PROVIDER APPLICATION

Transcription

1 PROVIDER APPLICATION NEW MEXICO DEPARTMENT OF HEALTH DEVELOPMENTAL DISABILITIES SUPPORTS DIVISION COMMUNITY PROGRAMS BUREAU DEVELOPMENTAL DISABILITIES WAIVER MEDICALLY FRAGILE WAIVER P. O. Box Santa Fe, New Mexico or 810 San Mateo Road, Suite 103 Santa Fe, New Mexico Effective October 1, 2012 Revised February 2018 Cabinet Secretary Lynn Gallagher

2 TABLE OF CONTENTS SECTION I LETTER OF INTRODUCTION 2 SECTION II OVERVIEW OF MEDICAID WAIVER PROGRAM 4 SECTION III OVERVIEW OF MEDICAID WAIVER APPLICATION 7 1. Application Requirements 2. Where to Submit 3. Application Format 4. Term of Agreement 5. How to Bill SECTION IV REQUIRED FORMS and DOCUMENTATION 9 Developmental Disabilities Support Division (DDSD) Regional Map 1. DDSD REQUIRED FORMS 10 a. DDSD Provider Information Sheet(s) b. Attachment A-Scope of Work Form(s) c. MAD 335 Provider Participation Agreement (New Providers Only) d. W-9 Form (New Providers Only) e. DDSD Statement of Assurances f. Provider Agency Status Sheet (Renewing Providers Only) 2. DDSD REQUIRED DOCUMENTATION a. Articles of Incorporation and Current Board Members b. IRS FEIN Letter (New Providers Only) c. Professional Licensure / Academic Credentials d. General or Professional Liability Insurance e. Surety or Dishonesty Bond Insurance f. Current New Mexico Business License (New Providers Only) g. CRS Certificate h. NPI Number (New Providers Only) i. Accreditation Requirements 3. FINANCIAL INFORMATION

3 TABLE OF CONTENTS (continued) SECTION V DD WAIVER PROGRAM DESCRIPTIONS DD Waiver Standard Program Descriptions 2. DD Waiver Policy and Procedures 3. Additional Program Descriptions for DD Waiver Adult Nursing Services 4. Additional Program Descriptions for DD Waiver Assistive Technology Purchasing Agent 5. Additional Program Descriptions for DD Waiver Personal Support Technology 6. Additional Program Descriptions for DD Waiver Behavioral Support Consultation 7. Additional Program Descriptions for DD Waiver Crisis Supports 8. Additional Program Descriptions for DD Waiver Socialization and Sexuality Education 9. Additional Program Descriptions for DD Waiver Preliminary Risk Screening and Consultation 10. Additional Program Descriptions for DD Waiver Case Management Services 11. Additional Program Descriptions for DD Waiver Customized Community Supports 12. Additional Program Descriptions for DD Waiver Community Integrated Employment Services 13. Additional Program Descriptions for DD Waiver Living Supports 14. Additional Program Descriptions for DD Waiver Customized In-Home Supports 15. Additional Program Descriptions for DD Waiver Independent Living Transition Service 16. Additional Program Descriptions for DD Waiver Therapies 17. Additional Program Descriptions for DD Waiver Environmental Modification Service 18. Additional Program Descriptions for DD Waiver Non-Medical Transportation 19. Quality Assurance/Quality Improvement (QA/QI) Plan MF WAIVER PROGRAM DESCRIPTIONS MF Waiver Standard Program Descriptions 2. MF Waiver Policy and Procedures 3. Additional Program Descriptions for MF Waiver Case Management Services 4. Additional Program Descriptions for MF Waiver Therapy (Occupational, Physical and Speech) Services 5. Additional Program Descriptions for MF Waiver Behavior Support Consultation Services 6. Quality Assurance/Quality Improvement (QA/QI) Plan SECTION VI DDSD CONTACT INFORMATION Developmental Disabilities Supports Division Contact List SECTION VII APPENDICES Appendix 1 Medicaid Regulations 2. Appendix 2 DD Waiver Standards 3. Appendix 3 Billing Rates 4. Appendix 4 DDSD Sample Provider Agreement 5. Appendix 5 DDSD Accreditation Policy 6. Appendix 6 Incident Management System Guide 7. Appendix 7 Transition of DD Individuals-CST 150 Policy 8. Appendix 8 Training Requirements 9. Appendix 9 Definition of a Meaningful Day

4 SECTION I LETTER OF INTRODUCTION

5 Dear DDSD Provider Applicant: This provider application packet and the attached forms contain the necessary information needed to apply to become a provider for the Developmental Disabilities (DD) and/or the Medically Fragile (MF) Medicaid Waiver Programs. All Medicaid Waiver Programs shall be subject to all New Mexico Human Services Department, Medical Assistance Division and Department of Health (DOH) regulations governing Medicaid Waiver Services. In addition, all Provider Agreements awarded shall be subject to the DD and/or MF Waiver Service Standards and other general provider requirements of the DOH. For assistance in completing the application, please contact Tammy M. Barth at (505) or via at Tammy.Barth@state.nm.us. Sincerely, Jim Copeland Jim Copeland Director Developmental Disabilities Supports Division DEVELOPMENTAL DISABILITIES SUPPORTS DIVISION 810 San Mateo, Suite 104 P.O. Box Santa Fe, New Mexico Phone (505) Fax (505) Page 5

6 SECTION II OVERVIEW OF MEDICAID WAIVER PROGRAM Page 6

7 Overview of Waiver Program and Waiver Background Information The Developmental Disabilities Supports Division (DDSD) of the New Mexico Department of Health (DOH) herein referred to as the DEPARTMENT administers provider enrollment for the Developmental Disabilities (DD) and Medically Fragile (MF) Medicaid Waivers. All waiver programs are jointly administered with the New Mexico Human Services Department (HSD) - the single state Medicaid Agency. Recipients of Medicaid Waiver services must meet both financial and medical eligibility as determined by the Human Services Department (HSD), Income Support Division (ISD) in accordance with Medicaid Waiver Regulations. The DEPARTMENT has the authority to approve individual program services based upon budgetary considerations and availability of approved waiver enrollment slots. The DEPARTMENT also has the ability to approve the area(s) and specific service(s) for authorized and approved waiver service providers. Medicaid Waiver services are not an entitlement for eligible Medicaid recipients. Funding is not guaranteed to a provider under the Medicaid Waiver Program. Reimbursement for service(s) is based upon the recipient s selection of approved service providers as contained in an Individual Service Plan (ISP) and as approved by the DDSD and/or the Medicaid Utilization Review Agent. Reimbursement for Medicaid Waiver Programs is based upon a Fee for Service. Reimbursement is at the established service reimbursement rates as shown in the Billing Rates Appendix 3. In order to avoid conflicts of interest, an applicant may not apply to become both a Case Management Provider and a Service Provider under the DD Waiver. Developmental Disabilities (DD) Waiver Summary The DD Waiver is a home and community-based alternative to institutionalization in an intermediate care facility for the mentally retarded (ICF/MR). The program serves individuals who: Meet the state/federal definition of developmental disabilities; Meet the clinical criteria for placement in an ICF/MR facility; May currently be in an alternative placement in the community; Meet established Medicaid financial and non-financial eligibility criteria, and; May reasonably be expected to receive services and supports in the community at a cost equal to or less than the cost of institutional care. (Note: Exceptions may be made to this as long as the aggregate cost of care for all consumers receiving service and supports under the DD Medicaid Waiver program is less than the cost of institutional care.) The individual also has intellectual/developmental disabilities or a specific related condition. Page 7

8 Related conditions are limited to cerebral palsy, autism (including Asperger s Syndrome), seizure disorder, chromosomal disorders (e.g. Downs), syndrome disorders, inborn errors of metabolism, and developmental disorder of brain formation. Developmental Disabilities (DD) Definition The Center for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (DHHS) allows the states to define developmental disabilities as long as that definition is equal to or more comprehensive than the Federal definition. For the purposes of the DD Waiver services, the State of New Mexico s definition of a developmental disability is: A severe chronic disability that meets all the following conditions: a. Is attributable to a mental or physical impairment, including the result from trauma to the brain, or a combination of mental and physical impairments; b. Is manifested before the person reaches 22 years of age; c. Is expected to continue indefinitely; d. Results in substantial functional limitations in three or more of the following areas of major life activity: Self-care; Receptive and expressive language; Learning; Mobility; Self-direction; Capacity for independent living; and Economic self-sufficiency. e. Reflects the person s need for a combination and sequence of special, interdisciplinary, or generic care treatment or other supports and services that are of life-long or extended duration and are individually planned and coordinated. For a list of services offered through the DD Waiver Program, please refer to the DD Waiver Service Standards, Table of Contents. Page 8

9 Medically Fragile (MF) Waiver Summary The MF Waiver program is intended for individuals who have been determined prior to the age of twenty-two (22) to be both medically fragile and developmentally disabled or developmentally delayed; or at risk for developmental delay. Individuals must meet the same level of care criteria required for institutional care and must meet all Medicaid eligibility criteria for income and resources as those served in an institutional care setting. Medically fragile is defined as a chronic physical condition, which results in a prolonged dependency on medical care for which daily skilled (nursing) intervention is medically necessary and is characterized by one or more of the following: 1. There is a life-threatening condition characterized by reasonably frequent periods of acute exacerbation that requires frequent medical supervision, and/or physician consultation and which in the absence of such supervision or consultation, would require hospitalization; 2. The individual requires frequent time-consuming administration of specialized treatments, which are medically necessary, or; 3. The individual is dependent on medical technology such that without the technology a reasonable level of health could not be maintained. Examples include but are not limited to ventilators, dialysis machines, external or paternal nutrition support and continuous oxygen. For a list of services offered through the MF Waiver Program, please refer to MF Waiver Service Standards, Table of Contents. Page 9

10 SECTION III OVERVIEW OF MEDICAID WAIVER APPLICATION 1. Application Requirements 2. Where to Submit 3. Application Format 4. Term of Agreement 5. How to Bill Page 10

11 1. Application Requirements: All applications submitted to DDSD must be submitted with all necessary information and forms. Incomplete applications may be denied and returned to the applicant. Under certain circumstances DDSD may request additional information from the applicant, which must be submitted within timelines determined by DDSD. 2. Where to Submit: Submit one (1) complete original application to: DOH / DDSD / Provider Enrollment Unit (PEU) PO Box San Mateo Road, Suite 103 Santa Fe, New Mexico or Santa Fe, New Mexico Application Format a. Applications that do not conform to the required outline described in all sections may be returned. b. DDSD will not collate, merge, copy or otherwise manipulate the application. c. It is the applicant s responsibility to ensure that all pages and appropriate documents are included. DO NOT send double-sided copies, staple, bind or place your application in a three-ring binder for submission. Please use paper clips, binder clips and/or rubber bands. 4. Term of Agreement a. For agencies that provide services which require accreditation: i. New agencies will be awarded two (2): one (1) year provisional Provider Agreements. This will allow time for your agency to obtain accreditation as required by the DDSD Accreditation Policy. ii. For agencies that have received accreditation, your Provider Agreement will not exceed your accreditation term. iii. Agencies which have received a waiver from the Accreditation requirement may receive up to a three (3) year term depending on the recommendations of the DDSD personnel. b. For agencies that provide services which do not require accreditation: i. New agencies will receive a one (1) year provisional term. ii. Renewing agencies will receive up to a three (3) year term depending on the recommendations received by DDSD personnel. 5. How to Bill: It is recommended, that you contact Xerox the New Mexico Medicaid Fiscal Intermediary and set up an appointment with a Medicaid billing trainer at or at (505) prior to your first billing. Page 11

12 SECTION IV REQUIRED FORMS and DOCUMENTATION DDSD Regional Map 1. DDSD REQUIRED FORMS 11 a. DDSD Provider Information Sheet(s) b. Attachment A-Scope of Work Form(s) c. MAD 335 Provider Participation Agreement (New Providers Only) d. W-9 Form (New Providers Only) e. DDSD Statement of Assurances f. Provider Agency Status Sheet (Renewing Providers Only) 2. DDSD REQUIRED DOCUMENTATION 12 a. Articles of Incorporation and Current Board Members b. IRS FEIN Letter (New Providers Only) c. Professional Licensure / Academic Credentials d. General or Professional Liability Insurance e. Surety or Dishonesty Bond Insurance f. Current New Mexico Business License (New Providers Only) g. CRS Certificate h. NPI Number (New Providers Only) i. Accreditation Requirements 3. FINANCIAL INFORMATION Page 12

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14 1. DDSD requires that the applicant submit forms and documentation as outlined below. Please note, certain forms must be signed and dated by the applicant. a. DDSD Provider Information Sheet(s): This form must be completed by the provider and used as a cover page when the application is submitted to DDSD. i. Developmental Disabilities (DD) Waiver. ii. Medically Fragile (MF) Waiver. b. Attachment A-Scope of Work Form(s): If deleting services, please submit a statement advising DDSD whether your agency is still providing the service(s) you are requesting to delete and the expected date transition(s) are to be completed. Providers must ensure that all individuals receiving services be transitioned to another provider agency, as required in the CST 150 Policy (see Appendix 7): Applicants use this form to identify: i. The waiver program (DD and/or MF) ii. Services; and iii. County(ies) applicant is applying to provide services in. (See Regional Map) c. MAD 335 Provider Participation Agreement (New Providers Only) d. W-9 Form (New Providers Only) e. DDSD Statement of Assurances: Each assurance must be initialed and dated. If not applicable, please state the reason. f. Provider Agency Status Sheet (Renewing Providers Only) 2. DDSD Required Documentation a. Articles of Incorporation or Organization and current board members (if applicable). *A current list of each board member s name, home address, phone number and address must be submitted to the PEU annually. b. IRS FEIN Letter showing your agency s Tax Identification Number. *Sole Providers can use their social security number. (New Providers Only) c. All professional licensure and academic credentials for all hired and subcontracted personnel must be submitted for the following services: DD Waiver i. Adult Nursing Services, Behavioral Support Consultation, Case Management Services, Environmental Modification Service, Intensive Medical Living, Nutritional Counseling, Occupational Therapists, Physical Therapists and Speech Language Pathologists. Page 14

15 MF Waiver ii. Behavior Support Consultation, Case Management Services, Home Health Aide, Nutritional Counseling, Occupational Therapists, Physical Therapists, Private Duty Nursing (LPN/RN) and Speech Language Pathologists. Agencies providing Medically Fragile Waiver services must submit a copy of their Home Health Agency license, if providing Home Health Aide Services. d. Proof of General or Professional Liability Insurance (one million dollar minimum), naming Department of Health as an additional insured. (New Providers, within 30 days of approval ) e. Proof of Surety Bond (individual) or Fidelity Bond (group) Insurance (ten thousand dollar minimum) naming the Department of Health as loss payee. (New Providers, within 30 days of approval) f. Current New Mexico Business License (New Providers Only) g. CRS Certificate - Proof of registration with the NM Department of Taxation and Revenue. h. NPI Number, if providing medical services. (New Providers Only) i. Accreditation Requirements - All providers who are required to hold an accreditation status must follow the DDSD Accreditation Policy (see Appendix 5): a. Current Providers: Provide a copy of the letter and certificate showing your current accreditation status for your agency or a copy of the letter you received from the Department granting a waiver from the accreditation requirement. If you are requesting a waiver from the accreditation requirement, a new request must be submitted to the Department for consideration. Accreditation waivers are only good through the term of your agency s current Provider Agreement. b. Agencies renewing for the first time: Provide a detailed plan that outlines timelines to ensure your agency is accredited within the next nine (9) months and/or a letter from an accrediting body showing when your survey will take place. 3. Financial Information a. New Providers are required to provide: i. A business plan and anticipated expenses, including a narrative that demonstrates how you will sustain the business during the start-up phase. ii. Demonstrate the agency has an adequate amount of cash or line of credit to pay operating costs for a three (3) month period (i.e. financial institution statements, bank statement or line of credit). b. Renewing Providers are required to submit: Annual tax return, current year end Profit and Loss Statement and/or financial audit prepared by an accountant. Page 15

16 For the responses to the Standard Program Descriptions, Additional Program Descriptions and the Quality Management Plan: It is very important that Providers follow the layout of the PROGRAM DESCRIPTIONS, POLICY AND PROCEDURES AND QUALITY IMPROVEMENT PLAN exactly as it is written. Please place a cover page in front of each section you are responding to with the Section name, question number and PLEASE use page numbers. Please do not combine your responses for two different sections on one page. If your PROGRAM DESCRIPTIONS ARE NOT submitted in the requested format and do not have coversheets and page numbers; the application will be denied. Page 16

17 SECTION V DD WAIVER PROGRAM DESCRIPTIONS 1. DD Waiver Standard Program Description 2. DD Waiver Policy and Procedures 3. Additional Program Descriptions for DD Waiver Adult Nursing Services 4. Additional Program Descriptions for DD Waiver Assistive Technology Purchasing Agent 5. Additional Program Descriptions for DD Waiver Personal Support Technology 6. Additional Program Descriptions for DD Waiver Behavioral Support Consultation 7. Additional Program Descriptions for DD Waiver Crisis Supports 8. Additional Program Descriptions for DD Waiver Socialization and Sexuality Education 9. Additional Program Descriptions for DD Waiver Preliminary Risk Screening and Consultation 10. Additional Program Descriptions for DD Waiver Case Management Services 11. Additional Program Descriptions for DD Waiver Customized Community Supports 12. Additional Program Descriptions for DD Waiver Community Integrated Employment Services 13. Additional Program Descriptions for DD Waiver Living Supports 14. Additional Program Descriptions for DD Waiver Customized In-Home Supports 15. Additional Program Descriptions for DD Waiver Independent Living Transition Service 16. Additional Program Descriptions for DD Waiver Therapies 17. Additional Program Descriptions for DD Waiver Environmental Modification Service 18. Additional Program Descriptions for DD Waiver Non-Medical Transportation 19. Quality Assurance/Quality Improvement (QA/QI) Plan Page 17

18 1. DD Waiver Standard Program Description (coversheet and page numbers required) a. Provide a statement describing your agency s: i. Mission; ii. Vision; and iii. Values. b. Please summarize why your agency would like to provide services to individuals on the DD Waiver. c. Please describe: i. Your agency s or your personal experience working with individuals with intellectual/developmental disabilities. ii. Your agency s or your personal experience providing each of the services your agency is applying for. iii. Please provide your Director s resume. d. To ensure the health and safety of individuals receiving services, please describe in detail (NOTE: Environmental Modification, Assistive Technology Purchasing Agent and Personal Support Technology do not need to answer i, iii, v): i. Your agency s master staffing plan, number of staff by title or position, hours scheduled and their qualifications. ii. Fully describe your agency s approach to delivering each of the services that you are applying to provide. iii. Plans for back-up staff for all individuals receiving services by the agency. (NOTE: Therapy Providers must provide plans for backup in case of emergency and/or extended vacations). iv. How ALL staff will be informed and updated of the needs and service goals of the individuals to be served. v. Where the individual s emergency medical and/or behavioral crisis information will be physically located. For example: Behavioral Crisis Intervention Plans (BCIP) is written by the Behavioral Support Consultant and the plans will be maintained appropriately by the provider agency. In addition to the Standard Program Descriptions, agencies that provide the following services must also submit the following Additional Program Descriptions: Adult Nursing Services Assistive Technology Purchasing Agent Personal Support Technology Behavioral Support Consultation Crisis Supports Socialization and Sexuality Education Preliminary Risk Screening and Consultation Case Management Services Customized Community Supports Community Integrated Employment Services Living Supports Customized In-Home Supports Independent Living Transition Service Therapies Environmental Modification Service Non-Medical Transportation Page 18

19 2. DD Waiver Policy and Procedures (coversheet and page numbers required) a. Submit one (1) copy of the following Policies and Procedures (NOTE: Environmental Modification Providers do not need to answer i.): i. Procedures to transition individuals upon termination or expiration of your agency s Provider Agreement or when an individual transitions to another agency; and ii. Procedures to maintain all individual s files for up to six (6) years after the termination or expiration of your agency s Provider Agreement or when an individual transitions to another agency. b. Please provide your agency s Incident Management Procedures that comply with the current NM Department of Health Improvement Incident Management Guide, available at c. The policies and procedures must emphasize (NOTE: Environmental Modification Providers do not need to answer ii.): i. Incident reporting related to Abuse, Neglect and Exploitation of individuals receiving services; and ii. Define staff training requirements, mandated DHI postings and Abuse, Neglect, and Exploitation tracking and trends for quality improvement purposes. (NOTE: BSC Providers do not need to include DHI postings) d. To ensure the health and safety of individuals receiving services, as required in the DDSD Service Standards, please provide your agency s (NOTE: Environmental Modification Providers do not need to answer the following): i. Emergency and on-call procedures. (NOTE: Therapy providers need to provide information regarding what arrangements have been made for vacations and/or extended absences, i.e., who the individuals and/or teams would call when the therapist is unable to respond within twenty-four (24) hours during regular business hours); ii. iii. iv. Training plan and policies that describe how personnel employed by or subcontracting with your agency will meet all applicable department training requirements; Procedures on how your agency will ensure that medical, clinical and/or behavioral information regarding the individuals served will be communicated to all staff and subcontracted personnel; and Procedures for conducting a background check on the applicant to include personal and professional references. (NOTE: Therapy provider procedures need to address how they conduct personal/professional reference checks ONLY.) Page 19

20 3. Additional Program Descriptions for DD Waiver Adult Nursing Services (coversheet and page numbers required) a. Describe your agency s arrangements for on-call nursing coverage to comply with PRN aspects of the DDSD Medication Assessment and Delivery Policy and Procedure as well as response to individuals changing condition/unanticipated health related events; b. Describe your agency s procedure for RN supervision of LPNs and if applicable Certified Medication Aides (CMAs); c. Submit your agency s policy and procedures to ensure compliance with New Mexico Nurse Practice Act requirements regarding delegation of specific nursing functions; d. Describe how your agency will coordinate with providers of other services for individuals mutually served (e.g. Customized Community Supports, Home Health or Hospice, Therapies, Customized In-Home Supports); and e. Describe how your agency will ensure all nurses are competent in the use of required Therap components including the electronic Comprehensive Health Assessment Tool (e-chat), associated Aspiration Risk Screening Tool, Medication Administration Assessment Tool, Health Passport, Health Tracker, and General Events Reporting. 4. Additional Program Descriptions for DD Waiver Assistive Technology Purchasing Agent (coversheet and page numbers required) a. Describe your agency s experience and capacity to fulfill fiscal intermediary functions. b. Identify the accounting or software system that will be utilized to manage data to support tracking of: i. Received and processed request; ii. Cashed and un-cashed checks; iii. Voided/returned checks; iv. Remaining balance for each individual; v. Tracking receipts for all devices or materials purchased; vi. Annual reports for each individual; and vii. Administrative fee amounts. c. Identify the personnel who will be directly responsible for managing this service (including plan for back-up staffing); and d. Provide all policies and procedures to maintain compliance with the current DDSD Assistive Technology standards pertaining to: i. All aspects for processing applications, including time lines; ii. Maintaining the financial system; iii. Distribution of annual reports; and iv. Monitoring integrity of financial systems. Page 20

21 5. Additional Program Descriptions for DD Waiver Personal Support Technology (coversheet and page numbers required) a. Describe your agency s experience and capacity to fulfill all functions of the Personal Support Technology Service Standards; b. Identify the software and accounting system that will be utilized to manage data for the tracking of services and financial information; c. Identify the personnel who will be directly responsible for managing the financial installation /maintenance, monitoring and education services. Include a plan for on-call and back-up staffing and provide all contact information including and fax numbers; d. All policies and procedures to maintain compliance with the current DDSD Personal Support Technology Service Standards; and e. Renewing providers must submit to DDSD: A summary of updates to include any personnel changes and their contact information; any revisions to policies and procedures and a summary of all QA/QI activities since the last application. 6. Additional Program Descriptions for DD Waiver Behavioral Support Consultation (coversheet and page numbers required) a. Describe your agency s experience using Positive Behavior Support as a model for practice; b. Describe your agency s approach to providing services through a consultation model; c. Describe your agency s approach to development and implementation of a PBS plan; d. Describe how your agency will fulfill the 2012 Behavior Support Consultation Service Standards with regard to training of IDT members and DSPs [refer to I.1.B.6 a-c, 2012]; and e. Describe how your agency will work to ensure implementation of the least intrusive effective behavior interventions and describe how your agency will work with provider agencies to ensure proper Human Rights Committee reviews when necessary. 7. Additional Program Descriptions for DD Waiver Crisis Supports (coversheet and page numbers required) a. Submit a schedule of proposed staffing patterns, illustrating how your agency will ensure that sufficient crisis response staff will be available to respond to Crisis Supports events on a twentyfour (24) hours/seven (7) days a week basis. b. Prepare a written statement indicating how your agency will insure that essential individual, medical and behavioral information is communicated to crisis response staff. Indicate if applicable, where the individual s emergency medical and/or behavioral crisis information will be kept within the individual s Crisis Supports residential setting. Page 21

22 c. Crisis Supports providers must also provide relevant policies for: i. Orientation for agency management related to Crisis Supports. A policy regarding designation and training of crisis response staff, including identification of additional crisis response staff as turnover occurs; and ii. Crisis prevention and intervention, in accordance with the current Behavioral Crisis Intervention Plan Policy. d. Does the application describe what positions within the agency will be responsible for coordination and oversight of Crisis Supports services? e. Please describe what job position within your agency will be responsible for coordination and oversight of Crisis Supports services. Please indicate how your agency will assure the Crisis Supports service requirements fit into current agency operations. Please include: i. 26+ hours training for crisis response staff; ii. Required orientation for upper and middle management; iii. Training in one DDSD-approved emergency physical intervention methods (e.g. The Mandt, Crisis Prevention Institute s Nonviolent Crisis Intervention protocol or Handle with Care); iv. 1:1 or higher crisis response staff to consumer ratios; v. IDT coordination including weekly updates or site visits bi-monthly IDTs; and vi. QA/QI program requirements, especially use of QA/QI committee. 8. Additional Program Descriptions for DD Waiver Socialization and Sexuality Education (coversheet and page numbers required) a. Please describe your agency s philosophy around provision of socialization and sexuality education to individuals with intellectual/developmental disabilities; b. Please describe why your agency would like to provide this service and what benefits and impact you believe it will have on individuals served under the DDW; c. Identify at least one (1) BBS certified lead teacher and describe their experience and strengths in providing this service; d. Please describe the process your agency will use to identify/train student teachers when needed by the agency; and e. Please describe the process your agency will use to identify, train and hire self-advocate peer mentors. 9. Additional Program Descriptions for DD Waiver Preliminary Risk Screening and Consultation (coversheet and page numbers required) a. Provide documentation that your agency s identified Risk Evaluator (RE) has met all OBS qualifications and prerequisites for provisional BBS approval. (If Renewing: Provide documentation related to requirements for full and ongoing BBS approval.) Page 22

23 b. Please provide responses directly from the RE applicant for provisional approval for the following items: i. Describe your capacity to commit the time necessary to complete all ongoing training and supervision requirements in order to participate in a competency review with BBS for full approval for this service; ii. Please describe your agency s professional goals and how they relate to the level of training and supervision necessary to obtain BBS approval for this service; and iii. Please describe the RE s experience working with IDT members who are dealing with difficult, emotionally charged issues and their experience with making clinical recommendations in this context. 10. Additional Program Descriptions for DD Waiver Case Management Services (coversheet and page numbers required) a. The individual s information must be kept current and accessible at all times. Please state the methods that your agency will use to ensure adherence to this service standard. b. Prepare a written statement of assurance acknowledging the following requirements: i. Provide a list of generic community resources available to individuals in the DDSD Region(s) you are applying for; ii. iii. iv. Submit copy(ies) of each case manager s educational degree. If the degree requirement has been waived by DDSD, include a copy of the DDSD waiver approval letter; Describe how your agency will encourage, promote and support individuals to gain meaningful employment; and Describe how your agency intends to meet the requirement that there will be a minimum of three (3) case managers or your intention to apply for a temporary waiver of this requirement. 11. Additional Program Descriptions for DD Waiver Customized Community Supports (coversheet and page numbers required) a. Describe how your agency will or has achieved the following: i. Deliver services and supports in integrated, community settings rather than segregated settings and/or explain how individuals will be transitioned into more integrated, age appropriate options (at least 50% of program time for Customized Community Supports- Group setting or 100% of program time for Customized Community Supports; Small Group and Individual); ii. Provide support to individuals receiving services to engage in individually defined Meaningful Day, Action Plan and Measurable Outcome activities as identified in their ISPs at least 80% of the billable time; Page 23

24 iii. iv. Discuss individual employment for at least minimum wage as a priority service over other options for all working age adults with the individual and the IDT s of people served. Please provide an example of that process based on your agency s experience and success or what policies and procedures your agency will develop to address the Employment First principle; Provide individualized support to individuals receiving services to engage in communitybased volunteer activities that support skill building, community connections, a sense of giving back to the community and the potential for employment opportunities. Please describe an example based on your agency s experience and success or what policies and procedures your agency will develop to address building volunteer experience; v. Decrease dependence on paid supports as the individual is supported to increase their community connections. Please describe an example based on your agency s experience and success or what policies and procedures your agency will develop to address; and vi. Assure that Direct Service Personnel are trained on and consistently implement Written Direct Support plans/instructions from therapists as applicable. 12. Additional Program Descriptions for DD Waiver Community Integrated Employment Services (coversheet and page numbers required) a. Describe how your agency will or has achieved the following: i. Develop community integrated employment at minimum wage or higher for individuals with intellectual/developmental disabilities. Please provide an example based on your agency s experience and success or what policies and procedures your agency will develop in this area; ii. Assist individuals to start his/her own business when specified in the ISP. Please provide an example based on your agency s experience and success or policies and procedures your agency will develop to address; iii. Decrease dependence on and reduce the amount of paid supports needed as the individual accesses natural supports (fading plan). Please provide an example based on your agency s experience and success or policies and procedures your agency will develop to address; and iv. Assure that Direct Service Personnel are trained on and consistently implement Written Direct Support plans/instructions from therapists as applicable. b. Provide a copy of the following documents: i. A sample Vocational Assessment Profile (VAP) completed by your agency. (If a formal VAP has not been completed, provide examples of what vocational assessments have been utilized or are intended to be used.); ii. Job descriptions for Job Developers, Job Coaches and supervisory staff; iii. A plan to recruit and /or retain specified full-time personnel designated for job development, VAP facilitation and job coaching; and Page 24

25 iv. A sample of an employer satisfaction survey or current survey with previous year results as applicable. 13. Additional Program Descriptions for DD Waiver Living Supports (Family Living, Supported Living and Intensive Medical Living) [coversheet and page numbers required] a. General Questions for all Living Supports Providers: i. Describe how your agency will assure compliance with Therap to include, General Events Reporting and the requirement for the e-chat (Electronic Comprehensive Health Assessment Tool); ii. iii. iv. Please submit your agency s policies and procedures regarding the safe transportation of individuals in the community and how you will comply with the New Mexico regulations governing the operation of motor vehicles; Please provide your agency s policies and procedures regarding the use of individual's SSI payment or other personal funds; Describe how your agency will ensure timely implementation of healthcare orders, tracking of individual health indicators (e.g. weight, seizure frequency, etc.) and development, training, implementation, and monitoring of required Healthcare Plans and Medical Emergency Response Plans; v. Describe how your agency will ensure all nurses are competent in the use of required Therap components including electronic Comprehensive Health Assessment Tool (e- CHAT) and associated Aspiration Risk Screening Tool and Medication Administration Assessment Tool, Health Passport, Health Tracker, and that all staff complies with General Events Reporting; vi. Describe how your agency will provide support to individuals receiving services to engage in Meaningful Day activities identified in their ISP; vii. Describe how your agency will promote and support individuals to participate in integrated activities in the community; viii. Describe how your agency will encourage, promote, and support individuals to gain meaningful employment; and b. Please describe how the agency will monitor all Assistive Technology to ensure that the needed adaptive equipment, augmentative communication and assistive technology devices are available and functioning properly. c. Family Living: i. Please provide an assurance statement that your agency will also provide Adult Nursing Services and comply with the DDW Service Standard requirements for this service. ii. Please submit policies and procedures regarding nurse delegation that are also in compliance with the Nurse Practice Act. Page 25

26 iii. Standards/Procedures for application process and approval of Family Living Direct Support Provider. Submit a copy of your application the subcontractor completes. iv. Standards/Procedures for Family Living Support Services Applicant Self-Assessment. Submit a copy of the Self-Assessment Form the subcontractor completes. v. Standards/Procedures and content for the Family Living Supports Home Study Assessment. Submit a copy of the home study template the provider agency completes. vi. Standards/Procedures for conducting a background check on the applicant to include personal and professional references. vii. Describe how your agency will assure that Direct Support Personnel Family Living are trained on and consistently implementing Therapy Support Plans and ISP Therapy Strategies. d. Supported Living: i. Please provide an assurance statement that an average of five (5) hours of documented nutritional counseling will be available annually, if recommended by the IDT and clinically indicated. ii. Describe or provide your agency's on-call nursing services that specifically state the nurse must be available to DSP during periods when a nurse is not present. The on-call nurse must be available to make an on-site visit when information provided by the DSP over the phone indicate, in the nurse's professional judgment, a need for a face to face assessment to determine appropriate action. iii. Describe your agency s arrangements for on-call nursing coverage to comply with PRN aspects of the DDSD Medication Assessment and Delivery Policy and Procedure as well as response to individual changing condition/unanticipated health related events. iv. Describe your agency s procedure for RN supervision of LPNs and if applicable Certified Medication Aides (CMAs). v. Submit your agency s policy and procedures to ensure compliance with New Mexico Nurse Practice Act requirements regarding delegation of specific nursing functions. vi. Describe how your agency will coordinate with providers of other services for individuals mutually served (e.g. Customized Community Supports, Hospice, and Therapies/Behavioral Support Consultation). e. Intensive Medical Living: i. Describe your agency s arrangements for on-call nursing coverage to comply with PRN aspects of the DDSD Medication Assessment and Delivery Policy and Procedure as well as response to individual s changing condition/unanticipated health related events. ii. Describe your agency s procedure for RN supervision of LPNs and if applicable, Certified Medication Aides (CMAs). Page 26

27 iii. Submit your agency s policy and procedures to ensure compliance with New Mexico Nurse Practice Act requirements regarding delegation of specific nursing functions. iv. Describe how your agency will coordinate with providers of other services for individuals mutually served (e.g. Customized Community Supports, Hospice, and Therapies/Behavioral Support Consultation). v. Describe your arrangements for availability of care for short term stays as outlined in DDW Service Standards Chapter 13 1.B and 3.B. 14. Additional Program Descriptions for DD Waiver Customized In-Home Supports (coversheet and page numbers required) a. Describe how your agency will ensure that services will be provided in integrated settings, versus segregated settings; b. Describe how your agency will provide support to individuals, to design and manage their services in their own home or their family living home; c. Describe how your agency will promote and support individuals to participate in integrated activities in the community; d. Describe how your agency will encourage, promote and support individuals to gain meaningful employment; e. Describe how your agency will promote skill development and retention to enhance their ability to live independently; and f. Describe how your agency will assure compliance with Therap to include General Events Reporting and the requirement for the e-chat (Electronic Comprehensive Health Assessment Tool). 15. Additional Program Descriptions for DD Waiver Independent Living Transition Service (coversheet and page numbers required) a. Describe how your agency will assure this is a one-time support; b. Describe how your agency will assure that the money requested will be used toward allowable expenses as found in the DDW Service Standards; c. Describe how agency will assure that the DD Waiver funds are payer of last resort; d. Submit your agency s policies and procedures on assuring proper maintenance of documentation, logs and receipts; e. Submit your agency s policies and procedures for assuring that the agency is maintaining financial capacity to serve present and additional individuals who select the agency for this service; and Page 27

28 f. Describe how your agency will track and ensure timely submission and distribution of required documentation and reports. 16. Additional Program Descriptions for DD Waiver Therapies (coversheet and page numbers required) a. Describe your agency s experience providing therapy to individuals with intellectual/developmental disabilities; b. Describe your agency s plan to ensure that all agency therapists are familiar with and are correctly implementing the following key elements for the provision of therapy on the DD Waiver: i. Aspiration Risk Management Policies and Procedures; ii. Integration of the Participatory Approach; and iii. The current DD Waiver Therapy Service Standards. c. How will your agency assure that therapists are completing the Therapy Support Plans, written Direct Support Instructions, training Direct Support Personnel and fading therapy when appropriate? d. Attach your agency s formal security management process including how your agency will comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations. It must contain your agencies full spectrum of protection: i. HIPAA Compliant Protected Health Information (PHI) Safeguards and Client Rights to Privacy. ii. HIPAA Compliant Physical Safeguards and Storing/Retention of PHI. iii. HIPAA Compliant Technical Safeguards ( & Fax). iv. HIPAA Compliant Equipment Control (Computers, tablets, cell phones, etc.). v. HIPAA Compliant Encryption, Cloud Storage, Firewalls, Malware & Hosting Plans. vi. HIPAA Compliant Billing Companies & Firms that process electronic health information. vii. HIPAA Compliant Documentation Safeguards that you have in place/disposal/shredding Firms. viii. Breach Notification Procedures (1-500 and 500 and over). ix. Legal Involvement & Complaints. x. HIPAA Compliant Internal Audits/Contingency Plans. xi. HIPAA Compliance Training (Staff, Subcontractors, Business Associates, etc.). xii. Compliance Officer Information. 17. Additional Program Descriptions for DD Waiver Environmental Modification Service (coversheet and page numbers required) a. How does/will your agency assure that all environmental modifications address the individual s disability and enable the individual to function with greater health, safety and independence in the home? b. How does your agency assure the health and safety of the occupants of the home while modifications are being completed? Page 28

29 c. Describe your agency s experience in providing environmental modifications for people with physical and intellectual/developmental disabilities. This should include your experience in working with occupational therapists, physical therapists, case managers and other members of an interdisciplinary team, as well as ADA requirements. d. Describe your agency s capacity to address the Environmental Modification Service Provider Requirements as outlined in the New Mexico Medicaid DDW Service Standards, Chapter 9, section 2 and 3. e. What type of written warranty do you give? Please be specific to the different types of modifications you provide. f. Describe your procedure for assuring consultation is provided to family members, waiver providers and contractors concerning environmental modification projects to the individual s residence. 18. Additional Program Descriptions for DD Waiver Non-Medical Transportation (coversheet and page numbers required) a. Provide your agency s policies and procedures regarding the safe transportation of individuals in the community and how they will comply with the New Mexico regulations governing the operation of motor vehicles. b. Provide information on how the agency will provide training to implement individualspecific techniques to ensure the safe transportation of individuals who have unique medical, physical, or behavioral considerations. c. Provide specific information about how staff will be trained the use of special lifts and other equipment for individuals in a wheelchair. d. Describe your agency s process for monitoring their vehicles for potential safety hazards while in use and routine repair checks as needed. e. Provide your agency s policy and procedure for staff having to deal with breakdowns or accidents on the road and what to do in case of an emergency. Page 29

30 19. Quality Assurance/Quality Improvement (QA/QI) Plan (coversheet and page numbers required) A. Quality Assurance/Quality Improvement (QA/QI) Plan: Community-based providers shall develop and maintain an active QA/QI plan in order to assure the provisions of quality services. 1. Development of a QA/QI plan: The QA/QI plan is used by an agency to continually determine whether the agency is performing within program requirements, achieving desired outcomes and identifying opportunities for improvement. The QA/QI plan describes the process the Provider Agency uses in each phase of the process: discovery, remediation and improvement. It describes the frequency, the source and types of information gathered, as well as the methods used to analyze and measure performance. The QA/QI plan must describe how the data collected will be used to improve the delivery of services and methods to evaluate whether implementation of improvements are working. The plan shall include but is not limited to: a. Activities or processes related to discovery, i.e., monitoring and recording the findings. Descriptions of monitoring /oversight activities that occur at the individual s and provider level of service delivery. These monitoring activities provide a foundation for QA/QI plan by generating information that can be aggregated and analyzed to measure the overall system performance. b. The entities or individuals responsible for conducting the discovery/monitoring process; c. The types of information used to measure performance; and d. The frequency with which performance is measured 2. Implementing a QA/QI Committee: The QA/QI committee must convene on at least a quarterly basis and as needed to review monthly service reports, to identify and remedy any deficiencies, trends, patterns, or concerns as well as opportunities for quality improvement. The QA/QI meeting must be documented. The QA/QI review should address at least the following: a. Implementation of the ISP, including: i. Implementation of outcomes and action steps at the required frequency outlined in the ISP; and ii. Outcome statements for each life area are measurable and can be readily determined when it is accomplished or completed. b. Compliance with Caregivers Criminal History Screening requirements; c. Compliance with Employee Abuse Registry requirements; d. Compliance with DDSD training requirements; e. Patterns in reportable incidents; Page 30