Section 300. Service description, criteria, limitations, and provider requirements

A. Service description.

1. The service shall be designed to enable clients qualifying for the CMH Waiver to live in their homes and shall include (i) training and assistance in or reinforcement of functional skills and appropriate behavior related to a client's health and safety, personal care, ADLs, and use of community resources; (ii) assistance with medication management and monitoring the client's health, nutrition, and physical condition; (iii) life skills training; and (iv) cognitive rehabilitation.

2. This service provides assistance or specialized supervision provided primarily in a client's home or foster home to enable a client to acquire, retain, or improve the self-help, socialization, behaviors and adaptive skills necessary to reside successfully in home and community-based settings.

3. This service must be provided on a client-specific basis according to the ISP, supporting documentation, and service setting requirements.

4. Room and board and general supervision shall not be components of this service.

5. This service shall not be used solely to provide routine or emergency respite care for the family or caregivers with whom the client lives.

6. Medicaid reimbursement is available only for in-home residential support services provided when the client is present and when a qualified provider is providing the services.

B. Criteria.

1. All clients must meet the CMH Waiver criteria in order for Medicaid to reimburse for in-home residential support services. The client shall have a demonstrated need for supports to be provided by staff who are paid by the in-home residential support provider.

2. A functional assessment must be conducted to evaluate each client in his home environment and community settings.

3. The supporting documentation must indicate the necessary amount and type of activities required by the client, the schedule of residential support services, and the total number of projected hours per week of waiver reimbursed residential support.

4. Routine supervision/oversight of direct care staff. To provide additional assurance for the protection or preservation of a client's health and safety, there are specific requirements for the supervision and oversight of direct care staff providing residential support as outlined below. All in-home residential support services must be provided under a DMHMRSAS license and include the following requirements:

a. An employee of the agency, typically by position, must be formally designated as the supervisor of each direct care staff person who is providing in-home residential support services.

b. The supervisor must have and document at least one supervisory contact per month with each staff person regarding service delivery and staff performance.

c. The supervisor must observe each staff person delivering services at least semi-annually. Staff performance and service delivery according to the ISP should be documented, along with evaluation and evidence of the client's and family/caregiver's satisfaction with service delivery by staff.

d. Providers of in-home residential supports must also have and document at least one monthly contact with the client and family/caregiver regarding satisfaction with services delivered by each staff person.

C. Service units and service limitations. In-home residential supports shall be reimbursed on an hourly basis for time the in-home residential support staff is working directly with the client. Total monthly billing cannot exceed the authorized amount in the ISP. The provider must maintain documentation of the date and times that services are provided, the specific services provided, and specific circumstances that prevented provision of all of the scheduled services, if applicable.

Service providers shall be reimbursed only for the amount and type of in-home residential support services included in the client's approved ISP. Services will not be reimbursed for a continuous 24-hour period.

D. Provider requirements. In addition to meeting the general conditions and requirements for home and community-based care participating providers as specified in 12VAC30-135-120 and 12VAC30-135-160, each in-home residential support service provider must be licensed by DMHMRSAS as a provider of supportive residential services. The provider must also have training in mental health and appropriate interventions, strategies, and support methods for persons with SED.

1. The ISP and ongoing documentation must be consistent with licensing regulations.

2. Documentation must confirm attendance and the amount of time services were provided and provide specific information regarding the client's response to various settings and supports as agreed to in the ISP objectives. Assessment results must be available in at least a daily note or a weekly summary. Data must be collected as described in the ISP, analyzed, summarized, and then clearly addressed in the CSP.

3. In addition to licensing requirements, persons providing residential support services are required to participate in training specified by DMAS in the characteristics of SED. The training shall include appropriate interventions, training strategies, and support methods for individuals with SED.

4. The ISP must be reviewed by the provider with the client or family/caregiver, as appropriate, and this review submitted to the case manager, at least semi-annually, with goals, objectives, and activities modified as appropriate.

5. Documentation must be maintained for supervision and oversight of all in-home residential support staff. All significant contacts must be documented.

6. Required documentation in the client's record. The provider agency must maintain records of each client receiving residential support services. Documentation must be completed and signed by the staff person designated to perform the supervision and oversight. At a minimum, these records must contain the following:

a. Date of contact or observation and the amount of time spent;

b. Person or persons contacted or observed;

c. A note regarding staff performance and ISP service delivery for monthly contact and semi-annual home visits;

d. Semi-annual observation documentation must also address client's and family/caregiver's satisfaction with service provision;

e. Any action planned or taken to correct problems identified during supervision and oversight;

f. A functional assessment conducted by the provider to evaluate each client in the residential environment and community settings; and

g. An ISP that must contain the following elements:

(1) The client's strengths, desired outcomes, required or desired supports, or both, and training needs;

(2) The client's or family/caregiver's goals and measurable objectives to meet the identified outcomes;

(3) The services to be rendered and the schedule of services to accomplish the goals, objectives, and desired outcomes;

(4) A timetable for the accomplishment of the client's goals and objectives;

(5) The estimated duration of the client's needs for services; and

(6) The provider staff responsible for the overall coordination and integration of the services specified in the ISP.

h. The ISP goals, objectives, and activities must be reviewed by the provider quarterly, annually, and more often as needed, modified as appropriate, and results of these reviews submitted to the case manager. For the annual review and in cases where the ISP is modified, the ISP must be reviewed with and approved by the client and family/caregiver.

Historical Notes

Derived from Volume 24, Issue 02, eff. December 1, 2007.

Statutory Authority

§§ 32.1-324 and 32.1-325 of the Code of Virginia.