Lead Agency Quality Assurance Plan Survey for Medical Assistance Waiver Home and Community-Based Services

Lead Agency Quality Assurance Plan Survey for Medical Assistance Waiver Home and Community-Based Services Introduction: The Minnesota Department of Human Services (DHS) has, in years past, required counties, tribes, and managed care organizations (referred to as Lead Agencies (LA)) to complete a biennial Quality Assurance (QA) Plan for waiver Home and Community-Based Service (HCBS) administered by the LA. DHS is now requiring each LA complete its QA Plan in preparation for its HCBS Waiver Review. The QA Plan will be compiled via an online survey tool once again, and although it has been updated, it remains very similar to the previous version. The QA Plan survey is designed to gather information to assess and verify that: The Lead Agency is implementing HCBS waiver programs appropriately and according the Federal and State requirements The Lead Agency is carrying out delegated quality assurance, monitoring, and assessment activities necessary to achieving desired HCBS program outcomes The Lead Agency has policies and practices in place to ensure the health and safety, and participation and choice-making of enrollees participating in the HCBS program. While not required to be submitted with the QA Plan at this time, the Lead Agency must be able to provide evidence and/or documentation to verify their answers to each question on this survey if requested by DHS in the future. Many of the requirements of LAs addressed in this survey will be verified during the Waiver Review process via case file reviews, MMIS data analysis, and staff and provider feedback. Home and Community-Based Services & Programs Included in this Survey: The survey includes questions related to the administration of any or all of the following programs: Alternative Care Program: State-funded home and community-based services program similar to the Elderly Waiver for persons 65 and older with nursing facility level of care needs (AC). Community Alternative Care Waiver: Home and community-based waiver program for persons with hospital level of care needs (CAC). Community Alternatives for Disabled Individuals Waiver: Home and community-based waiver program for persons under 65 with nursing facility level of care needs (CADI). Elderly Waiver: Home and community-based waiver program for persons 65 and over with nursing facility level of care needs (EW). Long Term Care Consultation Program: Program providing a variety of services available to all citizens regardless of age, disability, or eligibility for Minnesota Health Care Programs. (LTCC). Developmental Disabilities Waiver: Home and community-based waiver program for persons with developmental disabilities or a related condition with ICF/MR level of care needs (DD). Brain Injury Waiver: Home and community-based waiver program for persons with a brain injury and either nursing facility level of care (BI-NF) or neurobehavioral hospital level of care needs (BI-NB). 1

Please note that the term consumer used in the survey encompasses the person to whom services are being delivered. In cases where consumers are not able to make their own decisions or speak for themselves, the term consumer refers to their legal representative. Online Survey Instructions: Please submit only one completed survey from each Lead Agency. Please consult with others at the LA (e.g. Social Services Department, Public Health Department, etc.) whose input is needed prior to submitting the survey. We strongly encourage LAs to review the MS Word version of the survey and gather all information required before beginning the survey. You may also want to refer to the previous quality assurance survey as many of the questions are similar. The average time to complete the survey once all information is obtained will vary from 45 to 90 minutes. All questions require a response, unless it is labeled as "optional". Please note that question numbers may skip around. To shorten and customize the survey, it contains conditional branching of the questions so you will only see the appropriate questions based on your previous answers. To navigate between pages, use the BACK and NEXT buttons at the bottom of each page. You may also print out your answers at the end of the survey using the PRINT button. You are able to print this survey for your records or to gather input from colleagues at your Lead Agency. Please note that the survey will print on as many as 66 pages. 2

The majority of the survey questions use the following scale: Response Operational Definitions 1: Never Select this response if the LA does not a have a practice and/or policy in place to address the item in question and does not perform the activity/item for any of its waivers, clients, or case managers. 2: Some of the Time Select this response if the LA occasionally completes this item, but it is not a generally applied practice and/or policy. This response also applies to practices that are not consistently implemented across all waiver populations. For example, in a LA where the Public Health Department administers the aging waivers (EW,AC) and the Social Services Department administers the disability waivers (DD, CAC, CADI, BI), the Public Health Department may have practices in place to address requirements that the Social Services Department does not. 3: Most of the Time Select this response if the LA has a policy and/or practice in place that is consistently followed, but staff may experience an occasional barrier to full compliance with the policy and/or practice. For example, consumer cancelations could delay a timely LTCC Assessment. 4: Always Select this response if the item in question if the LA has a policy and/or practice to address the item, the policy and/or practice is always followed, and implementation is consistent across all waivers and case managers. Items proceeded by an asterisk (*) are activities recommended by DHS to LAs but not required under the federal HCBS quality protocol. For questions that inquire about required items or required LA duties, if the Lead Agency answers 1 (Never) or 2(Some of the Time), it will be prompted to submit a brief remediation proposal to address how the LA will meet the requirement. This proposal should be about three to five sentences and include time lines, objectives, and methods that will be utilized to correct the required item and come into compliance. DHS will discuss these items with LA s during the Waiver Review process and work cooperatively with LA s to address these items whenever possible. If the Lead Agency answers 3 (Most of the time), it will be prompted to briefly describe any occasional barriers preventing the agency from achieving full (100%) compliance regarding the requirement. Questions: If you have any technical problems with this survey, please contact Liz Radel Freeman at the Improve Group: LizF@theimprovegroup.com or 651.315.8922 If you have questions regarding the content of this survey, please contact the MN Department of Human Service s contact: Julia Wallis Holmoe; 651.431.2168; Julia.Holmoe@state.mn.us. 3

Lead Agency Quality Assurance Plan Survey for Medical Assistance Waiver Home and Community-Based Services Contact Information The focus areas or domains contained in the QA Plan are organized to reflect federal and state requirements regarding quality assurance in community-based settings. The person whose name appears below will be considered the contact person for questions about the quality assurance plan for all domains unless otherwise indicated below. Name of person completing the QA Plan A.1 First Name A.2 Last Name A.3 County or Tribe (Lead Agency): Drop down box list of all counties and 2 tribes. A.4 Address A.5 Phone A.6 Email A.7 Is the person listed above the contact for all contents of this QA Plan? Yes No A.8 If no, Second Name A.9 Phone A.10 Email 4

I. Participant Access: Individuals have access to home and community-based services and supports in their communities Long Term Care Consultation Program Requirements: Under the provisions of Minnesota Statute Section 256B.0911, qualified professionals provide Long Term Care Consultation (LTCC) services to enrollees. LTCC service includes assessment of individual consumer s needs and strengths in order to make recommendations regarding long term care services. One of the results of this assessment activity is the determination of the level of care. This determination process provides access to HCBS waiver services, and is also required for public payment of institutional services. Development Disabilities Screening Requirements: Under the provisions of Minnesota Statute Section 256B.092 and MN Rules, Chapter 9525, parts 9525.0004 to 9525.0036, persons with developmental disabilities shall have screening teams established to evaluate the need for the level of care provided by residential-based habilitation services, residential services, training and habilitation services, and nursing facility services. The screening process has additional timelines and follow up required under this statute. Information and Referral Indicate how often the Lead Agency staff does the following: B.1 Provides information and referral about long term care options If you responded never or some of the time to question B.1, your Lead Agency is not meeting the requirement of providing information and referrals about long term care options. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question B.1, briefly explain the occasional barriers requirement of providing information and referrals about long term care options, and how your agency deals with or manages these barriers. 5

B.2 Which of the following resources has the Lead Agency used in the past year to provide information and referrals about long term care options? Please check all that apply. Provider directory MinnesotaHelp.info Senior Linkage Line Visit Packets Brochures Other, please specify B.3 Carries out education activities related to the availability of HCBS If you responded never or some of the time to question B.3, your Lead Agency is not meeting the requirement of carrying out education activities related to availability of HCBS. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question B.3, briefly explain the occasional barriers requirement of carrying out education activities related to availability of HCBS, and how your agency deals with or manages these barriers. 6

B.4 Which of the following resources has the Lead Agency used in the past year for educational activities related to availability of HCBS? Please check all that apply. Brochures Newspaper articles Presentations to community groups Other, please specify B.5 Provides early intervention activities If you responded never or some of the time to question B.5, your Lead Agency is not meeting the requirement of providing early intervention activities. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question B.5, briefly explain the occasional barriers requirement of providing early intervention activities, and how your agency deals with or manages these barriers. B.6 Provides information about the availability of assistance in applying for Minnesota Health Care Programs If you responded never or some of the time to question B.6, your Lead Agency is not meeting the requirement of providing information about the availability of assistance in applying for Minnesota Health Care Programs. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. 7

If you responded most of the time to question B.6, briefly explain the occasional barriers requirement of providing information about the availability of assistance in applying for Minnesota Health Care Programs, and how your agency deals with or manages these barriers. Nursing Facility Admissions and Relocation Assistance B.15 Conducts telephone or in-person screenings for nursing facility admission If you responded never or some of the time to question B.15, your Lead Agency is not meeting the requirement of conducting telephone of in-person screenings for nursing facility admission. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question B.15, briefly explain the occasional barriers requirement of conducting telephone of in-person screenings for nursing facility admission, and how your agency deals with or manages these barriers. 8

B.16 Visits consumers under 65 admitted to facilities within timelines as outlined in law If you responded never or some of the time to question B.16, your Lead Agency is not meeting the requirement of visiting consumers under 65 admitted to facilities within timelines as outlined in law. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question B.16, briefly explain the occasional barriers requirement of visiting consumers under 65 admitted to facilities within timelines as outlined in law, and how your agency deals with or manages these barriers. B.17 Completes nursing facility level of care determination using criteria provided by DHS If you responded never or some of the time to question B.17, your Lead Agency is not meeting the requirement of completing nursing facility level of care determination using criteria provided by DHS. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. 9

If you responded most of the time to question B.17, briefly explain the occasional barriers requirement of completing nursing facility level of care determination using criteria provided by DHS, and how your agency deals with or manages these barriers. B.18 Completes Level I screening for mental illness or developmental disability as required under state and federal law for facility admissions If you responded never or some of the time to question B.18, your Lead Agency is not meeting the requirement of completing Level I screening for mental illness or developmental disability as required under state and federal law for facility admissions. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question B.18, briefly explain the occasional barriers requirement of completing Level I screening for mental illness or developmental disability as required under state and federal law for facility admissions, and how your agency deals with or manages these barriers. 10

B.19 Makes referrals to appropriate mental health/ developmental disability professionals for further diagnostic assessment or evaluation (OBRA Level II) If you responded never or some of the time to question B.19, your Lead Agency is not meeting the requirement of making referrals to appropriate mental health/ developmental disability professionals for further diagnostic assessment or evaluation (OBRA Level II). Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question B.19, briefly explain the occasional barriers requirement of making referrals to appropriate mental health/ developmental disability professionals for further diagnostic assessment or evaluation (OBRA Level II), and how your agency deals with or manages these barriers. B.20 Provides relocation assistance to assist consumers in returning to community settings after facility admission If you responded never or some of the time to question B.20, your Lead Agency is not meeting the requirement of providing relocation assistance to consumers returning to community settings after facility admission. Please submit a brief remediation 11

proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question B.20, briefly explain the occasional barriers requirement of providing relocation assistance to consumers returning to community settings after facility admission, and how your agency deals with or manages these barriers. B. 33 *Please describe any barriers your Lead Agency faces in meeting the requirements discussed above. (Optional) Community Indicate how often the Lead Agency staff does the following: B.34 Provides face-to-face assessment to all citizens requesting such assistance If you responded never or some of the time to question B.34, your Lead Agency is not meeting the requirement of providing face-to-face assessment to all citizens requesting such assistance. Please submit a brief remediation proposal to address how 12

the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question B.34, briefly explain the occasional barriers requirement of providing face-to-face assessment to all citizens requesting such assistance, and how your agency deals with or manages these barriers. B.35 Completes in-person assessments for HCBS waiver services within the required number of calendar days from the date on which an assessment was requested or recommended. (Applicable MN Statutes modified as of August 1, 2012.) Performance data for each Lead Agency can be found at: http://www.dhs.state.mn.us/main/idcplg?idcservice=get_dynamic_conversion&revision SelectionMethod=LatestReleased&dDocName=dhs16_145379# If you responded never or some of the time to question B.35, your Lead Agency is not meeting the requirement of in-person assessments for HCBS waiver services within the required number of calendar days from the date on which an assessment was requested or recommended. (Applicable MN Statutes modified as of August 1, 2012.) Please submit a brief remediation proposal to address how the LA will meet the 13

requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question B.35, briefly explain the occasional barriers requirement of in-person assessments for HCBS waiver services within the required number of calendar days from the date on which an assessment was requested or recommended (Applicable MN Statutes modified as of August 1, 2012.),and how your agency deals with or manages these barriers. B.36 Completes Level I screening as part of community assessment for HCBS waiver services If you responded never or some of the time to question B.36, your Lead Agency is not meeting the requirement of completing Level I screening as part of community assessment for HCBS waiver services. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. 14

If you responded most of the time to question B.36, briefly explain the occasional barriers requirement of completing Level I screening as part of community assessment for HCBS waiver services, and how your agency deals with or manages these barriers. B.37 Assesses family/informal caregiver concerns and needs If you responded never or some of the time to question B.37, your Lead Agency is not meeting the requirement of assessing family/informal caregiver concerns and needs. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question B.37, briefly explain the occasional barriers requirement of assessing family/informal caregiver concerns and needs, and how your agency deals with or manages these barriers. B.37.5 Assessment/Screening provides information about competitive employment, with or without supports, for school-age youth and working-age adults and referrals to the Disability Linkage Line and Disability Benefits 101 to ensure that an informed choice about competitive employment can be made (Applicable for DD, CAC, CADI, BI waivers as of August 1, 2012.) 15

If you responded never or some of the time to question 39, your Lead Agency is not meeting the requirement of providing information about competitive employment, with or without supports, for school-age youth and working-age adults and referrals to the Disability Linkage Line and Disability Benefits 101 to ensure that an informed choice about competitive employment can be made (Applicable for DD, CAC, CADI, BI waivers as of August 1, 2012). Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question 39, briefly explain the occasional barriers requirement of providing information about competitive employment, with or without supports, for school-age youth and working-age adults and referrals to the Disability Linkage Line and Disability Benefits 101 to ensure that an informed choice about competitive employment can be made (Applicable for DD, CAC, CADI, BI waivers as of August 1, 2012), and how your agency deals with or manages these barriers. B.38 Provides information to the consumer about freedom of choice between institutional and community-based services If you responded never or some of the time to question B.38, your Lead Agency is not meeting the requirement of providing information to the consumer about freedom of choice between institutional and community-based services. Please submit a brief 16

remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question B.38, briefly explain the occasional barriers requirement of providing information to the consumer about freedom of choice between institutional and community-based services, and how your agency deals with or manages these barriers. B.39 Indicate whether the Community Support Plans/Individual Service Plan (CSP/ISP) for consumers participating in face-to-face assessment include the following information: Yes, for all consumers Yes, for all consumers that have this need B39.a How informal caregivers will be supported O O O B39.b An evaluation by professionals (e.g., O O O occupational or physical therapy) B39.c Assistive technology to increase independence or O O O reduce reliance on human assistance B39.d How mental health needs will be addressed O O O B39.e Cultural considerations for care that are respectful O O O No If you responded no to any of the items in question B.39, your Lead Agency is not meeting one or more of the requirements around Community Support Plans/Individual Service Plan (CSP/ISP) for consumers participating in face-to-face assessment. Please submit a brief remediation proposal to address how the LA will meet 17

the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. B.54 *Please describe any barriers your Lead Agency faces in meeting the requirements discussed above. (Optional) 18

Access to Publicly- Funded Home and Community-Based Waiver programs: In addition to the requirements under the LTCC program itself, the LTCC assessment process, DD screening, level of care determination, additional assessments and support planning help establish service eligibility for several home and community-based waiver programs. All items in this section are required under the federally approved waiver programs: Elderly Waiver program, Minnesota Statutes, sections 256B.0913 (AC), section 256B.0915 (EW), 256B.49 (CAC, CADI, BI), 256B.092 (DD) and Minnesota Rules, Chapter 9525, parts 9525.0004 to 9525.0036 (DD). Indicate how often the Lead Agency staff does the following: C.1 Uses the MN DHS Long Term Care Consultation Assessment form or its successor, MN Choices, upon implementation to complete face-to-face assessments If you responded never or some of the time to question C.1, your Lead Agency is not meeting the requirement of using the MN DHS Long Term Care Consultation Assessment form or its successor, MN Choices, upon implementation to complete face-to-face assessments. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question C.1, briefly explain the occasional barriers requirement of using the MN DHS Long Term Care Consultation Assessment form or its successor, MN Choices, upon implementation to complete face-to-face assessments, and how your agency deals with or manages these barriers. 19

C.2 Uses the MN DHS DD screening document or its successor, MN Choices, upon implementation when completing full-team face-to-face assessments If you responded never or some of the time to question C.2, your Lead Agency is not meeting the requirement of using the MN DHS DD screening document or its successor, MN Choices, upon implementation when completing full-team face-toface assessments. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question C.2, briefly explain the occasional barriers requirement of using the MN DHS DD screening document or its successor, MN Choices, upon implementation when completing full-team face-to-face assessments, and how your agency deals with or manages these barriers. Indicate how often your Lead Agency applies the following criteria when determining consumer eligibility for HCBS Waiver Programs: C.3 The consumer has been assessed using the required assessment tools and processes (such as BI and CAC assessment tools). If you responded never or some of the time to question C.3, your Lead Agency is not meeting the requirement of using required assessment tools and processes (such as BI and CAC assessment tools) to determine consumer eligibility for HCBS Waiver Programs. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. 20

If you responded most of the time to question C.3, briefly explain the occasional barriers requirement of using required assessment tools and processes (such as BI and CAC assessment tools) to determine consumer eligibility for HCBS Waiver Programs, and how your agency deals with or manages these barriers. C.4 The consumer has been determined to meet level of care requirements (including, when applicable, hospital, nursing facility and ICF/DD level of care determinations). If you responded never or some of the time to question C.4, your Lead Agency is not meeting the requirement of determining if the consumer meets the level of care requirements for HCBS Waiver Programs (including, when applicable, hospital, nursing facility and ICF/DD level of care determinations). Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question C.4, briefly explain the occasional barriers requirement of determining if the consumer meets the level of care requirements for HCBS Waiver Programs (including, when applicable, hospital, nursing facility and ICF/DD level of care determinations), and how your agency deals with or manages these barriers. 21

C.5 The consumer s community support plan indicates the need for a service, in addition to case management, that is only available through one of the HCBS waiver programs. If you responded never or some of the time to question C.5, your Lead Agency is not meeting the requirement of including need for service, in addition to case management, in the consumer s community support plan. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question C.5, briefly explain the occasional barriers requirement of including need for service, in addition to case management, in the consumer s community support plan, and how your agency deals with or manages these barriers. C.6 The consumer s community support plan includes services, supports and/or strategies to reasonably maintain health and safety. If you responded never or some of the time to question C.6, your Lead Agency is not meeting the requirement of including need for service, supports and/or strategies to reasonably maintain health and safety. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. 22

If you responded most of the time to question C.6, briefly explain the occasional barriers requirement of including need for service, supports and/or strategies to reasonably maintain health and safety, and how your agency deals with or manages these barriers. C.7 There is no alternative payer for the HCBS waiver service needed. Your response indicates that the Lead Agency is not meeting a requirement of assessing if there is no alternative payer for the HCBS waiver service. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question C.7, briefly explain the occasional barriers requirement of assessing if there is no alternative payer for the HCBS waiver service, and how your agency deals with or manages these barriers. 23

C.8 A reassessment is conducted to determine re-eligibility at the required minimum frequency including the ICF/DD level of care. If you responded never or some of the time to question C.8, your Lead Agency is not meeting the requirement of conducting a reassessment to determine re-eligibility at required minimum frequency including the ICF/DD level of care. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question C.8, briefly explain the occasional barriers requirement of conducting a reassessment to determine re-eligibility at required minimum frequency including the ICF/DD level of care, and how your agency deals with or manages these barriers. C.9 Care plans are updated at least annually or when significant changes occur. If you responded never or some of the time to question C.9, your Lead Agency is not meeting the requirement of updating care plans at least annually or when significant changes occur. Please submit a brief remediation proposal to address how the LA will 24

meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question C.9, briefly explain the occasional barriers requirement of updating care plans at least annually or when significant changes occur, and how your agency deals with or manages these barriers. C.10 Care plans are competed in a timely manner following the assessment/screening. If you responded never or some of the time to question C.10, your Lead Agency is not meeting the requirement of completing care plans in a timely manner following the assessment/screening. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question C.10, briefly explain the occasional barriers requirement of completing care plans in a timely manner following the assessment/screening, and how your agency deals with or manages these barriers. 25

C.11 When a consumer on the CAC, CADI or BI waiver turns 65 they are reassessed and the assessment reflects the consumer s choice between their existing waiver and EW. If you responded never or some of the time to question C.11, your Lead Agency is not meeting the requirement of reassessing consumers on CAC, CADI, or BI when they turn 65 and reflecting consumer s choice between existing waiver and EW. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question C.11, briefly explain the occasional barriers requirement of reassessing consumers on CAC, CADI, or BI when they turn 65 and reflecting consumer s choice between existing waiver and EW, and how your agency deals with or manages these barriers. C.34 *Please describe any barriers your Lead Agency faces in meeting the requirements discussed above. (Optional) C.35 *Please use this space to make any comments regarding the Lead Agency's activities regarding access to HCBS or how practices are different between program areas. (Optional) 26

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II. Participant-Centered Service Planning and Delivery: Services and supports are planned and effectively implemented in accordance with each participant s unique needs, expressed preferences and decisions concerning his/her life in the community. Lead Agency Self-Assessment: The Lead Agency must be able to demonstrate that assessment of strengths and needs is linked to care and community support planning, and that services planned are individualized, appropriate, and preferred. Indicate how often the community support plan (CSP)/ Individual Service Plan (ISP) is: D.1 Based on and documents assessed needs and strengths of the consumer, as expressed by that consumer and/or identified in an assessment If you responded never or some of the time to question D.1, your Lead Agency is not meeting the requirement of basing the CSP/ISP on documents assessing needs and strengths of the consumer, as expressed by that consumer and/or identified in the assessment. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question D.1, briefly explain the occasional barriers requirement of basing the CSP/ISP on documents assessing needs and strengths of the consumer, as expressed by that consumer and/or identified in the assessment, and how your agency deals with or manages these barriers. D.2 Verifies consumer s choice between waiver services and institutional care 28

If you responded never or some of the time to question D.2, your Lead Agency is not meeting the requirement of verifying consumer s choice between waiver services and institution care in the CSP/ISP. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question D.2, briefly explain the occasional barriers requirement of verifying consumer s choice between waiver services and institution care in the CSP/ISP, and how your agency deals with or manages these barriers. Indicate how often the CSP/ISP includes goals that reflect consumer-identified choices and preferences regarding: D.3 Community access and inclusion If you responded never or some of the time to question D.3, your Lead Agency is not meeting one of the requirements about including goals that reflect consumeridentified choices and preferences regarding community access and inclusion in the CSP/ISP. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. 29

If you responded most of the time to question D.3, briefly explain the occasional barriers requirement of including goals that reflect consumer-identified choices and preferences regarding community access and inclusion in the CSP/ISP, and how your agency deals with or manages these barriers. D.4 Exercise of rights If you responded never or some of the time to question D.4, your Lead Agency is not meeting one of the requirements about including goals that reflect consumeridentified choices and preferences regarding exercise of rights in the CSP/ISP. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question D.4, briefly explain the occasional barriers requirement of including goals that reflect consumer-identified choices and preferences regarding exercise of rights in the CSP/ISP, and how your agency deals with or manages these barriers. 30

D.5 Control over support and services If you responded never or some of the time to question D.5, your Lead Agency is not meeting one of the requirements about including goals that reflect consumeridentified choices and preferences regarding control over support and services in the CSP/ISP. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question D.5, briefly explain the occasional barriers requirement of including goals that reflect consumer-identified choices and preferences regarding control over support and services in the CSP/ISP, and how your agency deals with or manages these barriers. Indicate how often the community support plan (CSP)/ Individual Service Plan (ISP): D.6 Documents the range of service options or types that will fulfill the consumer s identified needs (including services available through state plan, consumer directed community supports, formal and informal means) If you responded never or some of the time to question D.6, your Lead Agency is not meeting the requirement of documenting the range of service options or types that will fulfill the consumer s identified needs (including services available through state 31

plan, consumer directed community supports formal and informal means). Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question D.6, briefly explain the occasional barriers requirement of documenting the range of service options or types that will fulfill the consumer s identified needs (including services available through state plan, consumer directed community supports formal and informal means), and how your agency deals with or manages these barriers. D.7 Documents that the most cost-effective alternatives available were offered to the consumer (Applicable for EW, AC, DD, CAC, CADI, BI waivers as of August 1, 2012.) If you responded never or some of the time to question D.7, your Lead Agency is not meeting the requirement of documenting that the most cost-effective alternatives available were offered to the consumer. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question D.7, briefly explain the occasional barriers requirement of documenting that the most cost-effective alternatives available were offered to the consumer, and how your agency deals with or manages these barriers. 32

D.8 Documents that all available options and choices for case management services and providers were presented to the consumer (Applicable for EW, AC, DD, CAC, CADI, BI waivers as of August 1, 2012.) If you responded never or some of the time to question D.8, your Lead Agency is not meeting the requirement of documenting that all available options and choices for case management services and providers were presented to the consumer (Applicable for EW, AC, DD, CAC, CADI, BI waivers as of August 1, 2012.) Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question D.8, briefly explain the occasional barriers requirement of documenting that all available options and choices for case management services and providers were presented to the consumer (Applicable for EW, AC, DD, CAC, CADI, BI waivers as of August 1, 2012.), and how your agency deals with or manages these barriers. 33

D.9 Incorporates assistive technologies that support increased independence or a reduced reliance on human assistance If you responded never or some of the time to question D.9, your Lead Agency is not meeting the requirement of incorporating assistive technologies that support increased independence or a reduced reliance on human assistance. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question D.9, briefly explain the occasional barriers requirement of incorporating assistive technologies that support increased independence or a reduced reliance on human assistance, and how your agency deals with or manages these barriers. D.10 Documents consumer s choice between service providers 34

If you responded never or some of the time to question D.10, your Lead Agency is not meeting the requirement of documenting consumer s choice between service providers. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question D.10, briefly explain the occasional barriers requirement of documenting consumer s choice between service providers, and how your agency deals with or manages these barriers. D.11 Includes the consumer s choice of supports as well as professional recommendations for supports If you responded never or some of the time to question D.11, your Lead Agency is not meeting the requirement of including the consumer s choice of supports as well as professional recommendations for supports. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question D.11, briefly explain the occasional barriers requirement of including the consumer s choice of supports as well as professional recommendations for supports, and how your agency deals with or manages these barriers. 35

D.12 Documents how the consumer will exercise their right to personally manage risks If you responded never or some of the time to question D.12, your Lead Agency is not meeting the requirement of documenting how the consumer will exercise their right to personally manage risks. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question D.12, briefly explain the occasional barriers requirement of documenting how the consumer will exercise their right to personally manage risks, and how your agency deals with or manages these barriers. D.13 Includes the frequency, mode, and purpose of case management contact If you responded never or some of the time to question D.13, your Lead Agency is not meeting the requirement of including frequency, mode, and purpose of case management contact. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. 36

If you responded most of the time to question D.13, briefly explain the occasional barriers requirement of including frequency, mode, and purpose of case management contact, and how your agency deals with or manages these barriers. D.14 Includes provider(s), service type, frequency, and duration of services to be provided to the consumer If you responded never or some of the time to question D.14, your Lead Agency is not meeting the requirement of including provider(s), service type, frequency, and duration of services to be provided to the consumer. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question D.14, briefly explain the occasional barriers requirement of including provider(s), service type, frequency, and duration of services to be provided to the consumer, and how your agency deals with or manages these barriers. 37

D.15 Documents that reassessment/rescreening was completed when significant change occurs If you responded never or some of the time to question D.15, your Lead Agency is not meeting the requirement of documenting that reassessment/rescreening was completed when significant change occurs. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question D.15, briefly explain the occasional barriers requirement of documenting that reassessment/rescreening was completed when significant change occurs, and how your agency deals with or manages these barriers. D.16 Documents changes to services that result from a reassessment/rescreening If you responded never or some of the time to question D.16, your Lead Agency is not meeting the requirement of documenting changes to services that result from a reassessment/rescreening. Please submit a brief remediation proposal to address how 38

the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question D.16, briefly explain the occasional barriers requirement of documenting changes to services that result from a reassessment/rescreening, and how your agency deals with or manages these barriers. Please note that other additional CSP/ISP requirements are covered in the Participant Safeguards section of this survey. D.49 *Please describe any barriers your Lead Agency faces in meeting the requirements discussed above. (Optional) Consumer Choice of HCBS Waiver Service Providers D.50 *How often does the Lead Agency access or develop information about all qualified service providers for CASE MANAGER use? 39

D.51 *How do CASE MANAGERS access information about qualified service providers? Please check all that apply. Directory developed by your Lead Agency Other locally designed community directory MinnesotaHelp.info Senior Linkage Line Visit Packets Shared drives in Lead Agency computer/network systems Staff meetings or events None of the Above Other (Text box) D.52 *Please use the space below to comment on your Lead Agency s process for participantcentered service planning. (Optional) 40

III. Provider Performance and Capacity: There are sufficient HCBS providers and they possess and demonstrate the capability to effectively serve participants Performance of Providers: States must be able to provide evidence to CMS that there are sufficient HCBS providers and they possess and demonstrate the capability to effectively serve participants. Lead Agencies carry out activities that support achievement of the desired outcomes. Provider Contracting When contracting with HCBS waiver providers, please indicate how often the following contracting processes are in place: E.1 All contracts are verified to be signed and executed for services being provided, including host county contracts. If you responded never or some of the time to question E.1, your Lead Agency is not meeting the requirement of ensuring all contracts are verified to be signed and executed for services being provided, including host county contracts. Please submit a brief remediation proposal to address how the LA will meet the requirement, including time lines, objectives, and methods that will be utilized to come into compliance. If you responded most of the time to question E.1, briefly explain the occasional barriers requirement of ensuring all contracts are verified to be signed and executed for services being provided, including host county contracts, and how your agency deals with or manages these barriers. 41