Header:
NEW YORK CODES, RULES AND REGULATIONS
TITLE 14. DEPARTMENT OF MENTAL HYGIENE
CHAPTER XIV. OFFICE OF MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES
PART 635. GENERAL QUALITY CONTROL AND ADMINISTRATIVE REQUIREMENTS APPLICABLE TO PROGRAMS, SERVICES
Date:
08/31/2009
Document:
ยง 635-10.4 Allowable services
(a) Case Management Services.
(1) Every person approved for participation in the HCBS waiver, shall be assisted by a specific case manager chosen by him or herself or his/her advocate (see Glossary), regardless of the type or amount of service(s) received.
(2) The chosen case manager is responsible for assisting the person and/or his/her advocate, as needed, to create and sustain an individualized service environment by developing, implementing, reviewing and revising the person's individualized service plan. To the extent possible, providers of case management services shall attempt to ensure the avoidance of a conflict of interest between the provision of case management services and other services in which the person is participating or receiving.
(3) Case management services include the following categories of activities:
(i) Assessment-actions taken to determine a person's functional status, service needs, personal goals and preferences. This category includes:
(a) Arranging for and obtaining any needed clinical assessments to determine the person's functional status, service needs and recommendations for interventions.
(b) Interviews with the person, the person's advocate and service providers.
(c) Evaluating the information obtained from (a) and (b) above of this subparagraph with the person and his/her advocate to reach consensus on the person's functional status, service needs, recommendations for interventions, and the person's personal goals and preferences in order to assist the person in choosing the types of services, supports, and activities that create the individualized service environment and the resulting individualized service plan.
(d) Ensuring the assessment of, at least annually, the person's specific needs relative to his or her capacity to evacuate the home in a timely manner in the event of a fire emergency. Said assessment shall take into account the person's ability to walk, to follow directions and the circumstances of his/her home (i.e., layout, number of occupants and their needs relative to fire evacuation, and availability of assistance.)
(ii) Service planning and coordination-actions taken to develop the individualized service plan, (based on the assessment process), and to coordinate service provision including:
(a) Coordination of the services, supports and activities identified as components of the individualized service plan;
(b) Completion of a written individualized service plan; and
(c) Ensuring the performance of the as-needed reviews of the individualized service plan and documenting the outcomes.
(iii) Linkage and referral-the process of assisting the person and his/her advocate to identify and access specific service providers by:
(a) Providing information on services and supports;
(b) Making referral and placement arrangements and ensuring access; and
(c) Accompanying the person to the new service or support to participate in the placement process.
(iv) Follow-up and monitoring-actions taken to oversee the person's participation in the needed/desired HCBS waiver services, supports and activities, according to the individualized service plan. This includes taking into account the changing needs and personal goals of the person and taking any actions necessary to ensure the person's stability in, and ongoing benefit from his/her individualized service environment. These actions include:
(a) Making ongoing arrangements for the person's use of services and supports;
(b) Maintaining ongoing contact with the person and his/her advocate and service providers, and intervening when the person, his/her advocate, or a provider identifies a problem;
(c) Accompanying the person to the service or other problem source to aid the person by assisting in communication and resolution of the issues. It may also include the representation of the person where the person and his/her advocate are unable to present their case;
(d) Ensuring that the actions and recommendations relative to addressing the person's fire safety needs, as determined during the assessment pursuant to clause (i)(d) of this paragraph, are carried out as specified in the person's individualized service plan;
(e) Performing the as-needed reviews of the individualized service plan and the ICF/MR level of care determination and documenting the outcomes; and
(f) Maintaining an up-to-date written individualized service plan.
(4) A provider of case management services shall be incorporated pursuant to the New York State Not-for-Profit Corporation Law, or shall be a governmental entity and shall demonstrate to OMRDD, prior to certification, that the applicable case management provider has the capacity to deliver the full range of case management services, in a competent manner, to the persons likely to be served by the provider. There shall be:
(i) Documentation that any parties delivering case management hold at least a bachelor's degree and have at least one year's practical experience in serving persons with developmental disabilities or hold a high school diploma, have at least one year's practical experience in serving persons with developmental disabilities and have completed an OMRDD-approved competency-based training program in case management.
(ii) A process in place to provide adequate supervision and oversight of the case manager using personnel with greater credentials than the minimal qualifications for case managers.
(iii) A means made available to all persons receiving case management services and/or their advocates by which complaints may be registered and resolved without threat of reprisal, including the selection of a new case manager or another case management agency.
(b) Habilitation services are designed to provide general assistance to persons, in accordance with their individualized service plan, to acquire and maintain those life skills that enable them to cope more effectively with their environments. Habilitation services are directed toward acquiring, retaining, and improving the self-help, socialization and adaptive skills necessary to reside successfully in home and community-based settings. Services offered are designed to correspond to the person's strengths and needs. These services include activities and tasks required to design, implement and support the individualized service plan. The individualized service plan includes specifically stated objectives and tasks related to physical, social, psychological, and pre-vocational skills or supports which are designed to achieve performance levels associated with the specified objectives.
(1) Residential habilitation services are generally provided in the person's home, and include assistance with acquisition, retention or improvement in skills related to life safety and fire evacuation; to activities of daily living, such as personal grooming and cleanliness, bed making and household chores, eating and the preparation of food; and social and adaptive skills necessary to enable the person to reside in a noninstitutional setting. These services are distinct from any programming provided as day habilitation pursuant to paragraph (b)(2) of this section, but will in some circumstances involve the person's involvement in learning situations outside of the home. Allowable activities include:
(i) Training in independent performance of personal hygiene tasks such as appropriate toileting, bathing, toothbrushing, hand and face washing, shaving, and use of deodorant and mouthwash.
(ii) Training in independent performance of self-care tasks such as eating and use of appropriate dining utensils, dressing and use of grooming aids such as hairbrushes, combs, nail clippers, razors, etc.
(iii) Training in independent performance of general household chores such as meal preparation, routine shopping, laundry, cleaning, and maintenance of an orderly environment.
(iv) Mobility training for maximum independence in travel to and from work or activity center, community stores, recreational sites, etc. It includes training in the use of public transportation.
(v) Training to maximize independence in personal health care such as regular medical and dental appointments, basic first aid skills, self-medication, where appropriate and basic knowledge of proper nutritional habits.
(vi) Training to maximize personal financial management such as recognition and counting skills, use of money for over-the-counter purchases, and change making.
(vii) Training in appropriate social behaviors which are normative in both the community and household settings such as conducting oneself appropriately in restaurants, on public transportation vehicles, in recreational facilities, and in stores and other public places.
(viii) Training in the performance of fire evacuation behaviors and other appropriate life safety activities.
(ix) Providing "hands-on" assistance with the person's physical dependency needs related to the residential habilitation services to ensure health and safety and/or attainment of personal objectives/goals.
(x) Necessary transportation (see Glossary ). Further, effective July 1, 1996, the provider of residential habilitation services in an individualized residential alternative (IRA) shall be responsible for any necessary transportation to and from physician, dentist, and other clinical services. Nothing herein shall be interpreted as precluding the accessing of separate Medicaid claiming for emergency/nonemergency ambulance services (as defined in 18 NYCRR 505.10) necessitated by the person's medical condition. It shall be the responsibility of the residential habilitation services provider to:
(a) arrange for the use of public transportation when appropriate;
(b) arrange special transportation to meet the transportation needs of the individuals; and
(c) keep records which indicate the transportation usage of each participant including whether it is claimed as part of residential habilitation services or as Medicaid transportation as a State plan service.
(xi) Providing professional services for the individual by qualified members of a clinical discipline which are part of the development or implementation of an individualized service plan and which are intended to enable the person and, as appropriate, his or her family to cope with health care, emotional, psychological, behavioral or programmatic issues. The purpose of the professional service is to maintain or improve the person's health, safety or level of functioning.
(xii) Training, support and assistance in pursuing personal valued outcomes as stated in the person's individualized service plan (ISP).
(xiii) Training, support and assistance in self-advocacy and making informed choices.
(xiv) Training, support and assistance with community inclusion and relationship building.
(xv) Residential habilitation services in a supervised IRA shall include services which:
(a) are necessary to meet the needs of consumers while in residence, and
(b) prior to August 1, 2004 could have been met by home health aide or personal care services separately billed to Medicaid.
(2) Day habilitation services are delivered primarily in a nonresidential setting separate from the person's home/residence with exceptions allowed to promote transition or adaptation. Such services shall provide assistance with acquisition, retention or improvement of self-help, socialization, adaptive skills and development of manual and perceptual motor skills. Allowable activities include:
(i) Mobility training to maximize the use of public transportation in traveling to and from work, training or activity centers, community stores, recreation, and the like.
(ii) Assessment, training and assistance in developing appropriate social behaviors which are normative in the surrounding community such as conducting oneself appropriately in restaurants, on public transportation vehicles, in recreational facilities, and in stores and other public places.
(iii) Assessment, training, and assistance in developing communication skills; language development; speech therapy; patterns of living; activities and routines which are appropriate to the person's age and the practices of the surrounding community and which are consistent with the individual's interests and capabilities.
(iv) Training and assistance in developing basic safety skills.
(v) Training and assistance in developing competency in housekeeping skills, including, meal preparation, laundry, and shopping.
(vi) Training and assistance in developing competency in personal care skills such as bathing, toileting, dressing, and grooming.
(vii) Training and assistance in developing health care skills, including, maintaining proper dental hygiene, carrying out recommendations of a dentist or physician, using medication appropriately, and summoning emergency assistance.
(viii) Training and assistance in developing money management skills which include recognition of currency and making change.
(ix) Provision of individual and group social, health-related, and recreation activities. Recreational activities may be covered only to the degree that they are meaningful and not merely diversional in nature and are included in an individualized service plan.
(x) Necessary transportation (see Glossary). Further, effective July 1, 1996, the day habilitation provider shall be responsible for both transportation to and from the day habilitation service setting and any other transportation during the day associated with day habilitation service delivery.
(xi) Professional services provided for the individual by qualified members of a clinical discipline which are part of the development or implementation of an individualized service plan and which are intended to enable the person and, as appropriate, his or her family to cope with health care, emotional, psychological, behavioral or programmatic issues. The purpose of the professional service is to maintain or improve the person's health, safety or level of functioning.
(xii) Training, support and assistance in pursuing personal valued outcomes as stated in the person's individualized service plan (ISP).
(xiii) Training, support and assistance in self-advocacy and making informed choices.
(xiv) Training, support and assistance with community inclusion and relationship building.
(xv) Day habilitation services shall include services which:
(a) are necessary to meet the needs of consumers while receiving day habilitation services, and
(b) prior to August 1, 2004 could have been met by home health aide or personal care services separately billed to Medicaid.
(3) Community habilitation services (CH) are similar in scope to residential habilitation services and day habilitation services, however, the focus of these services is directed towards service delivery occurring largely in the community (non-certified) settings to facilitate and promote independence and community integration.
(i) Community habilitation services include all of the types of services specified in paragraphs (1) and (2) of this subdivision.
(ii) Allowable activities include all of the allowable activities specified in subparagraphs (1)(i)-(xiv) and (2)(i)-(xiv) of this subdivision.
(c) Prevocational services are activities specified in the person's individualized services plan, that prepare an individual for paid or unpaid employment, but which are not job task oriented. Said services include support and training in behaviors related to following directions, attending to task, task completion, problem solving and safety and/or may also focus on assisting the person to adjust to the productive and social relationship demands of the work place. The purpose of the service is habilitative rather than teaching a specific job task skill. Prevocational services are provided to persons not expected to join the general work force within one year (excluding supported employment programs).
(1) Said services shall include, but not be limited to, the following tasks and activities:
(i) training the person to follow directions, adapt to work routines, and carry out assigned duties in an effective manner;
(ii) helping the person to acquire appropriate attitudes and work habits, including instruction in socially appropriate behaviors on and off the job site;
(iii) assisting the person to adjust to the productive and social demands of the workplace;
(iv) familiarizing the person with job production and performance requirements;
(v) providing mobility training, including the utilization of public and para-transit systems; and
(vi) instruction in the appropriate use of job-related facilities (e.g., lounge areas, lunch rooms/cafeterias, and rest rooms).
(2) To participate in prevocational services, the person must have a demonstrated or assessed earning capacity relative to the prevocational task(s) involved, of less than 50 percent of the current Federal minimum wage or prevailing wage, whichever is greater, and be expected to have such an earning capacity while participating in waiver prevocational services.
(3) The person shall not be receiving waiver prevocational services, if they can otherwise be obtained pursuant to section 110 of the Rehabilitation Act of 1973, during the time the person is to receive waiver prevocational services. * (d) Supported employment under the HCBS waiver, is a program of appropriate staff and/or material supports for a person desiring to obtain, or be maintained in a compensated employment setting.
(1) Supported employment as a service is conducted in a variety of settings, particularly work sites in which those without disabilities are employed.
(2) When supported employment services are provided at a work site where those without disabilities are employed, payment will be made only for the adaptations, supervision and training required by the person as a result of his/her disabilities, and will not include payment for the supervisory activities rendered as a normal part of the employment setting.
(3) Intensive supported employment services include those individual service plan specified services and/or interventions required by the person to become employable within the integrated community labor market. These intensive supported employment services lead to a level of employment or stabilization where it is anticipated that the person will be able to sustain employment with the level of support provided by extended supported employment services.
(4) Extended supported employment services include those individual service plan specified services and/or interventions required to enable the supported person to remain effectively employed in the integrated community labor market once the intensive supported employment job site training phase ends.
(i) Such services shall include continuing or periodic skill training services provided at least twice monthly at the work site throughout the term of employment to enable the person to perform the work unless the person's individual service plan provides for off-site monitoring.
(ii) Extended services may also include services provided away from the work site as required to maintain the person's community employability.
(5) Within the context of the respective definitions, both intensive (see paragraph (4) of this subdivision) and extended (see paragraph (5) of this subdivision above) supported employment services include the following as allowed activities.
(i) Any activity needed to sustain paid work by the person, including supervision, training and transportation.
(ii) Situational assessments and reassessments of the person's skills and the impact of other environmental factors such as family and transportation in development of the job site and this component of the person's individualized service plan.
(iii) Obtaining employer participation to maximize the person's integration and independence at the worksite.
(iv) Job coaching provided to service delivery agencies to ensure that assistance, support, or intervention is provided as necessary to help the person learn to perform job tasks and increase the person's capacity for independent functioning on the job. It also includes group counseling when necessary.
(v) Skill training that addresses job duty performance, related work behaviors (such as the effective and appropriate use of community resources and lounge/lunch areas), transportation and mobility training, communication, and interpersonal skills, including assessment and periodic assessment of the person's support needs.
(vi) Adaptive equipment necessary to obtain and retain employment and which is used exclusively or primarily at the employment setting.
* NB Effective until September 1, 2001 for providers of service located in New York City (including the counties of New York, Bronx, Kings, Queens and Richmond). For all other providers of HCBS Waiver supported employment services effective until June 1, 2001.
* (d) Supported employment under the HCBS waiver, is a service providing appropriate staff and/or material supports for a person obtaining or being maintained in a compensated employment setting in accordance with individual capabilities, choices and employment goals.
(1) Supported employment as a service is conducted in a variety of settings, particularly work sites in which those without disabilities are employed.
(2) When supported employment services are provided at a work site payment will be made only for the adaptations, supervision and training required by the person as a result of his/her disabilities, and will not include payment for the supervisory activities typically rendered other non-supported employment employees as a normal part of the employment setting.
(3) Supported employment services include those individual service plan specified services and/or interventions required by the person to become employable and/or remain effectively employed within the integrated community labor market.
(4) Supported employment services may include the following:
(i) Continuing or periodic skill training services provided at the work site or off-site.
(ii) Supervision, training and transportation.
(iii) Situational assessments and reassessments of the person's skills and the impact of other environmental factors such as family and transportation in development of the job site and this component of the person's individualized service plan.
(iv) Obtaining employer participation (e.g. training and support to employers and co-workers) to maximize the person's inclusion and independence at the worksite.
(v) Job coaching provided by an authorized service provider to ensure that assistance, support, and/or intervention are provided as necessary to assist the person to learn, maintain, and enhance job performance and completion of tasks by increasing the person's capacity for independent functioning on the job. It also includes group counseling when necessary.
(vi) Skill training that addresses job duty performance, related work behaviors (such as the effective and appropriate use of community resources and work space), transportation and mobility training, communication, and interpersonal skills, including assessment and periodic reassessment of the person's support needs.
(vii) Adaptive equipment necessary to obtain and retain employment and which is used exclusively or primarily at the employment setting.
* NB Effective date: For providers of service located in New York City (including the counties of New York, Bronx, Kings, Queens and Richmond) on September 1, 2001. For all other providers of HCBS Waiver supported employment services effective June 1, 2001.
(e) Environmental modifications are selected internal and external changes to a person's physical home environment, required by the person's individualized service plan, which provide appropriate site accommodations to meet the person's fire safety evacuation needs identified pursuant to clause (a)(3)(i)(d) of this section, and which are necessary to ensure the health, welfare and safety of the person or which enable him or her to function with greater independence in the home and without which the person's continued residence could be jeopardized. A given environmental modification(s) will be provided on a limited one-time only installation/construction basis to a given residence to the extent necessary to enable people with physical infirmities and disabilities to live safely in community homes outside the institutional setting. Nothing herein shall preclude additional environmental modifications at the same site at a time in the future, if the person's needs substantially change; or at a new site if the move was due to causes beyond the person's control; or was programmatically justified (e.g., the person chose to live at a greater level of independence). Allowable modifications include:
(1) Modifications to allow access to or in the home, including:
(i) ramps;
(ii) lifts of a hydraulic, manual or electrical nature for porch, stairs and/or bathroom;
(iii) widen doorways/hallways;
(iv) hand railings/grab bars; and
(v) automatic or manual door openers/door bells which are required as part of a residential habilitation service plan.
(2) Bathroom/kitchen modifications, additions or adjustments when necessary to allow accessibility or improved functioning including:
(i) roll-in showers;
(ii) sinks/tubs;
(iii) water faucet controls;
(iv) plumbing adaptations (cut-outs, toilet/sink adaptations);
(v) turnaround space changes/adaptations;
(vi) worktables/work surfaces adaptations; and
(vii) cabinetry/shelving adaptations.
(3) Other adaptations including:
(i) medically necessary heating/cooling adaptations as required as part of a residential habilitation services plan or medical treatment. Any such adaptations, utilized to solely improve a person's living environment, are to be included as part of room and board costs;
(ii) electrical wiring to accommodate other adaptations or equipment installation;
(iii) specialized electric and plumbing systems which are necessary to accommodate the medical equipment and supplies necessary for the person's welfare; and
(iv) other appropriate environmental modifications, adaptations, or repairs necessary to make the living arrangement accessible or accommodating of the person's fire safety evacuation needs.
(f) Adaptive technologies are those devices, aids, controls, appliances or supplies of either a communication or adaptive type, determined necessary to enable the person to increase his or her ability to function in a home and community-based setting with independence and safety. The equipment, whether of a communication or adaptive type, must be documented in the person's individualized service plan as being essential to the person's habilitation, ability to function, or safety (including fire safety evacuation needs); and have an essential relationship to support/maintain (or obtain) the person's current or desired residence.
(1) Within the category of adaptive technology, the unit of service consists of one approved communication or adaptive piece of equipment as specified in the person's individualized service plan. A person may, based on need, receive more than one unit of service.
(2) Allowable adaptive technologies include:
(i) Communication aids and devices including:
(a) personal emergency response systems which are electronic devices that enable high-risk patients to secure help in the event of an emergency. They also include portable "help" buttons to allow for mobility;
(b) direct selection, alpha-numeric, scanning, and encoding communicators;
(c) speech amplifiers;
(d) electronic speech aids/devices; and
(e) voice, light or motion activated electronic devices.
(ii) Adaptive aids and devices, including:
(a) standing boards/frames;
(b) adaptive switches/devices;
(c) meal preparation aids/devices/appliances;
(d) specially adapted locks;
(e) motorized wheelchairs; and
(f) guide dogs and similar trained animals.
(iii) Other such adaptive aids and devices as are required pursuant to the individualized service plan that would not otherwise be covered by the State Medicaid Plan and whose purchase price is approved by the person's case manager prior to purchase.
(iv) Repairs and maintenance to such adaptive technologies (i.e., equipment) which will be cost-effective and approved by the person's case manager.
(g) Respite services are broadly defined as the provision of intermittent, temporary substitute care of a person on behalf of a primary caregiver who is either a family member, a legal guardian, an advocate, or a family care provider. It is a means of providing relief from the responsibilities of daily caregiving.
(1) Respite may be provided only to persons living at home or in family care.
(2) Respite may be provided in any setting that is operated or certified by OMRDD. Respite may also be provided in a setting that is not operated or certified by OMRDD, including a private residence.
(3) Respite may be provided for as many as 24 hours in one day.
(4) Respite care services in the person's home shall be delivered by parties who are qualified to provide the level of care specified in the person's individualized service plan.
(5) Respite care provided in a certified residential setting shall comply with all regulations applicable to that residential setting.
(6) Respite provided by a family care provider shall comply with terms of the HCBS waiver service provider agreement.
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