and/or activities from their PCP. • If someone gets tired or agitated and cannot complete the entire survey, that is okay. Simply note where they stopped in the survey and provide this in the “Notes” section when uploading it into the portal. Maine Department of Health and Human Services 25

Completing the IEA: Supporting People Using Non-Traditional Modes of Communication • All efforts must be exhausted to make it possible for participants to participate in the IEA process. If the person has limited natural supports and uses non-traditional modes of communication, attempt to use evidence-based strategies to engage them to the best of your ability. • If it is not possible to engage an individual in completing an IEA in its entirety due to limited natural supports and non-traditional modes of communication, CMs are instructed to: • Check “Unsure” for each question that the individual was unable to answer and in the narrative answer state: “Did not answer the questions due to typical communication resources (i. e. bridges, those familiar with the person being assessed) not participating in the assessment (due to conflict of interest)”. Maine Department of Health and Human Services 26

Completing the IEA: Engaging the Individual • If it is not possible to engage an individual in completing an IEA in its entirety due to limited natural supports and non-traditional modes of communication, CMs are instructed to: • Include a short narrative at the end of the IEA explaining the communication deficits and why it was not possible to have the person assessed. • State’s Long-Term Goal: Engage with our non-traditional communication consultant to start building HCBS standards into an assessment process with participants with non-traditional communication skills and build their communication toolbox/ update their augmented devices to be able to answer these questions in the future. Maine Department of Health and Human Services 27

Experiences of Piloting the IEA: Recommendations • Case Managers are strongly encouraged to re-review the most recent person-centered plan of each participant prior to conducting the IEA. • A suggested guide of talking points is available as a supplemental resource for use with anyone who needs additional assistance with understanding specific questions. • Case Managers should document all responses to the questions both by marking a specific response as well as providing additional context in the “Notes” section. Maine Department of Health and Human Services 28

Completing the IEA: Process • The goal is to get a completed IEA from all of the individuals residing in residential settings not receiving an onsite validation. • The goal is to have all IEAs completed by 7/31/20 • Plan is to assign CMs particular individuals on their caseload each month, based on their residential provider (and specific list of settings they operate) being selected for that month. • Each month, Liaisons will notify CMs which providers/settings to target for completion of IEAs in that month. • IEAs can start 2/18/20. Maine Department of Health and Human Services 29

Instructions for Case Managers on IEAs USING THE IEA TOOL AND UPLOADING TO THE PORTAL Maine Department of Health and Human Services 30

Using the IEA Tool: Econ. Sys Portal Econ. Sys Maine HCBS Compliance Portal: https: //Maine. HCBScompliance. com • Expect to receive an email invitation with instructions on how to sign on the portal • Password recovery is through the portal. • Econ. Sys staff are available to answer any technical questions you may through the helpdesk at: helpdesk@Maine. HCBScompliance. com Maine Department of Health and Human Services 31

Using the IEA Tool: Econ. Sys Portal (continued) • What does the IEA Survey Instrument look like? • It is a fillable MS Excel file! • One file for each interview/assessment! • Am I going to use the portal to enter responses for each IEA? • No. The best way is to enter responses directly in the Excel file. • You have the option of using a print copy of the survey, handwriting the responses. With this option, you still will be required to enter the handwritten responses and notes into the Excel file later, doubling the effort. Maine Department of Health and Human Services 32

Using the IEA Tool: Econ. Sys Portal (continued) • Each CM/CC will have access to the survey instruments through the portal • Once you sign in, you will see the IEAs assigned to you for each individual • • For example, if you are assigned to complete IEAs for 2 individuals at a provider setting (location), you will see 2 separate IEAs (2 Excel files) to download. After you complete an IEA for an individual, you will save the Excel file with the following name convention: <Person. ID>. xls. • Person. ID is an alphanumeric, nine-digit character set. • Then you will sign in the portal and upload the completed file (with the proper file name) with a couple of clicks. • A mini FAQ/Guide will be available on the portal soon. Maine Department of Health and Human Services 33

POST-VALIDATION ACTIVITIES Maine Department of Health and Human Services 34

Proposed Plan: After Validation • Providers will receive the results of a setting validation within 30 days of the validation process being completed for that setting • Based on the setting validation results, each setting with areas of partial or noncompliance with be required to have a setting-specific Transition-to. Compliance Plan. DHHS/Econ. Sys will provide a plan and template for providers to use • After they receive their settings’ validation results, providers will have 30 days to submit an approvable Transition-to-Compliance Plan for the setting. State and/or Econ. Sys staff will be available to answer questions and provide technical assistance to providers as they develop these Transition-to. Compliance Plans Maine Department of Health and Human Services 35

Proposed Plan: After Validation (cont. ) • All Transition-to-Compliance Plans must be fully implemented (all action steps completed) by October 31, 2021. The state and Econ. Sys will monitor provider progress on implementation of their Transition-to-Compliance Plans to ensure the October 31, 2021 deadline is met. • If any setting does not meet the October 31, 2021 deadline, the state is required to ensure safe and orderly transitions of individuals wishing to continue to receive HCBS to compliant settings so that these relocations are completed in the personcentered manner by no later than March 17, 2022. Maine Department of Health and Human Services 36

Information for Case Managers & Support Coordinators • OADS HCBS webpage: http: //www. maine. gov/dhhs/oads/hcbs/index. shtml • Econ. Sys’ Maine HCBS Compliance Portal: https: //maine. hcbscompliance. com • Econ. Sys’ Training & Resources: https: //maine. hcbscompliance. com/training_materials • Additional Resources (Pending): – One-Page Info Sheet for CMs to use with participants in helping them understand what the federal HCBS rule is and the purpose of the IEA – Portal Users Guide – Updated State PCP Manual – Virtual Community of Practice for CMs/Care Coordinators • Please share future meeting HCBS topics with us through the HCBS. DHHS mailbox: HCBS. DHHS@maine. gov Maine Department of Health and Human Services 37