DEPARTMENT of SOCIAL SERVICES. Notice of Intent to Amend Personal Care Assistant, Home Care Program for Elders, and Acquired Brain Injury Waivers

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1 DEPARTMENT of SOCIAL SERVICES Notice of Intent to Amend Personal Care Assistant, Home Care Program for Elders, and Acquired Brain Injury Waivers In accordance with the provisions of section 17b-8 of the Connecticut General Statutes, notice is hereby given that the Commissioner of the Department of Social Services intends to amend the Personal Care Assistant (PCA), Acquired Brain Injury (ABI) and Elder waivers to (1) add additional services; (2) incorporate changes due to the collective bargaining agreement for personal care assistants; and (3) solicit comments regarding amendments to these programs that are being made to comply with federal requirements that mandates all states reevaluate their Home and Community-Based Service (HCBS) programs. New Services The Department is proposing to add two new services to the PCA Waiver; agency based Personal Care Assistant (PCA) and Independent Support Broker. The agency based PCA service provides individuals who choose not to self -direct their services the option of obtaining PCA services through an agency. An Independent Support Broker is a service that provides support and consultation to individuals and/or their families to assist them in directing their own supports. This service is limited to those who direct their own supports. The service includes: Assistance with developing a natural community support network; Support with and training on how to hire and train staff; Training and support with managing staff; Accessing community activities and services, including helping the individual and family with the coordination of needed services; Developing and maintaining an emergency backup plan; and Self-advocacy training and support. PCA Collective Bargaining Agreement The PCA collective bargaining agreement resulted in the need to increase the cost caps for both the PCA and Elder Waivers from one hundred percent of the average cost of nursing home to one hundred twenty percent of the average cost of nursing home. It also resulted in changes to the rate setting methodology and the cost estimates for the services included in the collective bargaining agreement.

2 Evaluation of HCBS Programs In January 2014, the Centers for Medicaid and Medicare Services (CMS) announced a requirement for states to review and evaluate current home and community based (HCBS) settings, including residential and nonresidential settings, and to demonstrate how our waivers comply with the new federal HCB Settings requirements that went into effect March 17, CFR (c)(4)-(5). CMS posted additional guidance to help states assess compliance and remediate areas that are not fully incompliance. The Department is seeking comments on both the amendments and the transition plan outlined in this notice. The Department is reviewing all the state s Medicaid waiver programs for compliance with the federal HCB settings requirements. The state will file a report with CMS regarding the state s evaluation of the existing waiver programs and the state must include the following information: A plan for assessing all HCBS settings, including a 30-day public comment period; A response summary of public comment received; An inventory and description of all HCBS service settings by size, type, location, and service delivery characteristics; A summary of how each setting meets or does not meet the federal HCB settings requirements; A list of any areas of non-compliance that need to be addressed; A transition plan and process for bringing all HCBS settings into compliance; and A plan for ensuring the health and safety of participants who reside in locations that need to meet corrective action requirements for the setting to come into compliance during the state s specified transition plan Additional information regarding the CMS settings requirements may be found at: Term-Services-and-Supports/Home-and-Community-Based-Services/Home-and- Community-Based-Services.html

3 The transition plan for these waivers is as follows: In preparing for the amendments, the state reviewed the waivers and identified three services and one setting that required further review to assure compliance with the new HCBS requirements. The three services are Adult Day Health (Elder Waiver), Adult Family Living (Elder and PCA Waivers) and Assisted Living (Elder Waiver). The only setting identified as requiring review is the Residential Care Home which is exclusive to the Elder Waiver. The transition plan for the three services and one setting identified as requiring further review are: Adult Day Health: This is a community-based service that brings waiver participants to a center to receive services, meals care and opportunities to participate in activities both within the center and in the greater community. Some centers are located adjacent to or on the grounds of long term care facilities. The certification process requires that there be a separate entrance and separate bathing and bathroom facilities. The service is freely chosen by the participant from a range of services and providers as part of the person centered planning process. In reviewing this service, the state has determined that it is fully compliant with the new CMS regulations but will work on several enhancements to ensure the home based look and feel the is expected under the regulations. As part of the overall transition plan, the department will review its own regulations regarding this service and make modifications and be more explicit about the expectations of community integration and the overall look and feel of the setting itself. In addition, the department has already engaged in conversations with the certification reviewers and there is agreement to make modifications to the certification process to describe expectations of community inclusion and activities as well as a clear description of the expectations of the appearance of a home like environment. As part of the transition plan, the state will include sample of monthly calendars from a range of Day Centers that illustrate activities to promote community inclusion that comply with the new rules. Adult Family Living: This service is provided in either the home of the participant or the caregiver. This service is freely chosen by the participant from a range of services by qualified providers as part of the person centered plan. Assisted Living: The state reviewed the settings in which assisted living services are provided and also met with representatives of the CT Assisted Living association. Our analysis concluded that the state is in full compliance with the new HCBS settings requirements. Assisted living services are provided in a

4 managed residential community. The community assists residents in integrating into the greater community, is a setting freely selected by the waiver participant, ensures the individuals rights to privacy and dignity and facilitates choice for services available outside of the bundled assisted living service. All persons residing in managed residential communities have a lease with eviction protections, their doors are lockable, they have cooking facilities and access to food at any time, are free to decorate their unit as they choose, can have visitors at any time and the setting is physically accessible. The setting is a private apartment unless a roommate option is selected by the waiver participant. Residential Care Homes: Initially, the department set out to identify the number of waiver participants residing in Residential Care Homes (RCHs). An analysis indicates there are 254 participants residing in RCHs. These locations in the state vary widely in the appearance, size and home like qualities. The state recognizes that some of the settings will be fully compliant with the new regulations while others will need to make changes to become compliant. To accomplish compliance, the state has a number of steps it needs to take. First, all case managers were trained on the new rules and were introduced to a survey to be utilized from July 1-December 31 when performing the annual or semi-annual reassessment at the RCH. Each client will be asked about the choice of setting they prefer to live in and will also focus on areas such as privacy, dignity and respect as well as choice of HCBS waiver providers. Case managers will evaluate if the setting was clearly chosen by the participant as part of the person entered plan. A survey will also be developed and distributed to all RCHs in the state to do a selfassessment of compliance. It is anticipated that a meeting with the association would need to take place either prior to or after the analysis of the survey data. The department will also engage in conversations with the CT Department of Public Health that licenses RCHs to determine if regulatory changes might be needed to ensure compliance with the HCBS settings rules. A summary of the survey findings will identify areas that changes will need to be made to bring the setting into full compliance. The state will engage with stakeholders to provide input on a final transition plan that will be submitted to CMS for final approval. A complete text of the waiver amendment is available, at no cost, upon request to the Alternate Care Unit, Department of Social Services, 55 Farmington Ave., Hartford, Connecticut 06106; shirlee.stoute@ct.gov. All written comments, questions, and concerns regarding this renewal application may be submitted within 30 days of the publication of this notice to the Department of Social Services, Alternate Care Unit, 55 Farmington Ave, Hartford,

5 Connecticut, Attention: Kathy Bruni, Manager;