Tennessee Department of Intellectual and Developmental Disabilities

Provider Manual

15th Floor Andrew Jackson Building 500 Deaderick Street Nashville, TN 37243 615-532-6530 / 800-535-9725 615-532-9940 (Fax) www.tn.gov/didd/

Table of Contents
SECTION IN.1 IN.2 IN.3 IN.4 IN.5 IN.6 IN.7 Introduction Welcome Development/Update and Distribution of the Provider Manual Purpose of the Provider Manual Organization of the Provider Manual Description of DMRS Programs State and Federal Laws, Rules, Regulations and Policies Governing Programs State and Federal Agencies Directly Involved in Administration, Operation and Oversight of Medicaid-Funded Waiver Programs Other Agencies Involved in Administration of DMRS Programs DMRS Vision, Mission and Values Chapter 1 Eligibility, Enrollment and Disenrollment Introduction Initial Contact and Referral Eligibility for DMRS Services Additional Eligibility Criteria for Enrollment into DMRS Service Programs Financial Eligibility for Medicaid Programs Medical Eligibility for Medicaid Services Enrollment into Medicaid Waiver Programs Disenrollment from Medicaid Waiver Programs Chapter 2 Consumer Rights and Responsibilities Rights Applicable to All People with Mental Retardation Title 33 of the Tennessee Code Annotated (TCA) Department of Mental Health and Developmental Disabilities (DMHDD) Licensure Rules Pertaining to the Rights of Service Recipients The Rights of DMRS Service Recipients Balancing the Rights of Individuals and Families Provider Responsibilities Related to Individual Rights Title VI of the Civil Rights Act of 1964 Rights Related to Participation in a Medicaid Waiver Provider Responsibilities Related to Confidentiality of Personal Records and Information Provider Responsibilities for Conflict Resolution DMRS Conflict Resolution Procedures TennCare Resolution Processes Title VI Complaints Retaliation for Involvement in a Complaint Process PAGE IN-1 IN-1 IN-2 IN-3 IN-4 IN-5

IN-7 IN-8 IN-9

IN.8 IN.9

1-1 1.2 1.3 1.4 1.5 1.6 1.7 1.8

1-1 1-1 1-1 1-2 1-4 1-7 1-7 1-9

2.1 2.2 2.3

2-1 2-1

2.4 2.5 2.6 2.7 2.8 2.9 2.10 2.11 2.12 2.13 2.14

2-2 2-4 2-7 2-9 2-10 2-12 2-13 2-13 2-14 2-16 2-16 2-18

ii

Table of Contents
SECTION 2.15 2.16 2.17 2.18 2.19 2.20 2.21 2.22 Access to State-Funded Services Medicaid/TennCare Eligibility Appeals Service Appeals Title VI Appeals Service Recipient Responsibilities Related to Participating in a Medicaid Waiver Service Recipient Responsibilities Related to Participation in DMRS Service Programs Options for Service Recipients Determined Unable to Make Decisions Human Rights Committees Chapter 3 Individual Support Planning and Implementation Person-Centered Planning The Circle of Support The Planning Team Responsibility for Developing the ISP The Role of Assessment in the Person-Centered Planning Process The Uniform Assessment Professional/Clinical Assessments and Evaluations Vocational Assessments Risk Assessments The Individual Support Plan (ISP) Preplanning Activities The (ISP) Planning Meeting Ensuring That Other Alternatives for Services Are Exhausted Prior to Requesting DMRS Services Use of the ISP for Service Authorization Distribution of the Final ISP Appeals of Service Denials Provider Responsibilities for Implementation of the ISP Monthly Reviews The Support Planning Process for State-Funded Service Recipients Not Receiving Support Coordination or DMRS Case Management Services Planning for Transition from a Developmental Center to the Community Community Transition Planning for Residential Services Transition Process for Non-Residential Services Chapter 4 Services: Support Coordination and Case Management PAGE 2-18 2-19 2-21 2-31 2-32 2-32 2-33 2-34

3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 3.10 3.11 3.12 3.13 3.14 3.15 3.16 3.17 3.18 3.19

3-1 3-1 3-4 3-7 3-7 3-8 3-9 3-10 3-10 3-12 3-14 3-18 3-21 3-22 3-22 3-23 3-23 3-23

3-25 3-26 3-28 3-35

3.20 3.21 3.22

iii

Table of Contents
SECTION 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 4.10 4.11 4.12 Waiver Definition Responsibility for Support Coordination/Case Management Independent Functioning of Support Coordination Agencies Qualifications of Individuals Employed as Support Coordinators/Case Managers Accessibility to Support Coordination Services Caseload Assignments to Support Coordinators and Case Managers Providing Support Coordination/Case Management as a Service Documentation of Support Coordination/Case Management Services Changing Support Coordinators/Case Managers Changing Support Coordination Providers Changing from Case Management to Support Coordination or from Support Coordination to Case Management Annual Re-Evaluation and Re-Determination Chapter 5 Application for Provider Status Introduction Obtaining an Application Packet Submission and Review of New Provider Applications Processing Provider Applications Provider Approval Criteria Disposition of Provider Applications Requests for Expansion of Services Licensure Requirements Revoking a Provider Approval Establishing a Provider Agreement Provider Orientation Chapter 6 General Provider Requirements Introduction Licensure Requirements Personnel Requirements Provider Conflict Resolution Procedures Required Provider Policies The Provider Management Plan Provider Governance Assuring Staff Sufficient to Provider Services and Adhering to Service Schedules Provider Subcontracts Provider Responsibilities Pertaining to Personal Funds Management PAGE 4-1 4-2 4-2 4-3 4-6 4-6 4-8 4-12 4-14 4-14 4-15 4-15

5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 5.10 5.11

5-1 5-2 5-2 5-2 5-3 5-5 5-6 5-7 5-8 5-8 5-9

6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9 6.10

6-1 6-1 6-1 6-4 6-5 6-6 6-10 6-12 6-13 6-13

iv

Table of Contents
SECTION 6.11 6.12 6.13 Implementation of the Individual Support Plan (ISP) Notification of DMRS of Changes in Provider Information Electronic/Computer Capability Requirements and Considerations PAGE 6-18 6-18 6-19

7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 7.9 7.10 7.11

Chapter 7 General Provider Requirements Provider Training Introduction General Provider Training Requirements Provider Business Entities and Staff Titles Staff Categories and Training Requirements Information Specific to Particular Training Courses and Provider Categories Training of Developmental Center Staff Employed by Providers in the Community Training Requirements for Volunteers Training Available to Natural Supports Documenting Staff Training Documenting Training Provided to Volunteers Provider Trainers Chapter 8 Creation and Maintenance of Provider Records Introduction General Records Requirements for Service Recipient Records Confidentiality of and Access to Service Recipient Records The Health Insurance Portability and Accountability Act (HIPAA) Record Sets The Service Recipient Comprehensive Record The Service Recipient Residential Record The Support Coordination Record Clinical Service Record The Day Services Record The Personal Assistant Record Respite Record Ancillary Provider Records Provider Personnel Records Provider Administrative Records Distribution and Transfer of Records Between Providers Chapter 9 Residential Services Introduction Residential Habilitation

7-1 7-1 7-4 7-6 7-12 7-13 7-18 7-18 7-19 7-21 7-21

8.1 8.2 8.3 8.4 8.5 8.6 8.7 8.8 8.9 8.10 8.11 8.12 8.13 8.14 8.15 8.16

8-1 8-1 8-3 8-4 8-5 8-6 8-8 8-10 8-11 8-14 8-15 8-16 8-16 8-17 8-18 8-18

9.1 9.2

9-1 9-1

Table of Contents
SECTION 9.3 9.4 9.5 9.6 9.7 9.8 9.9 9.10 9.11 9.12 9.13 9.14 9.15 Family Model Residential Support Medical Residential Services Supported Living Semi-Independent Living Services Out-of-State Residential Services Staffing Plans Health Oversight Personal Funds Management Home Environmental and Safety Requirements Applicable to Residential Services Transportation Provided as a Component of a Residential Service Inappropriate Charges to Service Recipients or Service Recipient Families Sign-In Logs Housing Resources Chapter 10 Day Services Introduction Waiver Definition of Day Services Planning for Day Services Requirements for Provision of Day Services Utilizing Natural Supports in the Provision of Day Services Documentation Requirements for Provision of Day Services Vocational Rehabilitation Services Chapter 11 Health Management and Oversight Introduction Provider Responsibilities Related to Maintaining Optimal Health Documenting Health Management and Oversight The Health Passport Physician Services Management of Medication Administration Management of Psychotropic Medications Managing Medication Errors Response to Medical Emergencies Provision of Basic First Aid Response to Changes in Behavior or Dangerous Behaviors Reporting Health Related Events Management of Diet and Nutrition Informed Consent Health Care Decision-Making Ensuring Continuity of Care PAGE 9-3 9-5 9-8 9-11 9-12 9-12 9-13 9-13 9-14 9-15 9-15 9-15 9-15

10.1 10.2 10.3 10.4 10.5 10.6 10.7

10-1 10-2 10-3 10-5 10-8 10-9 10-10

11.1 11.2 11.3 11.4 11.5 11.6 11.7 11.8 11.9 11.10 11.11 11.12 11.13 11.14 11.15 11.16

11-1 11-1 11-5 11-5 11-6 11-8 11-9 11-11 11-13 11-14 11-14 11-15 11-16 11-18 11-19 11-19

vi

Table of Contents
SECTION 11.17 Death Reviews Chapter 12 Behavior Health Introduction Diagnostic Considerations for People with Mental Retardation Diagnostic Assessments Documentation of Information Related to Behavior Treatment Challenges Treatment Considerations Psychopharmacology Crisis Prevention and Support Continuity of Care Related to Psychiatric Hospital Admissions DMRS Funded Behavior Services The DMRS Behavior Service Model The Assessment Phase of Behavior Services The Behavior Change Service Phase The Behavior Maintenance Service Phase The Closure (Discharge) Phase Crisis Prevention Plans Training Primary Provider Trainers or Direct Support Staff to Implement Behavior Support/Maintenance Plans and Crisis Prevention Plans DMRS Approval Behavior Interventions Restraint, Protective Equipment and Exclusionary Time-Out Behavior Support Committees Orientation for Behavior Service Providers Behavioral Respite Services Non-Reimbursable Activities Chapter 13 Therapy Services Introduction Waiver Definition for Physical Therapy Waiver Definition for Occupational Therapy Waiver Definition for Speech, Language and Hearing Services Licensure Requirements Other Requirements for Therapy Services Limits on Units of Service Establishing the Need for a Therapy Assessment Assessing Durable Medical Equipment and Assistive Technology Needs Referrals for Therapy Assessments PAGE 11-21

12.1 12.2 12.3 12.4 12.5 12.6 12.7 12.8 12.9 12.10 12.11 12.12 12.13 12.14 12.15 12.16 12.17

12-1 12-2 12-4 12-7 12-8 12-9 12-10 12-11 12-13 12-14 12-17 12-17 12-18 12-20 12-21 12-21

12.18 12.19 12.20 12.21 12.22 12.23

12-22 12-23 12-24 12-25 12-26 12-27 12-28

13.1 13.2 13.3 13.4 13.5 13.6 13.7 13.8 13.9 13.10

13-1 13-1 13-2 13-4 13-5 13-6 13-9 13-9 13-12 13-13

vii

Table of Contents
SECTION 13.11 13.12 13.13 13.14 13.15 13.16 13.17 13.18 Completing a Therapy Assessment Development of a Therapy Plan of Care Approval of Therapy Services Identified in the ISP Provision of Therapy Services Documenting the Provision of Therapy Services Maintaining and Distributing Therapy Records Services Reimbursement Rates Integration of Therapy Services Into the Service Recipients Daily Schedule Chapter 14 Therapy-Related Services Introduction Specialized Medical Equipment/Supplies and Assistive Technology Environmental Accessibility Modifications Vehicle Accessibility Modifications Orientation and Mobility Training Chapter 15 Nursing, Nutrition, Vision and Dental Services Introduction Nursing Services Nutrition Services Vision Services Adult Dental Services Chapter 16 Other Services Introduction Respite Services Personal Assistance Services Personal Emergency Response Systems Individual Transportation Services Chapter 17 Conservatorship and Advocacy Services Introduction The Conservatorship Process Duties and Responsibilities of a Conservator Advocacy Services Provider Responsibilities Related to Court-Appointed Legal Representatives and Advocates Chapter 18 Protection From Harm Introduction Prevention Plans PAGE 13-14 13-15 13-17 13-17 13-22 13-22 13-23 13-24

14.1 14.2 14.3 14.4 14.5

14-1 14-1 14-3 14-5 14-6

15.1 15.2 15.3 15.4 15.5

15-1 15-1 15-4 15-7 15-7

16.1 16.2 16.3 16.4 16.5

16-1 16-1 16-2 16-5 16-5

17.1 17.2 17.3 17.4 17.5

17-1 17-2 17-5 17-8 17-9

18.1 18.2

18-1 18-1

viii

Table of Contents
SECTION 18.3 18.4 18.5 18.6 18.7 Complaint Resolution and Appeals Processes Provider Agency Response Systems for Reportable Incidents and Service Recipient Abuse, Neglect and Exploitation Investigation of Incidents Incident Review and Corrective/Preventive Action Requirements Death Reviews Chapter 19 Quality Management Introduction Responsibility for Quality Management Activities Development of the Current DMRS Quality Management System Evaluating the Quality of Service and Supports DMRS Quality Assurance Surveys Support Coordination/Case Management Monitoring and Reporting Satisfaction Surveys Incident Management and Complaint Resolution Other DMRS QMS Activities Regional Agency Teams QMS Follow-Up Activities Provider QA/QI Activities Chapter 20 Provider Claims Submission and Processing Introduction Description of the Claims Processing System Provider Responsibilities Related to Reimbursement of Claims Claims Processing Requirements Service Authorization Claims Processing Financial Report Requirements Provider Rates Chapter 21 Tennessee Self-Determination Waiver Program Applicability Overview of the Tennessee Self-Determination Waiver Program Roles and Responsibilities: Participant-Managed Service Delivery Method Eligibility and Enrollment Consumer Rights PAGE 18-3 18-3 18-10 18-12 18-18

19.1 19.2 19.3 19.4 19.5 19.6 19.7 19.8 19.9 19.10 19.11 19.12

19-1 19-1 19-4 19-6 19-8 19-12 19-12 19-14 19-15 19-15 19-15 19-20

20.1 20.2 20.3 20.4 20.5 20.6 20.7 20.8

20-1 20-1 20-2 20-2 20-3 20-4 20-5 20-5

21.1 21.2 21.3 21.4 21.5

21-1 21-1 21-3 21-7 21-7

ix

Table of Contents
SECTION 21.6 21.7 21.8 21.9 21.10 21.11 21.12 ISP Planning and Implementation Case Management Application for Provider Status General Provider Requirements General Provider Requirements Provider Training Creation and Maintenance of Provider Records Services Available Under SDWP Glossary Appendix A Acronyms Appendix B Contact Information Appendix C Quick Reference for Rules and Regulations Appendix D Forms Appendix E PSR Guidelines Appendix F Useful Websites Appendix G Services Available Thru DMRS Programs Appendix H Summary of Court Orders and Lawsuits Appendix I Tuberculin Skin Testing Policy Appendix J Advance Psychiatric Directives Appendix K Behavior Support Plan Appendix L Protocol for Request for Variance Appendix M Behavior Assessment Report Appendix N Behavior Provider Qualifications Appendix O Processing A Crisis Prevention Plan Appendix P Restraints and Protective Equipment Appendix Q Clinical Service Monthly Review for Behavior Providers PAGE 21-8 21-12 21-19 21-19 21-20 21-20 21-20

Table of Contents
SECTION Appendix R Behavior Support Committee Minutes Appendix S Human Rights Committee Minutes Appendix T Sample Universal Precautions Appendix U Principles of Informed Consent in Psychiatry PAGE

xi

IN
INTRODUCTION

IN.1. Welcome Thank you for your participation as a provider in the Tennessee system of programs for people with mental retardation. An adequate network of providers with the ability to deliver quality services and supports is a primary asset in ensuring the ability to maintain the health, safety, welfare and quality of life for people with mental retardation who make the choice to pursue life in the community. We are glad that your agency has made the choice to participate as a provider in these programs. We look forward to working with your agency to assist people with mental retardation in having a successful experience with community life. IN.2. Development/Update and Distribution of the Provider Manual IN.2.a. Development: This manual was developed by the staff of the Division of Mental Retardation Services (DMRS). Many stakeholders, including providers of all types, provider organizations, consumers, family members and advocacy organizations were involved in the development and review of this manual. We extend our sincere thanks for their patience and willingness to devote time and energy to the completion of the Provider Manual. This Provider Manual will replace all provider manuals, operational guidelines, information bulletins, policy memos, or other documents previously distributed by DMRS that contain provider requirements. Any TennCare policies that have been distributed by DMRS pertaining to Medicaid Waiver programs continue to be applicable to waiver service providers. If any conflict is found to exist between requirements found in this manual and requirements found in applicable state or federal law, federal court order or state/federal Medicaid policy, the requirement found in the law, court order or Medicaid policy will prevail until resolution of the conflict is achieved. The Provider Manual is effective upon initial distribution and will be promulgated as required by state statute (Tennessee Code Annotated, Chapter 1, Part 309). IN.2.b. Distribution: Primary responsibility for distribution of the manual and manual updates will rest with the Office of Policy Development, Planning and Consumer Relations within the Division of Mental Retardation Services. Copies may be obtained as follows:

Provider Manual, Introduction Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

IN-1

IN
1) Printable copies will be available on the DMRS website (www.state.tn.us/dmrs) in PDF format. 2) Hard copies will be available for pickup at the DMRS Central Office and at each DMRS Regional Office. Addresses for DMRS offices are listed in Appendix B. 3) Copies may be requested by telephone from any DMRS office. Copies will be mailed to the provider via regular mail. Telephone numbers for the Central Office and each Regional Office are listed in Appendix B. IN.2.c. Updates: The provider manual will be updated annually and as needed to communicate changes in policy and program requirements. Annual revisions will be performed to update manual information such as telephone numbers, addresses and changes in terminology. Such updates will not change provider requirements and will not require promulgation. Changes in provider requirements that result in manual updates will require promulgation of applicable manual sections as required by state law. Updates will be accomplished by updating files on the DMRS website and mailing or faxing replacement pages to contracted providers. IN.3. Purpose of the Provider Manual IN.3.a. Basic Purpose: The purpose of this manual is to outline the basic principles and requirements for delivery of quality services to people with mental retardation. All providers who participate in state and federally funded service delivery programs must have an executed provider agreement which requires compliance with this manual. Some sections of the manual apply to all providers, whereas other sections refer to specific types of providers. IN.3.b. Provider Resources: There is information throughout the manual which references additional provider resources such as best practice guidelines; state and federal statutes, rules and regulations; other tools and manuals; and websites. These types of materials are available to assist providers in the development of policies and practices that meet the requirements specified in this manual and promote a good system of service delivery. IN.3.c. Relationships with Service Recipients: The service recipient is the most important participant in the system. It is essential that providers have the ability to develop and maintain effective working relationships with service recipients, their families, their legal representatives and advocates who may assist them in exercising their rights. Information in the manual outlines requirements and resources intended to promote respectful, effective relationships between the service recipient (and those assisting or representing them) and the providers delivering the services.

Provider Manual, Introduction Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

IN-2

IN
IN.3.d. Relationships with Other Providers of Services and Supports: Information included in the manual is intended to assist providers in developing relationships with other types of providers and in accessing/maximizing resources available through other programs available within the state. This information is intended to promote the ideal that people who participate in different programs must be treated in a holistic manner. In other words, the programs described in this manual will not meet all the social and health-care needs of people with mental retardation. It is essential that providers develop an understanding of how the services available through these programs fit within the broader system of state healthcare, educational and social programs. Effective integration of services offered through the programs described in this manual with external services and natural supports is a goal that the state will continue to work toward. IN.4. Organization of the Provider Manual IN.4.a. Organization of Content: A Table of Contents is followed by an introduction and twenty-one (21) chapters, each of which describes expectations and requirements related to a particular component of service delivery. Following the body of the manual, a glossary is provided which lists terms and phrases used throughout the manual. Following the glossary, appendices are provided which present forms, helpful websites, contact information, and other information referenced in the manual. Appendix A lists commonly used abbreviations. Terms, phrases and abbreviations will be listed in alphabetical order. IN.4.b. Numbering System: A simple numbering system has been employed to ensure readability and ease in referencing sections and pages within chapters. The numbering system employed within the manual will be as follows: 1) IN is used to refer to sections within the Introduction. Each chapter following the Introduction is numbered 1, 2, 3, etc.; 2) Each chapter has sections numbered 1.1., 1.2., etc.; 3) Subsections will be numbered 1.1.a., 1.1.b., etc.; 4) Lists within sections and subsections will be numbered 1), 2), 3), etc.; 5) Appendices will be shown as Appendix A, Appendix B, etc.; 6) The Table of Contents pages will be numbered with lower case Roman numerals such as page i., page ii., etc.; 7) Each page within the body of the manual will be numbered with the chapter number and the page number separated with a hyphen such as page1-1, page 1-2, etc.; 8) Pages in the appendices will be numbered with the letter of the appendix and the page number separated by a hyphen, such as page A-1, page A-2, etc.; and

Provider Manual, Introduction Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

IN-3

IN
9) Tables and Illustrations will be numbered with the chapter number followed by section number and subsection number if applicable, such as Table 1.5., Table 1.8.a., Illustration 2.2., etc. IN.5. Description of DMRS Programs IN.5.a. Consumer Directed Support Services: Consumer Directed Support services are available pursuant to recent settlement of the Brown/People First class action lawsuit. Consumer-directed supports are state-funded and will be available to limited numbers of people who are on the waiting list for services. Funding for this program became available as of July 1, 2004. The program provides state funds up to $2,280 per person per year up to a total annual state expenditure of $5 million. The money provided to each person may be used for respite, transportation or other services (see Appendix G for a summary chart of services available in different DMRS programs). IN.5.b. Early Intervention: The Early Intervention program is provided pursuant to Part C of the Individuals with Disabilities Education Act (IDEA) which became effective in 1997. IDEA originated from Part H of the Education of the Handicapped Act, enacted in 1986 and amended in 1990 and 1991. Tennessees Early Intervention System (TEIS) is administered through an interagency agreement between the Department of Education and the Division of Mental Retardation Services. The program provides an array of services to infants and toddlers with disabilities and their families. This manual will not provide information about the Early Intervention program beyond a basic description of the program and eligibility information. Additional information will be available through an Early Intervention Manual. An Early Intervention Manual is under development and will be available on the DMRS website or by contacting the DMRS Central Office when completed. IN.5.c. Family Support: The Family Support program is a community-based, statefunded program that provides assistance to families with a family member who has a severe disability. Some of the services provided through the family support program are shown in Appendix G; however, this program is very flexible and other services may be provided based on the needs of the family. Local Family Support Councils oversee the family support programs across the state. Services are provided by local agencies and providers who receive grant funds and technical assistance from DMRS. This manual will not address provider requirements for the Family support program. A basic description of the program and eligibility information will be provided. Any additional information needed about this program is available in the manual titled Tennessee Family Support Guidelines. This manual is available on the DMRS website or by contacting the DMRS Central Office Family Support Coordinator or the Regional Office Family Support staff. Contact information is provided in Appendix B.

Provider Manual, Introduction Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

IN-4

IN
IN.5.d. Medicaid Home and Community Based Waiver Services (HCBS) Programs: Medicaid HCBS waiver programs were developed as an alternative to services provided in an institutional setting, such as an Intermediate Care Facility for the Mentally Retarded (ICF/MR). HCBS Waiver programs have been in existence since 1981. Tennessees first HCBS waiver for people with mental retardation was approved in 1986. Currently, Tennessee has three waiver programs for people with mental retardation. The three waivers are the Arlington Home and Community Based Services Waiver for Persons with Mental Retardation (waiver control #0357.90), the Statewide Home and Community Based Services Waiver for Persons with Mental Retardation and Developmental Disabilities (waiver control #0128.90.R2A) and the Tennessee Self Determination Waiver Program (waiver control #0427). Appendix G shows services available under each of the existing waiver programs. IN.5.e. State-Funded Services: Each year the state legislature appropriates funding which allows DMRS to provide state-funded services to people who are not eligible or are otherwise not getting needed services through the Medicaid waivers and other DMRS programs. The services provided are generally the same as those available through the Medicaid Waiver programs. Appendix G shows the available state-funded services. IN.5.f. Case Management: Funding for case management services became available as of July 1, 2004, as a result of the recent settlement of the Brown/People First class action lawsuit. Case management will be provided with a combination of state and federal funding and will be available to people on the waiting list for Medicaid Waiver or DMRS state-funded services and to service recipients in the Self-Determination Waiver. Case management will be provided by state-employed staff. Case managers will provide information about DMRS programs and services, provide assistance with completing eligibility application forms, gather information to assess service needs, connect people to generic community services, provide ongoing contact and assistance as needed/requested and will refer people to advocacy organizations and support groups as needed/requested. IN.6. State and Federal Laws, Rules, Regulations and Policies Governing Programs IN.6.a. Federal Laws, Regulations and Policy: The requirements of different programs are typically spelled out in state and federal laws, rules and regulations. Federal laws apply to DMRS programs that utilize federal funding, such as the Early Intervention program and the Medicaid Waivers. At the federal level, laws or statutes are passed by congress and are incorporated in the United States Code Annotated (U.S.C.A.). A federal agency is designated to develop regulations that implement the laws or statutes. Federal regulations are published in the Code of Federal Regulations (CFR). Policies are generally a more detailed interpretation of regulations that is easier and less time

Provider Manual, Introduction Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

IN-5

IN
consuming to change because policies generally do not have to go through a promulgation process which involves public hearings and legal reviews. An example of federal policy is the State Medicaid Manual. Federal laws, regulations and policy applicable to DMRS programs are summarized in Appendix C. IN.6.b. State Laws, Regulations and Policy: State laws or statutes are passed by the state legislature. When laws are passed or amended, a particular state agency is responsible for developing or changing state rules to implement the law. Tennessee laws or statutes are published in the Tennessee Code Annotated (T.C.A.). State departments or agencies are responsible for developing rules to implement the law and developing any policies that are needed to interpret the state rules. Rules are promulgated or passed by publishing the proposed rule in the Tennessee Administrative Register (TAR) for thirty days prior to a rulemaking hearing. Written public comments are accepted in writing after the proposed rule is published or interested parties may appear in person at the rulemaking hearing to support or voice any concerns about the proposed rule. If the proposed rule is necessary to public welfare, there are provisions that allow rules to be effective upon publication and promulgated within 90 days. In Tennessee, a statute has been passed that requires any policies developed by DMRS that contain provider requirements to be promulgated similar to the way rules are promulgated. This manual is an example of a DMRS provider policy. State laws, rules and policy applicable to DMRS programs are summarized in Appendix C. IN.6.c. Court Orders: Court orders may contain programmatic requirements with which the state must maintain compliance. Court orders generally are the result of a lawsuit against the state alleging that the state has failed to follow a state or federal law in the operation of a particular program. If the state does not prevail in the case, a remedial order may result. In other cases, the state and the entity that filed the lawsuit may agree on measures to resolve the issues presented in the case and the parties may enter into a settlement agreement. There are several court orders that affect the operation of DMRS programs. These court orders are summarized in Appendix H. IN.6.d. Conflicts between Laws, Rules, Regulations and Policies: The state attempts to ensure that there is consistency in all of the governing requirements for programs. However, laws and regulations may be changed, resulting in temporary conflicts that have to be resolved all the way down to the policy level. When this occurs at the state and federal level, the language in the statute or law governs. When the law and rules are consistent and the related policy is in conflict, the rule or regulation governs over the policy. If a federal law, rule or policy is in conflict with a state law, rule or policy, the federal standard governs. States are not typically considered to be in conflict with federal requirements if they establish standards that are more stringent than the federal minimum requirement.

Provider Manual, Introduction Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

IN-6

IN
IN.7. State and Federal Agencies Directly Involved in Administration, Operation and Oversight of Medicaid-funded Waiver Programs IN.7.a. Centers for Medicare and Medicaid Services (CMS): CMS is the federal agency within the Department of Health and Human Services (HHS) responsible for implementing federal regulations governing Medicare and Medicaid services. CMS provides funding to designated Single State Medicaid Agencies for the administration of Medicaid programs in each state, including Medicaid Home and Community Based Services Waiver Programs. CMS reviews and approves waiver applications, develops federal Medicaid regulations and policy, provides technical assistance to states and conducts periodic audits to ensure compliance with federal requirements. A CMSapproved waiver application serves as a contract between CMS and the state for operation of a HCBS waiver program. IN.7.b. Bureau of TennCare: In Tennessee, the Bureau of TennCare, within the Department of Finance and Administration, is the designated Single State Medicaid Agency contracted with CMS to administer and oversee Medicaid HCBS waiver programs. The Division of Developmental Disability Services, within the Bureau of TennCare, is directly responsible for administration and oversight of Medicaid HCBS waivers for persons with mental retardation. The Bureau of TennCare has established a contractual relationship with the Division of Mental Retardation Services (DMRS) which makes DMRS responsible for daily operations of HCBS waiver programs for people with mental retardation. The TennCare/DMRS contract specifies administrative and oversight functions performed by TennCare including: 1) Development and promulgation of state rules for HCBS waiver programs; 2) Development and review/approval of HCBS waiver policies; 3) Provision of information to DMRS and HCBS waiver providers pertaining to changes in statute, regulation, policy, procedures or guidelines affecting the operation of HCBS waiver programs; 4) Execution of contracts with HCBS waiver providers; 5) Submission of applications to CMS for waiver approval and renewal; 6) Adjudication of claims for payment of services rendered; 7) Completion of monitoring activities to determine if DMRS is in compliance with the approved waiver application and with state and federal rules, regulations and policy; and 8) Determination of medical eligibility for HCBS waiver programs. IN.7.c. Division of Mental Retardation Services (DMRS): The Division of Mental Retardation Services, within the Department of Finance and Administration, is the Operational Administrative Agency for Medicaid waiver programs for people with

Provider Manual, Introduction Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

IN-7

IN
mental retardation. DMRS is also the state agency responsible for the administration of other programs that provide services to people with mental retardation. DMRS is composed of a Central Office and three (3) Regional Offices. Branch Regional Offices exist in the East and West Regions. A single office serves the Middle Tennessee region. Addresses and telephone numbers for DMRS offices are listed in Appendix B. Administrative and operational functions performed by DMRS include: 1) Management of a qualified provider network sufficient to assure accessibility to services; 2) Development and implementation of approved policies and procedures; 3) Management of an intake process for people seeking services; 4) Enrollment of program participants; 5) Management of waiting lists for waiver and state-funded services; 6) Approval of individual support plans and pre-authorization of services; 7) Reimbursement of providers for services rendered; 8) Provision of training and technical assistance to providers; 9) Implementation of a quality management program to ensure that services are provided in accordance with state and federal laws, regulations, rules and policies; 10) Completion of monitoring activities to determine provider compliance with the approved waiver application and with state and federal rules, regulations and policies; 11) Implementation of grievance and appeals procedures applicable to program participants and providers; and 12) Provision of informational materials to providers, people receiving services and their families, potential applicants for services and other interested stakeholders. IN.7.d. Department of Human Services (DHS): DHS determines financial eligibility for Medicaid services. Financial eligibility determination for Medicaid waiver programs must be determined upon enrollment and annually thereafter. DHS also administers the Tennessee Adult Protective Services program. Contact information for local and state DHS offices are provided in Appendix B. IN.8. Other Agencies Involved in Administration of DMRS Programs: IN.8.a. Department of Mental Health and Developmental Disabilities (DMHDD): The DMHDD Office of Licensure must license providers of certain services before they are allowed to enroll as a provider in DMRS programs. Providers licensed by DMHDD include those providing residential services, day services, respite services and personal support services. Contact information for local and state DMHDD offices are provided in Appendix B.

Provider Manual, Introduction Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

IN-8

IN
IN.8.b. Department of Health (DOH): DOH licenses clinical providers, including physical therapists, occupational therapists, speech language pathologists and nurses. DOH also provides licensure for home care organizations and professional support services licensure of independent practitioners who provide services in DMRS programs. Contact information for local and state DOH offices are provided in Appendix B. IN.8.c. Department of Childrens Services (DCS): DCS administers Tennessees Child Protective Services program. Contact information for local and state DCS offices are provided in Appendix B. IN.8.d. Department of Education (DOE): DOE participates in the administration of the Early Intervention program and implements individual education plans (IEPs) required by the Individuals with Disabilities Education Act (IDEA) for services needed at educational facilities. IN.9. DMRS Vision, Mission and Values IN.9.a. Vision Statement: It is the vision of DMRS that Tennesseans with mental retardation will have the opportunity and needed support to be a part of the community in which they live. DMRS believes that people with mental retardation have a right to healthy, secure and meaningful lives surrounded by family and friends. IN.9.b. Mission Statement: The mission of DMRS is to provide leadership in the development and maintenance of a system that offers a continuum of services and supports which contribute to the goal of people with mental retardation having healthy, secure and meaningful lives in their chosen residence. DMRS will work to accomplish its Mission by recognizing that the values and principles outlined below are the cornerstones of the service delivery system. DMRS staff will act with professionalism, integrity and honesty to achieve and maintain the credibility that is required to fulfill the organizations mission. IN.9.c. Values: Values are the principles that apply to all levels of the service delivery system. Values guide the day to day decisions that are made in service delivery, as well as, the decisions that are made related to the system as a whole. The following values are to be recognized and utilized by all partners in service delivery: 1) Focus on the service recipients must be maintained at all levels of the system. People with mental retardation are the most important participants in the system. 2) Effective service/support planning and coordination is crucial to the quality of life, health and safety of service recipients.

Provider Manual, Introduction Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

IN-9

IN
3) Individual choices of the service recipients are the foundation of service planning and delivery. 4) Opportunities to accomplish personal outcomes, live a meaningful life and be included in the community are identified and supported in the development and implementation of support plans. 5) Safety and security are essential to a person being able to achieve personal outcomes. 6) Risk identification and planning are essential to achieving a balance between allowing personal choice and protection from harm. 7) Respect of people with mental retardation and the staff involved in direct delivery of their services is crucial at all levels of the system. 8) Professionalism of state and provider employees is essential to ensure the level of collaboration (guiding, coaching, modeling and supporting rather than supervising, controlling and care-taking) in the provision of services that will result in achievement of personal outcomes. 9) Person and family friendly information is necessary to promote understanding, choice, and ownership of the service delivery system. Training opportunities for people with mental retardation and their families are needed to ensure understanding and appropriate utilization of services within the system. 10) Reliable and valid data and information must be easily accessible to all stakeholders to promote understanding of the system, identification of problems and issues and planning for effective ways of improving the system. 11) Stakeholder input is essential to developing and maintaining service delivery mechanisms that meet the needs of persons with mental retardation, that pass the test of making sense from an operational standpoint and that ensure smooth implementation of changes in policy and operational procedure. 12) Systems change and quality improvement opportunities that benefit service recipients must be identified and implemented on an ongoing basis. Systemic issues, provider compliance issues and individual problems must be identified, analyzed and resolved in an organized, timely manner. 13) Innovative approaches that ensure the best use of available public funds must be employed to ensure that the maximum number of people with mental retardation have access to needed services. 14) Compliance with applicable state and federal statutes, rules, regulations and policies is necessary to ensure that adequate funding is available to provide access to services for people with mental retardation. 15) Quality assurance monitoring must be focused on achieving desired outcomes and ongoing compliance. Changes in quality monitoring must be accomplished in an organized manner that ensures stability of the system.

Provider Manual, Introduction Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

IN-10

IN
16) Effective provider training and technical assistance opportunities are necessary to ensure that providers achieve and maintain desired outcomes and programmatic compliance. 17) Equity must be achieved and maintained in the provision of services and treatment of providers. 18) Provider payment rates must be such that an adequate provider network is maintained and quality services are possible. The rate structure must include payment mechanisms, as well as, service approval, utilization review and monitoring processes that promote conscientious expenditure of funds.

Provider Manual, Introduction Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

IN-11

1
CHAPTER 1 ELIGIBILITY, ENROLLMENT AND DISENROLLMENT
1.1. Introduction This chapter describes the process of establishing eligibility for programs operated by the Division of Mental Retardation Services, as well as, requirements for establishing and maintaining eligibility for Medicaid-funded Home and Community Based Services (HCBS) waiver programs. 1.2. Initial Contact and Referral Local providers are not involved in the initial determination of eligibility for services, but may be the first point of contact for people seeking to apply for services. When this occurs, provider staff must refer the person to the appropriate DMRS Regional Office so that prescreening and eligibility determination processes can be initiated. Contact numbers for Regional Offices are provided in Appendix B. The person may contact the local Regional Office directly or the contact may be made by anyone who has the persons permission, including employees of a local provider. The DMRS intake process is described in DMRS Internal Operating Policies 04.300.10-.01 through .13. 1.3. Eligibility for DMRS Services To be eligible for any DMRS program with the exception of Family Support, there must be documentation or evidence of a diagnosis of mental retardation with an overall Intelligence Quotient (IQ) Score of seventy (70) or below. The onset of mental retardation must have occurred prior to the age of eighteen (18). For children under the age of five (5), IQ testing may be unreliable and services may be provided if there is presenting evidence of substantial developmental delay or if a condition is present that has a high probability of resulting in substantial developmental delay. If enrollment does occur prior to the age of five (5) due to developmental disability, the person will be evaluated for a diagnosis of mental retardation when testing is considered to be reliable.

Provider Manual, Chapter 1 Eligibility, Enrollment and Disenrollment Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

1- 1

1
1.4. Additional Eligibility Criteria for Enrollment into DMRS Service Programs 1.4.a. Consumer Directed Support Services: 1) The applicant must be on the waiting list for services in the crisis, urgent or active categories as of July 1 of the award year; 2) The applicant must not be receiving services in a Medicaid Waiver; and 3) The applicant must not be receiving any other DMRS-funded services such as Family Support. 1.4.b. Early Intervention 1) The applicant must be birth to age three (3); and 2) The applicant must meet DMRS or Individuals with Disabilities Education Act (IDEA) Part C eligibility criteria.
1.4.c. Family Support

1) The applying family must have a family member who has a severe disability; and 2) The severe disability must be one that is attributable to a mental or physical impairment; is likely to continue indefinitely; and results in substantial functional limitations in three or more major life activities, such as self-care, receptive/expressive language, learning, mobility, self-direction, capacity for independent living or economic self-sufficiency. 1.4.d. Medicaid Home and Community Based Services Waiver for Persons with Mental Retardation (#0357.90) (Arlington Waiver) 1) The applicant must be financially eligible for Medicaid in Tennessee; 2) The applicant must require ICF/MR care and must meet ICF/MR level of care criteria as evidenced by a PAE application which has been approved by the Bureau of TennCare; 3) The state must be able to assure the applicants service needs can be safely and effectively met through the waiver; 4) The applicant must have one or more designated adult caregivers present in the home on a daily basis or have individualized safety planning addressed in the ISP; 5) The applicant must have a place of residence that is adequate to ensure their health, safety and welfare; and 6) The applicant must be an Arlington Remedial Order class member.

Provider Manual, Chapter 1 Eligibility, Enrollment and Disenrollment Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

1- 2

1
1.4.e. Tennessee Self Determination Waiver Program (#0427) 1) The applicant must be financially eligible for Medicaid in Tennessee; 2) The applicant must require ICF/MR care and must meet ICF/MR level of care criteria as evidenced by a PAE application which has been approved by the Bureau of TennCare; 3) The individual must be on the DMRS Waiting List for services and be classified in one of the Crisis, Urgent or Active waiting list categories; 4) The state must be able to assure the applicants service needs can be safely and effectively met through the waiver, which is capped at a total annual expenditure of no more than $30,000 per service recipient; 5) The applicant must have one or more designated adult caregivers present in the home on a daily basis or have individualized safety planning addressed in the ISP; and 6) The applicant must have a place of residence that is adequate to ensure their health, safety and welfare. 1.4.f. Medicaid Home and Community Based Services Waiver for the Mentally Retarded and Developmentally Disabled (#0128.90R2A) (Statewide Waiver) 1) The applicant must be financially eligible for Medicaid in Tennessee; 2) The applicant must require ICF/MR care and must meet ICF/MR level of care criteria as evidenced by a PAE application which has been approved by the Bureau of TennCare; 3) The state must be able to assure the applicants service needs can be safely and effectively met through the waiver; 4) The applicant must have one or more designated adult caregivers present in the home on a daily basis or have individualized safety planning addressed in the ISP; 5) The applicant must have a place of residence that is adequate to ensure their health, safety and welfare. 1.4.g. State-funded Services Note: The amount of money available for state-funded services is limited. DMRS ability to offer state funded services is dependent upon available funding. 1) The applicant may be financially ineligible for participation in the Medicaid waiver; 2) The applicant may be ineligible for the Medicaid waiver due to not meeting ICF/MR level of care criteria; or

Provider Manual, Chapter 1 Eligibility, Enrollment and Disenrollment Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

1- 3

1
3) The applicant may need services that cannot be provided in a Medicaid waiver for other reasons. 1.4.h. Case Management 1) The applicant must be on the waiting list for Medicaid waiver or state-funded services; 2) The applicant must not be receiving independent support coordination services; and 3) The applicant is enrolled in the Self-Determination Waiver. 1.5. Financial Eligibility for Medicaid Programs 1.5.a. Responsibility for Financial Eligibility Determinations: The Bureau of TennCare contracts with the Department of Human Services (DHS) to accept applications and determine financial eligibility for Medicaid/TennCare services. DMRS has made arrangements with the DHS for specially trained staff persons to be designated to determine financial eligibility for the Medicaid waiver programs for persons with mental retardation. Contact information is provided in Appendix B. Financial eligibility determinations may take up to 45 days, unless a disability determination is needed. When disability determinations are required, the process can take up to 90 days. 1.5.b. Financial Eligibility Criteria: Financial eligibility determination is a very complex process which requires the individual circumstances of each applicant to be closely considered. DHS Rules (see Appendix C) describe in detail the criteria for eligibility determination. Some general statements can be made about financial eligibility determination: 1) Applicants who have been determined eligible for Supplemental Security Income (SSI) by the Social Security Administration (SSA) are also eligible for Medicaid in Tennessee. 2) Applicants receiving cash assistance via the Families First/Aid to Families with Dependent Children are eligible for Medicaid. 3) Applicants who are inmates in correctional facilities are not eligible for Medicaid services. 1.5.c. Financial Eligibility Forms: A provider must obtain verification of financial eligibility for long-term care services and keep this information on file. For the existing HCBS Waiver programs, the support coordinator has been designated as the provider group having responsibility for obtaining this information. For programs in which stateemployed case managers are assigned, the case manager will obtain the information. A

Provider Manual, Chapter 1 Eligibility, Enrollment and Disenrollment Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

1- 4

1
DHS Form 2350 is the form that must be submitted to DHS to obtain financial eligibility verification. The support coordinator submits the 2350 to the DHS within ten (10) days of enrollment into the waiver. DHS sends a Form 2362 back to the independent support coordinator to show that the service recipient is financially eligible for long-term care services. A Form 2362 also indicates if the service recipient is required to contribute to the cost of long-term care services, and if so, how much. The amount of a persons income to be collected each month to help pay for their services is called patient liability. Examples of these forms are provided in Appendix D. 1.5.d. Income Limits Applicable to Medicaid HCBS Programs: Federal law allows states some flexibility in establishing the amount of income an applicant or service recipient can have to be eligible for Medicaid programs. Institutional income standards (which allow an applicant/service recipient to be Medicaid eligible with more income) may be applied to applicants/service recipients who are considered institutionalized. To be considered institutionalized, an applicant/service recipient must be continuously confined for a period of at least thirty (30) days. For HCBS applicants, the DHS applies institutional income standards thirty days from the date of enrollment specified on the 2350 form. The CMS-approved Medicaid waiver document specifies the amount of income an applicant/service recipient is allowed to have and still qualify for Medicaid Waiver services. In Tennessee, the maximum allowable amount of 300% of the Supplemental Security Income Federal Benefit Rate (SSI/FBR) has been chosen. This allows an applicant/service recipient to have up to $1737 of monthly income to qualify for Medicaid waiver services during calendar year 2005. This amount is subject to change each year if the SSI/FBR is increased. However, an applicant/service recipient may have more income and still qualify if some of the income is excluded due to allowable expenses, such as medical bills. 1.5.e. Determination of the Amount the Service Recipient Must Contribute to Cost of Care: After an applicant is determined to be financially eligible for Medicaid longterm care services, the DHS then determines if the applicant is responsible for using some of his/her income to pay for the cost of care and establishes the amount he/she is responsible for paying. Federal law recognizes that service recipients who participate in Medicaid HCBS waivers may have to use part of their income to maintain a residence in the community. Consequently, the Medicaid waiver document that is reviewed and approved by CMS also requires states to specify how much of a service recipients available income can be set aside for living expenses and excluded from income when patient liability is established. Tennessee has specified that 200% of the SSI/FBR (up to $1158 per month for calendar year 2005) will be set aside for personal expenses for the Arlington Home and Community Based Services Waiver for Persons with Mental Retardation (waiver control #0357.90) and for the Statewide Home and Community Based Services Waiver for the Mentally Retarded and Developmentally Disabled (waiver

Provider Manual, Chapter 1 Eligibility, Enrollment and Disenrollment Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

1- 5

1
control #0128.90A). For the Tennessee Self Determination Waiver Program (waiver control #0427), Tennessee has specified that 300% of the SSI/FBR (up to $1737 per month during calendar year 2005) will be set aside for personal expenses. 1.5.f. Resource Limits: In addition to income limits, there are also limits on the resources an applicant/service recipient can have and still be eligible for Medicaid benefits. If an applicant/service recipient has more that $2000 in resources, he/she may not be financially eligible for Medicaid. The following may be excluded from consideration as resources: 1) An applicant/service recipients home; 2) A car, if modified for handicapped accessibility, if used to travel to a place of employment, if used to access medical treatment or if necessary to perform essential daily activities; 3) Life insurance (face value not to exceed $1500 per owner); and 4) Money set aside for burial expenses. Things that are generally counted as resources include: 1) 2) 3) 4) 5) Bank accounts; Cash on hand; Stocks and bonds; Life insurance with cash value exceeding $1500; and Second homes and second cars.

1.5.g. Denial of Financial Eligibility: When an applicant is denied eligibility for Medicaid, the DHS will notify the person in writing, including the reason for denial and right to request a fair hearing. Appeal procedures are discussed in Chapter 2. If a service recipient had been determined financially eligible and was later determined ineligible, involuntary disenrollment procedures would be followed. Discussion of involuntary disenrollment is provided later in this chapter. 1.5.h. Annual Re-determination/Reapplication and Ongoing Financial Eligibility for Medicaid Waiver Services: Unless the service recipient is actively receiving SSI Benefits, sufficient information must be provided to the DHS for determination of continuing financial eligibility to be made. When the re-determination/reapplication is due, the DHS will mail a Form 1860 to the designated representative payee. Upon receipt, the representative payee must complete the required forms and contact the appropriate DHS staff by telephone to complete an interview, during which, the service recipients current income and resources will be verified. If the forms and interview are not completed in a timely manner, the DHS will determine the service recipient to be ineligible for continuation of Medicaid waiver services. Providers who are involved with

Provider Manual, Chapter 1 Eligibility, Enrollment and Disenrollment Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

1- 6

1
managing or assisting in management of personal funds must track resources and be aware of changes in income that could affect Medicaid eligibility. Providers serving as the representative payee for a service recipient must complete the required forms and interview for annual re-determination/reapplication within the specified time frames to avoid discontinuation of Medicaid-funded services. 1.6. Medical Eligibility for Medicaid Services 1.6.a. Responsibility for Determination of Medical Eligibility: Medical eligibility determination is the responsibility of the Bureau of TennCare, Division of Developmental Disability Services. Contact information is provided in Appendix B. To be medically eligible to receive services in a Medicaid HCBS Waiver for people with mental retardation, level of care criteria for admission in an Intermediate Care Facility for the Mentally Retarded (ICF/MR) must be met. ICF/MR level of care criteria are provided in the TennCare Rules (see Appendix C). An application form for determination of medical eligibility is called a Pre Admission Evaluation (see form in Appendix D). 1.6.b. The Pre Admission Evaluation Process: A PAE application submitted to the TennCare Division of Developmental Disability Services will be reviewed within eight (8) business days. Financial and Medical eligibility determination processes may occur simultaneously. PAE applications are reviewed by a registered nurse under the supervision of the Medical Director of long-term care services. If level of care criteria are not met and the PAE is denied, the TennCare Division of Developmental Disability Services will send written notification to the applicant, including the reason for denial and a description of appeal rights. Appeals are discussed in more detail in Chapter 2. An ICF/MR PAE form is included in Appendix D. 1.6.c. Ongoing Medical Eligibility for Medicaid Waiver services: DMRS must ensure that a reevaluation of the service recipients need to continue to receive waiver services is done within 12 calendar months of enrollment and annually thereafter. The initial certification date or approved from date on the PAE determines when the annual reevaluation is due. Annual reevaluations are typically done by a Qualified Mental Retardation Professional (QMRP) employed by DMRS or a support coordination provider; however, a physician or registered nurse may also complete the reevaluation assessment and form. 1.7. Enrollment into Medicaid Waiver Programs 1.7.a. Enrollment of Persons Living in the Community: DMRS is responsible for enrolling service recipients in Medicaid waiver programs. When it is determined likely that an applicant/service recipient will meet Medicaid eligibility requirements, DMRS

Provider Manual, Chapter 1 Eligibility, Enrollment and Disenrollment Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

1- 7

1
must inform the service recipient or the service recipients legal representative of the right to choose between institutional and waiver services. The service recipient or representative must also be informed of any alternatives available under the waiver program. This includes the right to select any willing and available provider of the services that will be provided through the waiver program. Services may begin when services are authorized and providers have been identified. If a service recipient is enrolled in the Statewide or Arlington Waivers, the first provider chosen is generally the provider of support coordination, because the support coordinator is needed to assist in the selection of other providers, to assist in finalizing financial eligibility determination and to initiate the process of developing the Individual Support Plan (ISP). If enrolled in the Self-Determination Waiver or otherwise receiving DMRS case management, the DMRS case manager will assist in selection of other providers, in establishing program eligibility and in developing the ISP. The PAE, which includes a listing of initial services to be provided, serves as the plan of care until the ISP is developed. 1.7.b. Enrollment of Persons Living in a Private ICF/MR: A service recipient living in a private ICF/MR may have already been determined to be financially and medically eligible for Medicaid ICF/MR level of care. If the service recipient is receiving Medicaid-funded ICF/MR level of care, a new PAE is not required. It is required that a transfer form be completed and submitted to the TennCare Division of Developmental Disability Services. The transfer form must be accompanied by an initial plan for transitioning to community services. Apart from already having eligibility established, the process of enrollment does not differ significantly from the enrollment of service recipients who were living in the community. If Medicaid eligibility has not been established for a service recipient transferring to the waiver from a private ICF/MR, the process of establishing eligibility and completing waiver enrollment processes is the same as that described for enrollment of service recipients living in the community. 1.7.c. Enrollment of Persons Living in a State-Operated Developmental Center: Service recipients currently residing in a state developmental center are members of either the Arlington Remedial Order class or the Clover Bottom/Greene Valley Settlement Agreement class. For these class members, a process for transition to the waiver program is specified in the remedial order or settlement agreement. A service recipient living in a developmental center will probably have an approved PAE and be financially eligible for Medicaid. A transfer form is required to be completed and submitted to TennCare in lieu of a PAE. The transfer form must be accompanied by an initial plan for transitioning to the community. The transition process for class members is described in Chapter 3 of this manual.

Provider Manual, Chapter 1 Eligibility, Enrollment and Disenrollment Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

1- 8

1
1.8. Disenrollment from Medicaid Waiver Programs 1.8.a. Voluntary Disenrollment: A service recipient who is enrolled in a Medicaid Waiver may decide to disenroll at any time. Waiver participation is voluntary. To disenroll from the waiver program, written notice must be provided to the appropriate DMRS Regional Office by the service recipient or the service recipients legal representative. DMRS staff will assist the service recipient as needed/requested in arranging alternative placement or services. 1.8.b. Involuntary Disenrollment: DMRS may initiate involuntary disenrollment procedures in accordance with TennCare Rules with prior approval from the Bureau of TennCare if: 1) The HCBS Waiver in which the service recipient is enrolled is terminated. 2) The service recipient becomes financially ineligible for Medicaid or is found to be erroneously enrolled. 3) The service recipient moves out of Tennessee. 4) The service recipients condition improves and they no longer meet ICF/MR level of care criteria. 5) The service recipients condition gets worse and the waiver program cannot meet his/her needs. 6) The service recipients home or home environment becomes unsafe to the point that services could not be provided there without significant risk of harm or injury. 7) The service recipient or the service recipients legal representative refuses to abide by the plan of care or related waiver policies resulting in the inability of the Operational Administrative Agency to ensure quality care or the health and safety of the service recipient. 8) The service recipients health, safety and welfare cannot be assured due to lack of an approved Safety Plan. 9) The service recipient was transferred to a hospital, nursing facility, Intermediate Care Facility for the Mentally Retarded, Assisted Living Facility and/or Home for the Aged and has resided there for a continuous period exceeding one hundred twenty (120) days. 10) The cost for all covered waiver services, including Emergency Assistive services, for an individual enrolled in the Tennessee Self Determination Waiver Program has reached the waiver limit of $36,000 per year per recipient and the Operational Administrative Agency cannot assure the health and safety of the service recipient.

Provider Manual, Chapter 1 Eligibility, Enrollment and Disenrollment Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

1- 9

1
The TennCare Division of Developmental Disability Services must be notified in writing before involuntary disenrollment procedures are begun. To initiate involuntary disenrollment, DMRS must provide written notice to the service recipient and offer assistance with making arrangements for alternative services. Appeal rights must be described within the written notice. Appeal procedures are discussed in Chapter 2. The provider may be responsible for continuation of services, as directed by DMRS or TennCare, until appeal rights are exhausted.

Provider Manual, Chapter 1 Eligibility, Enrollment and Disenrollment Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

1- 10

2
CHAPTER 2 CONSUMER RIGHTS AND RESPONSIBILITIES

2.1.

Rights Applicable to All People with Mental Retardation People with mental retardation have the same rights as other people unless their rights have been limited by court order or law. Individuals do not give up their rights when they accept services from the Division of Mental Retardation Services (DMRS) or other state programs. There are basic human and civil rights that are protected by the Constitution, and state and federal laws. Many of the laws take the form of protecting people from discrimination. The Americans with Disabilities Act is an example of such a law. People with mental retardation should be treated fairly and equally when services are being developed and provided.

2.2.

Title 33 of the Tennessee Code Annotated (TCA) DMRS and all providers involved in delivering services must adhere to Title 33 as the primary state law governing the methods employed in service delivery to people with mental retardation. 2.2.a. Values: Title 33 (TCA 33-1-202) lists the following values as the basis for the service delivery to people with mental retardation: 1) 2) 3) 4) 5) Individual rights; Promotion of self-determination; Respect; Optimal health and safety; and Inclusion in the community, utilizing natural supports and generic community services as much as possible.

2.2.b. Principles: Title 33 (TCA 33-1-203) also lists fundamental service principles which govern the service delivery system for persons with mental retardation. They are: 1) Flexible and stable service systems which promote advocacy, effective communication, targeted outcomes, continuous evaluation, and improvement based on best practice and research; 2) Early identification of needs, including prevention and early intervention services and supports;

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 1

2
3) 4) 5) 6) 7) 8) 2.3. Timely response to the needs, rights and desires of those served; Treating service recipients and families with dignity and respect; Protecting those served from abuse, neglect, and exploitation; Accurate and responsible accountability for the use of public resources; Ongoing education and skills development of the workforce; and Cultural competence of persons providing service.

Department of Mental Health and Developmental Disabilities (DMHDD) Licensure Rules Pertaining to the Rights of Service Recipients The subject of service recipient rights is addressed in several different sections of promulgated DMHDD licensure rules, Table 2.3. provides a summary of applicable licensure rules.

Table 2.3 Summary of Licensure Rules Applicable to Service Recipient Rights

Rule Citation 0940-5-1-.03

Rule Section Definition of Terms Used in Mental Retardation Rules

Content Defines Human Rights Committees, restraint and other terms applicable to behavior management.

0940-5-6-.02 (1)

0940-5-6-.06

Policies and Procedures for All Requires policies addressing: Facilities 1) Service recipient rights and grievance procedures; 2) Confidentiality of client records; 3) Prohibition against service recipients caring for or supervising other service recipients or accessing confidential records of other service recipients; 4) Behavior management techniques, if used by the provider; and 5) Use of service recipients as research subjects Client Rights in All Facilities Addresses service recipient rights in all facilities licensed by DMHDD.

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 2

2
Rule Citation 0940-5-6-.07 Rule Section Modification or Limitation of Rights of All Clients by Facility Rules, Policies or Procedures Modification or Limitation of an Individual Clients Rights Requirements for the Use of Restrictive Behavior Management in Adult Habilitation Day Facilities Requirements for the Use of Restricted Behavior Interventions in Residential Habilitation Facilities Content Defines the circumstances under which service recipient rights may be limited

0940-5-6-.08

Defines the circumstances under which it is permissible to limit an individual service recipients rights. Defines the types of behavior management techniques that are prohibited and allowed. Defines the circumstances under which allowed techniques may be used. Defines assessment and planning requirements for restrictive interventions. Requires Behavior and Human Rights Committee approval prior to implementation of a plan utilizing restrictive interventions. Defines prohibited interventions. Requires documentation of a diagnosis and reason related to prescribing psychotropic medications. Requires informed consent. Defines restrictive techniques that are prohibited and allowed. Defines the requirements and circumstances under which allowed techniques may be used. Defines restrictive techniques that are prohibited and allowed. Defines the requirements and circumstances under which allowed techniques may be used. Defines restrictive techniques that are prohibited and allowed. Defines the requirements and circumstances under which allowed techniques may be used.

0940-5-20-.11

0940-5-24-.12

0904-5-24-.13

Use of Psychotropic Medications in Residential Habilitation Facilities Requirements for the Use of Restrictive Behavior Management in Residential Habilitation Facilities Requirements for the Use of Restrictive Behavior Management in Respite Care Services Facilities Requirements for the Use of Restrictive Behavior Management With Individuals Receiving Supported Living Services

0904-5-24-.14

0940-5-27-.07

0940-5-32-.11

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 3

2
2.4. The Rights of DMRS Service Recipients: DMRS is committed to taking an active part in assuring that service recipients understand their rights. DMRS is also committed to ensuring that providers train their staff to understand individual rights and focus on assisting people in exercising their rights. Service recipients must also be assisted in understanding the responsibilities associated with having certain rights. 2.4.a. Individual Rights: DMRS service recipients shall be entitled to the following rights without limitation: 1) To be treated with respect and dignity as a human being; 2) To have the same legal rights and responsibilities as any other person unless otherwise limited by law; 3) To receive services regardless of gender, race, creed, marital status, national origin, disability or age; 4) To be free from abuse, neglect and exploitation; 5) To receive appropriate, quality services and supports in accordance with an individual support plan (ISP); 6) To receive services and supports in the most integrated and least restrictive setting that is appropriate based on the service recipients particular needs; 7) To have access to DMRS rules, policies and procedures pertaining to services and supports; 8) To have access to personal records and to have services, supports and personal records explained so that they are easily understood; 9) To have personal records maintained confidentially; 10) To own and have control over personal property, including personal funds; 11) To have access to information and records pertaining to expenditures of funds for services provided; 12) To have choices and make decisions; 13) To have privacy; 14) To receive mail that has not been opened by provider staff or others unless the person or family has requested assistance in opening and understanding the contents of incoming mail; 15) To be able to associate, publicly or privately, with friends, family and others; 16) To have intimate relationships with other people of their own choosing; 17) To practice the religion or faith of ones choosing; 18) To be free from inappropriate use of physical or chemical restraint; 19) To have access to transportation and environments used by the general public; 20) To be fairly compensated for employment; and 21) To seek resolution of rights violations or quality of care issues without retaliation.

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 4

2
2.4.b. Provision of Individual Rights Information to People Entering the DMRS Service System, Families, Legal Representatives and Other Interested Parties: For people entering the DMRS service system, as of the effective date of this manual, information regarding the individual rights listed above will be provided by DMRS intake staff during the intake process. Illustration 2.4. on page 2-6 represents the intake process. A written copy of individual rights will be provided (a copy of the Individual Rights document included in the Intake Packet is provided in Appendix D). The intake staff person will explain, read, or provide a translated version of the individual rights if the person does not understand, is unable to read, or speaks a language other than English. If a person has a guardian, conservator, involved family member or has designated someone they wish to receive a copy of the rights, a copy and any necessary explanations or translations will be provided to these individuals as well. Consequently, all people entering the service system will have been provided basic rights information prior to receiving services. 2.4.c. Provision of Individual Rights Information to Service Recipients, Families, Legal Representatives and Other Interested Parties: After service provision begins, the support coordinator/case manager will have the primary responsibility for providing or arranging provision of new/revised, additional or repeated information about individual rights. Rights information will be provided by the case manager/support coordinator as necessary or requested and will be reviewed during the annual ISP update process.

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 5

2
Process to Apply for Services Table 2.4

Applicant

Contact DMRS Regional Office to request information about applying for services

DMRS Regional Office

DMRS provides information regarding services and assistance in completing application

Complete Application

Notification that services are available. Completion of a PAE and financial eligibility application for Mediciad PAE or Financial Eligibility Denied PAE and Financial Eligibility Approved

Placement on waiting list in the crisis, urgent active, or deferred category

Face to Face intake meeting between DRMS and applicant DMRS assist with submission of additional information and/or an appeal of the Medicaid eligibility denial DMRS assists in accessing statefunded services as funding is available

OR

Waiver Enrollment

Service Recipient selects a support coordination provider and circle of support members

Planning Team including COS develops a plans of care

COS & Planning Team meetings are ongoing for purpose of reviewing and revising the plan of care

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 6

2
2.5. Balancing the Rights of Individuals and Families The vision, mission and values articulated in Title 33 support the fundamental right and need of individuals with disabilities to control their own destinies. Many people with disabilities can speak for themselves or otherwise communicate their needs and desires. For others, it may be harder to understand what the person needs or wants. It can be especially challenging to determine needs and preferences when it is difficult to understand what a person is trying to express. Professionals and family members involved in the provision of services and supports must be vigilant and respectful in attempting to understand and honor the service recipients autonomy. Parents and family members have a tremendous responsibility to protect and assure the safety and health of family members who receive services and supports. A service recipients choices and those of his or her family sometimes result in conflict. Balancing family concerns with an individuals right to self-determination is never easy. Adequate planning and supports and good communication between service recipients, their families and professionals are critical to effectively balancing rights and needs. 2.5.a. Building Positive Relationships With Families: Receiving and providing services is less stressful when families and providers share good relations and work together. The following practices may contribute to building positive relationships with families: 1) Provide information (if not prohibited by confidentiality laws or if consent has been obtained) to families regarding the family members disability and what it may mean in regard to development, skills and lifestyle. 2) Assure that staff are knowledgeable about the individual rights of the service recipient and are able to assist the family in understanding those rights. 3) Assure that staff observe the service recipients rights in providing services. 4) Assure that families are provided information about conflict resolution procedures. 5) Provide information and records requested by the service recipient or family in a timely manner if proper consent forms have been provided. 6) Provide information and responses to questions and requests in writing. 7) Avoid using professional jargon or language that is hard to understand; explain things in clear and understandable terms. 8) Work diligently with families to resolve problems and complaints. 2.5.b. Resolving Conflict Between Service Recipients and Family Members: Providers have a responsibility to the service recipient to help family members understand that the person may make choices that they do not agree with. This may be a

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 7

2
difficult position for a provider, because the provider generally wants both the service recipient and family members to be pleased with the services provided. The ideal resolution to such a situation occurs when the person is able to maintain the right to make choices and independent decisions, the family member has concerns addressed and positive relationships are maintained between the service recipient, the provider and the family member(s). It may be necessary to seek the assistance of an advocate or advocacy organization to achieve the best possible resolution. A list of advocacy organizations and contact information is provided in Appendix B. Assistance may also be requested from DMRS. Mediation services available through the DMRS may provide a mechanism of achieving a resolution that is acceptable to all parties. 2.5.c. Relationships Between Professionals, Service Recipients and Family Members: Professional/clinical practitioners, such as nurses, therapists, nutritionists/ dietitians or behavior service providers may play a significant role in helping the service recipient achieve desired outcomes and have a successful life in the community. It can be very rewarding for the service recipient, the family and the professional staff when there is recognition of the unique contributions that can be made by all involved when those supporting the service recipient work together. At times, however, conflict may arise when professional or clinical staff complete assessments and make recommendations regarding the type of treatments and services that could be provided to improve independence, prevent regression or otherwise benefit the service recipient. There are a number of reasons why the service recipient or family could be unreceptive to the recommendations made. Previous experiences with similar treatments or services may influence the service recipient and/or family in making a decision to decline services or treatments suggested by professionals. The outcome anticipated to result from the treatment or service may not be important to the service recipient and/or family. Participating in the recommended treatment or service may interfere with or delay meeting another outcome that is more important to the service recipient and/or family. Professionals and families should recognize that the relationship a parent has with a son or daughter with disabilities is different than the relationships professionals have with those individuals. A parents or family members relationship is personal, lifelong, and caring. A providers involvement is time-limited and professional in nature. Both kinds of relationships contribute to the well being of individuals with disabilities and both are important. When conflicts arise, it is in the best interest of the service recipient for professionals and families to openly discuss and consider the recommendations made. Professionals must be able to explain how the services or treatments recommended fit into the ISP in terms of helping the service recipient complete action steps and achieve outcomes that are defined as important in the ISP. Professionals must recognize that the service recipient or a court-appointed legal representative acting on the service recipients behalf has the right

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 8

2
to refuse services and treatments. When the service recipient or legal representative has been provided the information needed to make an informed decision, the decision to refuse services or treatments must be honored. 2.6. Provider Responsibilities Related to Individual Rights Responsibility involves living up to obligations and keeping the promises made to others. When a provider establishes a provider agreement with DMRS, the provider is agreeing to accept the responsibility of providing quality services to people and to meet program requirements. Honoring individual rights and treating service recipients with respect and dignity is perhaps the most important component of providing quality services and is essential in maintaining compliance with program requirements. When a provider agrees to render services to a service recipient, the provider is in essence making a promise to honor the service recipients rights and provide services in a way that is in the best interests of that service recipient. All staff employed by the provider to directly provide or oversee services, including the executive director/chief executive officer, management/administrative staff, contracted staff/entities, direct support staff and volunteers have a role in contributing to the overall quality of services and in assuring that people are treated fairly and respectfully. 2.6.a. Staff Training: Providers must ensure that staff have a basic understanding of individual rights and how to honor those rights while providing services. This is generally accomplished through a combination of training, mentoring and providing adequate staff oversight. Many of the required staff training programs offer information applicable to honoring the individual rights described in this chapter. Staff training requirements are discussed in detail in Chapter 7. 2.6.b. Facilitating Understanding of Rights and Responsibilities: In addition to honoring individual rights and assisting people to exercise their rights, providers have a responsibility to help people understand that along with rights come responsibilities. To fully participate in community life, people must be assisted in learning what is expected of them when certain choices are made. For instance, a person who wants to own their own home should be helped in understanding to the extent practicable that home ownership results in certain obligations, such as mortgage payments, maintaining insurance, keeping the yard mowed, making repairs to things that break, etc. Providers are encouraged to assist service recipients and their informal support networks in accessing opportunities to learn about rights and responsibilities by offering regular forums that allow discussion of rights issues. Providers are also encouraged to distribute available information to service recipients, families and legal representatives regarding self-advocacy training courses, DMRS and TennCare consumer/family meetings and other opportunities to learn about rights and responsibilities.

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 9

2
2.6.c. Intimate Relationships: Intimate relationships and human sexuality are important parts of the human experience that by their very nature present many complex issues. Personal decisions about intimate relationships carry undeniable risks, rewards and responsibilities. Given this basic premise, each person must make his/her own determination as to the timing, nature and extent of such interactions in which to engage. The emotional, psychological, moral, ethical and physical components of this process require at least minimum abilities to discern and evaluate the consequences of such behavior. Service recipients have the right to have intimate relationships with other people of their own choosing, unless such rights have been restricted by a court. 2.7. Title VI of the Civil Rights Act of 1964 Title VI of the Civil Rights Act of 1964 prohibits discrimination in programs that utilize federal funds. Medicaid waivers are examples of programs that are partially funded with federal dollars. The Division of Mental Retardation Services (DMRS), as well as providers who sign provider agreements with DMRS must comply with Title VI requirements. DMRS and DMRS providers must not exclude, deny benefits to or otherwise discriminate against any applicant for services or service recipient based on race, color or national origin in the admission to or participation in any of its programs and activities. 2.7.a. Prohibited Practices: Prohibited practices include, but are not limited to, the following: 1) Denying any service, opportunity or other benefit for which an applicant or service recipient is otherwise qualified; 2) Providing any applicant or service recipient with any service or other benefit which is different or is provided in a different manner from that which is provided to others in the same program; 3) Subjecting any service recipient to segregated or separate treatment in any manner related to the receipt of a service; 4) Restricting any service recipient in any way in the enjoyment of services, facilities or any other advantage, privilege or benefit provided to others in the same program; 5) Adopting methods of administration that would limit participation or subject any group of applicants or service recipients to discrimination; 6) Addressing an applicant or service recipient in a manner that denotes inferiority because of race, color or national origin; or 7) Subjecting any applicant or service recipient to racial or ethnic harassment, to a hostile racial or ethnic environment or to a disproportionate burden of environmental health risks.

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 10

2
2.7.b. Provider requirements: All providers must ensure that applicants and service recipients receive equal treatment, equal access, equal rights and equal opportunities without regard to race, color, national origin or Limited English Proficiency (LEP). Providers must meet the following requirements: 1) Support coordinators/case managers must document that people on the waiting list for services or waiver service recipients are informed of Title VI protections and remedies for Title VI violations on an annual basis; 2) All providers must designate a Title VI Local Coordinator; 3) All providers must ensure that service recipients know who the Local Coordinator is and how to contact him/her; 4) All providers must develop and implement written policies and procedures addressing: Employee training to ensure Title VI compliance during service provision; Employee training to ensure recognition of and appropriate response to Title VI violations; Complaint procedures and appeal rights pertaining to alleged Title VI violations for service recipients; and Personnel practices governing response to employees who do not maintain Title VI compliance in interacting with service recipients; 5) All providers must provide or arrange language assistance (i.e. interpreters and/or language appropriate written materials) to persons of limited English proficiency (LEP); 6) All providers must provide meaningful access to services to LEP service recipients; 7) All providers must have a mechanism for advising service recipients regarding the options for filing a Title VI complaint; 8) All providers must display Title VI materials in conspicuous places accessible to service recipients. (Materials are available from Local Coordinators, DMRS Regional Office Title VI Coordinators or the DMRS Central Office Title VI Coordinator.); 9) Residential providers must ensure that room assignments and transfers are made without regard to race, color, or national origin; 10) All providers must complete and submit an annual Title VI self-survey in the format designated by DMRS as a part of their overall quality assurance efforts; 11) All providers must orient employees to their Title VI responsibilities and the penalties for noncompliance within the first sixty (60) days of employment and document such in the personnel files; 12) All providers must conduct an annual Title VI employee in-service training and document such in the personnel files; and

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 11

2
13) All providers must ensure that vendors, subcontractors and other contracted entities are clearly informed of Title VI responsibilities and are required to maintain Title VI compliance. 2.7.c. Management of Title VI Records: Title VI Local Coordinators are required to maintain all documentation pertaining to individual Title VI complaints for a minimum of three (3) years. Copies of Title VI documents related to individual complaints must be forwarded to the DMRS Regional Office Title VI Coordinator. Contact information for DMRS Regional and Central Office Title VI Coordinators is provided in Appendix B. 2.7.d. Failure to Maintain Title VI Compliance: Any service provider found to be in non-compliance with Title VI will be provided written notice. Failure to eliminate further discrimination within ninety (90) days of receipt of notice will be considered a violation of the terms of the provider agreement and basis for contract suspension, termination or rejection. 2.8. Rights Related to Participation in a Medicaid Waiver: People who apply for or receive services in a Medicaid-funded Home and Community Based Services (HCBS) Waiver have the following rights: 2.8.a. Fair Hearings (42 CFR 431.200): There are several situations when a person can appeal a determination made by the state and have the right to a fair hearing. Appeal rights will be discussed in greater detail in subsequent sections of this chapter. The basic circumstances that could result in a fair hearing are listed below: 1) If the Department of Human Services (DHS) notifies an applicant that they are not financially eligible for Medicaid Services, a financial eligibility appeal may be submitted to DHS requesting a fair hearing. 2) If the Bureau of TennCare notifies an applicant that the Pre Admission Evaluation has been denied, a medical eligibility appeal may be submitted to the TennCare Division of Developmental Disability Services requesting a fair hearing. 3) If the DHS or the Bureau of TennCare fails to process an application promptly, the applicant may submit a request for a fair hearing to the appropriate agency. 4) If a person is enrolled in an HCBS Waiver and is notified that they are no longer eligible to receive any services in a waiver program, they may submit an involuntary disenrollment appeal to the TennCare Division of Developmental Disability Services requesting a fair hearing. 5) If a person is enrolled in a waiver and a particular service is denied, suspended, terminated, delayed or reduced, an appeal may be submitted to the TennCare Solutions Unit requesting a fair hearing.

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 12

2
2.8.b. Freedom of Choice (42 CFR 441.302): Participation in a waiver program is voluntary. Prior to being enrolled in a waiver, an applicant has the right to freely choose whether they want to receive services in the waiver or in an Intermediate Care Facility for the Mentally Retarded (ICF/MR). Freedom of choice also includes the right to select any provider with an active provider agreement with DMRS and the Bureau of TennCare, if the provider is available, willing and able to provide the services needed. 2.8.c. Protection of Health, Safety and Welfare (42 CFR 441.352): A service recipient in an HCBS Waiver has the right to receive services from a qualified provider who meets the program standards for the service being provided. 2.9. Provider Responsibilities Related to Confidentiality of Personal Records and Information Applicants and service recipients have the right to have all records and information obtained and/or created by a provider maintained in a confidential manner, in accordance with applicable state and federal laws, rules, regulations, policy and ethical standards. In practical terms, this means that the provider must safeguard against personal information being disclosed to or seen by inappropriate persons or entities who could use the information in a manner that is not in a service recipients best interests. The provider must also provide access to personal records to service recipients and legal representatives as required by law. Providers must follow requirements specified in Title 33 (TCA 33-3-103 through 33-3112) pertaining to confidentiality and access to service recipients records. Confidentiality of service recipient records and requirements for providers related to the Health Insurance Portability and Accountability Act (HIPAA) are discussed in Chapter 8. 2.10. Provider Responsibilities for Conflict Resolution It is important for people to understand how they are to go about resolving issues and complaints with providers. It is equally important that service recipients, legal representatives and family members be able to trust providers to promptly resolve their concerns without retaliating against the service recipient or family. All parties involved should recognize that it is in the providers and service recipients best interest if the majority of complaints and issues can be worked out satisfactorily at the provider level. 2.10.a. Provider Conflict Resolution Procedures: Providers licensed in accordance with Title 33 are required to follow a written policy that describes how they will resolve complaints and other issues relative to the provision of service (TCA 33-2-602). DMRS requires that providers who are not licensed under Title 33, but have an active provider

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 13

2
agreement with DMRS, also implement a written conflict resolution procedure. Providers are required to ensure that information about such policies has been provided to service recipients and their legal representatives and/or involved family members. Providers are required to implement complaint/issue resolution processes to ensure that complaints are recorded, action is taken to resolve the complaint and complaint resolution is documented. 2.10.b. Other Resources for Resolution of Conflict Between Providers and Service Recipients and/or Those Representing Service Recipients: There are situations that are not under the providers control as well as situations where the service recipient and/or service recipient representative and the provider cannot work out an acceptable resolution. In such cases, the provider or service recipient/service recipient representative may need to request assistance from DMRS, TennCare or another external entity such as a Local or Regional Human Rights Committee to achieve resolution (discussed later in this chapter). The provider has an obligation to seek timely resolution by utilizing external sources if necessary. The provider is also obligated to advise the person presenting the complaint or issue of other options they have for reaching timely resolution. 2.11. DMRS Conflict Resolution Procedures DMRS has established conflict resolution procedures to assure expedient resolution of issues, to minimize the disruption of services and supports and to avoid potential consequences and costs that could result from ongoing unresolved conflicts within the service delivery system. 2.11.a. DMRS Options for Conflict Resolution: The following steps may be taken to resolve conflict that cannot be addressed at the provider level: 1) The DMRS complaint resolution process described in Chapter 18 may be initiated; 2) If a complaint is not satisfactorily resolved through the complaint process, a request may be submitted for intervention by the Regional Office Director; 3) If the Regional Director or designee is unable to facilitate satisfactory resolution of the conflict, a request may be submitted for intervention by the DMRS Deputy Commissioner; and 4) If all parties are agreeable, external mediation may be requested and arranged as directed by the DMRS Deputy Commissioner or designee.

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 14

2
2.11.b. DMRS Deputy Commissioner Intervention: The DMRS Deputy Commissioner or designee may intervene to ensure timely resolution of conflict in certain situations, including: 1) A written request for intervention is submitted to the DMRS Central Office because provider conflict resolution procedures, Regional Office intervention and/or the DMRS complaint resolution process has not resulted in timely and/or satisfactory resolution of an issue; 2) Immediate resolution of an issue is warranted to ensure the health, safety and welfare of a service recipient; or 3) It is determined that DMRS policy has not been followed in attempting to resolve conflict at the provider and Regional Office level. 2.11.c. Deputy Commissioner Response to Request for Intervention: The Deputy Commissioner may, at his discretion, take any of the following actions: 1) Refer the request to the DMRS Protection from Harm Director for Complaint Resolution; 2) Refer the request to other Central Office management staff for resolution; 3) Refer the issue back to the appropriate Regional Office Director with a request for the Regional Director to regularly report regarding progress in achieving resolution; 4) Initiate external mediation resources if all parties agree; or 5) Personally intervene to ensure resolution. In most cases where intervention by the Deputy Commissioner is requested, a decision or resolution of the issue would be expected to occur within thirty (30) days. However, the urgency of the situation may require more expedient resolution or the complexity of the situation may require additional time. The timeframe required for resolution will vary depending on the number of issues involved, the number of parties involved and the mechanism or route chosen for intervention. 2.11.d. External Mediation: External mediation may be requested by any of the parties involved in a dispute between a service recipient or a service recipient's family members and a provider of services. All parties must be agreeable to participating in mediation with the external mediator. External mediation may be requested by contacting or submitting a written request to the DMRS Central Office, Office of Consumer and Family Services. External mediation services will be arranged with the approval of the Deputy Commissioner or designee in accordance with DMRS Internal Operating Policy.

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 15

2
2.12. TennCare Resolution Processes A complaint may be submitted to the TennCare Division of Developmental Disability Services at any time. TennCare generally refers the complaint to DMRS and tracks it until resolved. The TennCare Division of Developmental Disability Services may also investigate the complaint if determined necessary depending on the nature of the complaint. If a complaint is submitted to TennCare and referral is made to DMRS, resolution will be expected to occur within thirty (30) days. In some situations, such as when conflicts result in delay or interruption of services, initiation of the Grier appeals process may be applicable. A detailed discussion of the Grier process is provided later in this chapter. 2.13. Title VI Complaints A Title VI complaint may be filed by a service recipient, a service recipients family member, a service recipients legal representative, a support coordinator/case manager or other entity acting on the service recipients behalf. The service recipient or other entity filing the complaint need not be the victim of discrimination. Title VI complaints may be submitted in writing to the Local (provider) Title VI Coordinator, the DMRS Regional Office Title VI Coordinator or the DMRS Central Office Title VI Coordinator (contact information for DMRS Title VI Coordinators is provided in Appendix B). Title VI complaints may also be filed with agencies external to DMRS, such as the Tennessee Title VI Compliance Commission or the U.S. Department of Health and Human Services Office of Civil Rights (contact information provided in Appendix B). A person filing a Title VI complaint has the right to file the complaint with the federal Office of Civil Rights at any stage of the complaint process. All Title VI complaints filed with the U.S. Department of Health and Human Services must be filed no later than 180 calendar days after the alleged discrimination occurred. Complaints may be filed by letter or by completing a Title VI Complaint Form (provided in Appendix D). 2.13.a. Required Components of Title VI Complaints: Title VI Complaints must contain the following information: 1) Name and address (a telephone number where the complainant can be contacted during business hours is helpful, but not required); 2) A general description of the person(s) or class of persons injured by the alleged discriminatory act(s) (names of the injured person(s) are not required); 3) The name and location of the provider that committed the alleged discriminatory act(s); and

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 16

2
4) A description of the alleged discriminatory act(s) in sufficient detail to enable DMRS to understand what occurred, when it occurred, and the basis for the alleged discrimination (race, color or national origin).
2.13.b. Disposition of Local Title VI Complaints: Complaints of alleged discrimination

received by Local (provider) Title VI Coordinators will result in the following actions: 1) The Local Coordinator will report the complaint to the DMRS Regional Office Title VI Coordinator within twenty-four (24) hours of the complaint being filed; 2) The Regional Office Title VI Coordinator will advise the Central Office Coordinator of the complaint filed in accordance with DMRS Internal Operating Procedures; 3) The Local Coordinator will investigate the complaint and submit a final report of findings to the Regional Office Title VI Coordinator within thirty (30) days of receiving the complaint; 4) When a violation of Title VI has occurred, the final report of findings will be accompanied by the responsible providers written description of proposed remedial action(s); 5) Within five (5) calendar days of completing the final written report of findings, the Local Coordinator will provide a copy of the report of findings to the person filling the Title VI complaint, along with notification of the right to file an appeal of the findings. 2.13.c. Disposition of Regional Title VI Complaints: Title VI Complaints may be presented directly to the Regional Office Title VI Coordinator. Depending on the circumstances, the Regional Office Coordinator may notify the Local Coordinator of the complaint and request that the Local Coordinator investigate. The Regional Office Coordinator may conduct the investigation or enlist the aide of other Regional Office staff to conduct the investigation upon request from the complainant or if it appears that it would be improper for the Local Coordinator to conduct the investigation. For example, if the complainant alleged that a person known to have a close personal relationship with the Local Coordinator violated Title VI, the Regional Office Title VI Coordinator would conduct the investigation or enlist other DMRS regional office staff to conduct the investigation. When responsibility for investigation of complaints of alleged discrimination lies with the Regional Office Title VI Coordinators the following actions will result: 1) The Regional Office Coordinator will report the complaint to the DMRS Central Office Title VI Coordinator within twenty-four (24) hours of the complaint being filed;

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 17

2
2) The Regional Office Coordinator will investigate the complaint or arrange for investigation of the complaint and submit a final report of findings to the Central Office Title VI Coordinator within thirty (30) days of receiving the complaint; 3) When a violation of Title VI has occurred, the final report of findings will be accompanied by the responsible providers written description of proposed remedial action(s); 4) Within five (5) calendar days of completing the final written report of findings, the Regional Office Coordinator will provide a copy of the report of findings to the person filling the Title VI complaint, along with notification of the right to file an appeal of the findings. 2.14. Retaliation for Involvement in a Complaint Process Retaliation against a service recipient or other party that occurs as a result of filing a complaint or involvement in a complaint process will not be tolerated by DMRS. If such retaliation is found to have occurred, appropriate action against the employee or provider will result, up to and including employee termination, provider fines or provider agreement termination. Federal law specifically prohibits retaliation following Title VI complaints. In accordance with Title VI of the Civil Rights Act of 1964 [45 C.F.R. Part 80.7(e)], no provider shall intimidate, threaten, coerce, or discriminate against any applicant or service recipient for the purpose of interfering with any right or privilege secured by Section 601 of the Act, or because the applicant or service recipient has made a complaint, testified, assisted, or participated in any manner in a discrimination investigation, proceeding or hearing. 2.15. Access to State-Funded Services: The process for appealing an action such as denial of eligibility for enrollment in service programs or termination or reduction of services is dependent upon how the service is funded. If a service is funded with only state funds, access to services is not guaranteed. The state legislature must make funding available in the state budget to initiate and ensure continuation of state-funded services. Providers may have the capacity to provide more state-funded services and there may be significant consumer demand for state-funded services; however, the demand more frequently exceeds the availability of funding. People are generally not able to appeal the fact that state-funded services are not available. If funding is not provided after state-funded services are started, the service can be terminated or reduced without the person having the opportunity to formally appeal. However, if state-funded services are denied for reasons other than the availability of funding, (e.g., inadequate justification for approval or continuation of a service) and if

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 18

2
there is evidence of improper application of DMRS policy in issuing a denial of services, the service recipient may request reconsideration from the DMRS Deputy Commissioner. The DMRS Deputy Commissioner or designee, upon receipt of such a request for reconsideration, will review all documentation provided by the person submitting the request, as well as all information available from the Regional Office. A reconsideration meeting may be held between involved parties if necessary. A decision will be rendered based on the information presented within 30-60 days. The decision rendered by the Deputy Commissioner or designee is final. 2.16. Medicaid/TennCare Eligibility Appeals: Federal Medicaid laws and regulations provide certain protections to people who apply for or receive services funded by Medicaid. One of these protections is the right to appeal when eligibility is denied or terminated. 2.16.a. Medicaid Financial Eligibility Appeals: As discussed in Chapter 1, certain income and resource standards must be met for a person to be eligible for Medicaid benefits. If an applicant is denied due to income or resources that exceed what is allowed for Medicaid eligibility to be established, the Department of Human Services is required to send the person a written notice of ineligibility for Medicaid benefits. The notice must inform the applicant of the right to appeal the denial and request a fair hearing. The notice must also advise the applicant of how long they have to submit an appeal, of where the appeal is to be submitted and of how to request assistance with submitting an appeal. Once a person is determined eligible for Medicaid and begins to receive services, it is possible that a determination could be made that the person no longer meets financial eligibility requirements for participation in the Medicaid program. This could result in the person being involuntarily disenrolled from the waiver program. Involuntary disenrollment is discussed later in this chapter. 2.16.b. Medicaid Medical Eligibility Appeals: To be eligible for Medicaid-funded long-term care services for people with mental retardation, applicants must meet the states criteria for admission to an Intermediate Care Facility for the Mentally Retarded (ICF/MR), whether they chose to receive services in an institutional or community setting. The Bureau of TennCare determines if an applicant is medically eligible for ICF/MR or waiver services via the Pre Admission Evaluation (PAE) Process. If the PAE is denied, the Bureau of TennCare must inform the applicant in writing that the PAE has been denied and that the applicant is not medically eligible to receive services in an ICF/MR or waiver program. The notice must provide information about why the applicant was denied, must inform the applicant of appeal rights and must provide information about how to appeal the denial.

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 19

2
Once a service recipient is determined eligible for Medicaid and begins to receive services, it is possible (although not likely for a person with mental retardation) that the service recipients condition could improve to the point that medical eligibility requirements for participation in the Medicaid program were no longer met. It is also possible that it could be discovered that the PAE was approved based on erroneous information. Such circumstances could result in the service recipient being involuntarily disenrolled from the waiver program. Involuntary disenrollment is discussed in the following section of this chapter. 2.16.c. Involuntary Disenrollment Appeals: An involuntary disenrollment, or disenrollment from the waiver program, cannot be initiated by a provider. DMRS must initiate involuntary disenrollment, if necessary, with approval from TennCare as specified in Chapter 1, Section 1.8.b. Appeal rights are applicable with the exception of when the waiver program is terminated or the service recipient moves out of state. If CMS terminated the waiver program, the waiver program would cease to exist and state would have no choice but to disenroll waiver service recipients. When service recipients move out of state, they are expected to access Medicaid benefits in the new state of residence. To initiate an involuntary disenrollment, DMRS is required to provide an advance written notice describing why the service recipient is no longer eligible for participation in the waiver and when the disenrollment will be effective. The notice will also provide information regarding how to appeal and request a fair hearing and the deadline for submitting an appeal. If the appeal is submitted within ten (10) days of the notice, the service recipient will have the right to have services continued while the appeal is pending. Notice requirements and other DMRS responsibilities related to involuntary disenrollment will be more extensively described in a DMRS Internal Operating Policy. 2.16.d. Provider Responsibilities Related to Eligibility Appeals: Support coordinators/case managers are required to assist applicants/service recipients in appealing eligibility denials or terminations of eligibility as necessary. This may involve explaining any denial notices received, explaining the appeals process, assisting the applicant/service recipient in submission of a timely appeal request, assisting the applicant/service recipient in preparing for the appeal hearing, assisting in making arrangements for a telephone or in-person hearing, assisting the applicant/service recipient in obtaining legal representation and/or providing testimony regarding needs and capabilities during an appeal hearing. Other providers may be required to provide records, information or hearing testimony that allow the judge to determine if eligibility criteria or requirements are met.

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 20

2
2.17. Service Appeals: Service appeals differ significantly from eligibility appeals. Eligibility appeals are related to whether the applicant/service recipient can participate in the Medicaid program or a particular program within Medicaid, such as a HCBS waiver. Service appeals are related to the ability to receive a particular service within a program that may offer a variety of different service options. The process for appealing an adverse action is defined by a court-ordered settlement agreement resulting from the class action lawsuit Grier vs. Wadley. An adverse action refers to a delay, denial, reduction, suspension or termination of benefits, as well as, any acts or omissions which impair the quality, timeliness or availability of benefits. The Grier order applies to services provided through TennCare Managed Care Organizations (MCO) and Behavioral Health Organizations (BHO), as well as, Medicaid HCBS waiver services. A copy of the Grier order can be obtained from any DMRS office. The Grier order is also available on the TennCare web site (see Appendix F). 2.17.a. The Service Authorization Process: DMRS reviews service requests for HCBS waiver services and is responsible for distribution of Grier-compliant notices of denial when requested HCBS services are not approved. DMRS is not involved in issuing service denials for MCO and BHO services, although DMRS staff and providers, particularly support coordinators and case managers, may be involved in assisting service recipients to exercise appeal rights for denied MCO/BHO services. Requests for approval of HCBS waiver services are submitted and processed in the following manner: 1) An ISP which includes a service request(s) is submitted to the appropriate DMRS Regional Office by the support coordinator/case manager. Supporting documentation justifying the need for the service requested is provided. 2) The service request is reviewed by designated DMRS Regional Office staff. Requests for clinical services such as nursing or therapy services may be reviewed by DMRS Regional Office clinical staff. 3) The request must be either approved or denied within twenty-one (21) days of DMRS receiving the request. If a service request is not acted upon within this time frame, the service is approved. If the service request is reviewed in time and additional information is needed, the support coordinator and/or other service providers may be contacted to provide the needed additional information. If such additional information is not received within the twenty-one (21) day period allowed for review of the service request, the service request will be denied. 4) If the request is approved, the service recipient and the designated representative (as applicable) is provided written notification of the approval. The support coordinator/case manager submitting the ISP will receive notification that the ISP and related service request(s) have been approved. 5) If the ISP and service request is denied, the service recipient, designated representative (as applicable) and support coordinator/case manager are notified

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 21

2
of the denial. The written notice of denial will include the reasons for the denial and a description of appeal rights. 2.17.b. Responsibility and Time Frames for Submitting an Appeal: All notices of denial will be dated. For purposes of calculating timely receipt of appeals, receipt of denial notices is presumed to have occurred by the fifth (5th) day following the date of the notice. Upon receipt of a denial notice, a decision must be made regarding whether to take further steps to obtain approval for the service requested. If a decision is made to proceed in obtaining approval, the service recipient or a representative of the service recipient could appeal the denial or ask the support coordinator or case manager to resubmit the service request with additional information. Service recipients in the DMRS system may need assistance filing an appeal. Anyone can file an appeal on behalf of a service recipient, including a provider, a case manager/support coordinator, an advocate, a family member, a friend or a legal representative. A period of thirty (30) days is always allowed for submission of an appeal request. However, in some cases, consideration should be given to submitting the appeal request within ten (10) days to avoid interruption of a service being provided. When the service recipient has been receiving a particular service and that service is to be terminated or suspended, notice must be provided at least ten (10) days before the date the service is scheduled to end. If an appeal is received within ten (10) days of notification that a service is to be terminated or suspended, the service recipient is entitled to continue to receive the service until the appeal is resolved. The service recipient must specifically request that the service be continued. If the person misses the ten (10) day deadline, the person still has a total of thirty (30) days to appeal, but services may be stopped while the appeal is being resolved. 2.17.c. The Grier Appeals Process: An appeal can be requested by telephone, fax or letter. If a letter is submitted, it should include the persons full name, Social Security number, the type of service being appealed, the reason for appealing and any other information that would be helpful in reviewing the appeal request. Appeals may be submitted to the DMRS Central or Regional Offices or the TennCare Solutions Unit (TSU). All Grier appeal requests are processed by the TSU (see contact information in Appendix B). Appeals received by DMRS offices or staff are promptly forwarded to the TSU. Appeal requests are processed in the following manner: 1) Upon receipt of an appeal request, the TSU will determine if the appeal was requested timely and if DMRS followed the appropriate procedures in issuing a service denial. The TSU may overturn the decision to deny the service if timeframes were not met or if appropriate policies and procedures were otherwise not followed in issuing the denial. When a denial is overturned by the TSU, the TSU will issue a written directive to DMRS with instruction to authorize and ensure provision of the service within five (5) days. The service recipient and

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 22

2
designated legal representative (as applicable) will be notified in writing that the service was approved by the TSU. DMRS may submit a written request to the TSU for additional time to arrange for the service to be provided, if there is a valid reason why the service cannot be provided within five (5) days. 2) If the denial is not overturned by the TSU, the TSU will notify DMRS of the appeal request and ask that the Regional Office reconsider the denial. A total of fourteen (14) days is allowed for reconsideration. Reconsideration may result in one of the following outcomes: The Regional Office may determine that the service should be approved based on additional information or a change in circumstances. When DMRS elects to overturn a denial, DMRS notifies the TSU that the service has been approved. The service recipient and support coordinator/case manager are also notified of approval and a withdrawal of the appeal request is obtained. The Regional Office may partially approve a service requested or approve an alternate service that meets the service recipients needs. When partial approvals occur, the service recipient has the option of continuing with the appeal hearing to obtain approval for the service as requested. If satisfied with the partial approval or alternate service approved, the service recipient or legal representative may cancel the appeal hearing by withdrawing the appeal request. The Regional Office may determine that the original denial must be upheld. Upon notification that DMRS intends to proceed with the denial, the TSU has another opportunity to either overturn or uphold DMRS decision. If DMRS decision is upheld, an administrative hearing will be scheduled. 2.17.d. Grier Appeal Hearings and Post-hearing Processes: The following provides a description of the Grier appeal hearing process: 1) Grier appeal hearings are held before an administrative law judge employed by the Office of the Secretary of State. 2) The hearing must be held and the judge must render a decision that is final within ninety (90) days of receiving the appeal request, unless an expedited hearing is requested (see Section 2.17.e.) or the service recipient requests a hearing continuance which is granted by the judge. 3) Grier appeal hearings may be held by telephone or in person, depending on which arrangement best meets the needs of the service recipient or the individual representing the service recipient. If an in-person hearing is needed, the TennCare Office of General Counsel should be contacted to request such.

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 23

2
4) The service recipient or service recipients representative has the right to review any documentation or facts DMRS relied upon to make the decision to deny the requested service. 5) DMRS will be represented by an attorney employed by the TennCare Office of General Counsel. 6) DMRS staff involved in making the decision to deny the service requested will be required to testify at the hearing. The service recipient or the service recipients representative may cross examine DMRS witnesses. 7) An attorney may represent the service recipient during an appeal hearing or the service recipient may represent himself/herself or select a family member or friend as a representative during the hearing. 8) Service recipients and/or individuals representing service recipients may need assistance preparing for the hearing and presenting arguments during the hearing. 9) The service recipient or his/her representative may present any evidence or call any witnesses that help make the case that the requested service should be approved. The documentation that is usually helpful to present during the hearing includes the ISP, any assessments that are relevant to the service requested, doctors orders that are relevant to the service requested and documents pertaining to service authorization and approval. 10) Although the judge may render a decision at the hearing, this typically does not occur. The judge will generally take all information presented during the hearing under advisement and issue a decision in the form of a written initial order at a later time. 11) The judges initial order must be issued no later than seventy-five (75) calendar days from the date the appeal request was received. In the event that the judge issues an order upholding DMRS decision to deny the requested service, a fifteen (15) day time period is provided for the service recipient to take further action before the order becomes final. The initial order will become final on the ninetieth (90th) day from the date the appeal request was received, if the service recipient does not take further action. Further actions that may be taken within the fifteen (15) day time period include: The service recipient or entity representing the service recipient may ask that the judge reconsider his/her decision. Upon receipt of a written request for reconsideration, the judge may either overturn the decision stated in the initial order, uphold the decision or not respond to the reconsideration request. If the judge does not respond to the request for reconsideration within twenty (20) days, the request for reconsideration is considered denied. When a request for reconsideration is denied, the service recipient has fifteen (15) more days to file an appeal of the judges decision.

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 24

2
The service recipient or entity representing the service recipient may also appeal the administrative law judges decision without first requesting reconsideration. The letter notifying the service recipient of the order will provide information regarding how to file an appeal of the administrative law judges decision. 12) Upon entry of a final order, the following actions may be taken by the service recipient or entity representing the service recipient: A stay of the final order may be requested within seven (7) days to stop the final order from being implemented. An appeal of the final order to Chancery Court may be requested within sixty (60) days. 13) If the administrative law judge issues an order overturning a DMRS denial, a directive will be issued requiring DMRS to authorize and arrange provision of the service within five (5) days. 14) Neither DMRS nor TennCare may appeal a decision made in favor of the service recipient. 2.17.e. Hearing Scheduling and Continuances: Hearings are scheduled by the TennCare Office of General Counsel and the Administrative Procedures Division of the Office of the Secretary of State. Each hearing is assigned a docket number. This docket number is the way the case is tracked within the Office of the Secretary of State. The docket number is needed for any inquiries made to the Administrative Procedures Division about the case. In most cases, both the state and the service recipient are anxious to complete the hearing and resolve the appeal as soon as possible. However, situations occur when illness or other valid reasons make it difficult or impossible for the hearing to be held as scheduled. When a hearing is scheduled and the service recipient or his/her representative is unable to attend on the date scheduled, the administrative law judge may be contacted to request a continuance or postponement of the hearing. When a continuance is requested, the TennCare Office of General Counsel may agree or oppose the continuance, depending on the reason the continuance was requested. The judge has final authority in granting or denying the continuance. Continuances are generally granted when a valid reason is presented. The time period allowed for completing the hearing process is usually always extended or tolled when a continuance is granted. For example, if the hearing is postponed for a period of thirty (30) days, then thirty (30) days will be added to the original ninety (90) day time period allowed for completion of the hearing process. 2.17.f. Additional Information About Grier Appeals: Variations in the Grier appeals process may occur depending on the reason for the appeal, the urgency of the appeal and other factors. The following provides additional information related to the Grier service authorization and appeal processes that may apply in specific situations:

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 25

2
1) A service may be approved by DMRS, but DMRS cannot ensure that the service is provided as soon as the person needs it. This could be because there is no provider to provide the service, a certain kind of living arrangement is desired, modifications have to be made to a home that was chosen, or for any number of other reasons. When the service approved is delayed, the service recipient must be notified in writing of the delay and why it is occurring. The notification must advise the person of when the service is likely to be available. The person can file an appeal when an approved service is delayed. If the service recipient does not initially appeal a delay and the service is not provided within the time period indicated, a second notice of delay must be issued, giving the service recipient another opportunity to appeal. 2) A situation may occur where a service is delayed or suspended or the quality of the service is affected without the person receiving advance notice. If an adverse action occurs without any notice being sent, an appeal may be filed at any time. 3) The service authorization request may be time-sensitive. Time-sensitive refers to a service authorization request that requires a prompt medical response in light of the persons condition and urgency of need, as defined by a prudent lay person. In other words, if the service being appealed is a medical service that is covered in the Medicaid waiver in which the service recipient is enrolled, and if the service 4) The recipient has an urgent need for such a medical service, the appeal may be considered time-sensitive. Shorter time frames are allowed for the state to act upon the request if the service requested is time-sensitive. When a service request is time-sensitive, the time period for responding to the request is five (5) days. If the service is denied and an appeal is filed, there is a shorter time frame allowed for reconsideration and for completion of the administrative hearing process. The time period for reconsideration is five (5) days instead of fourteen (14) days. The time frame for completion of the hearing process (i.e. a final administrative decision is provided) is thirty-one (31) days instead of ninety (90) days. Such hearings are referred to as expedited hearings. 2.17.g. Situations When Grier Does Not Apply: Grier appeals are not appropriate in the following circumstances: 1) When state-funded services are denied; 2) When a person is on the waiting list for services and is not yet enrolled as a Medicaid service recipient; 3) When services are provided without obtaining prior approval; and 4) When a provider and DMRS disagree about the rate to be paid for services to be provided.

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 26

2
2.17.h. Illustrations of the Grier Processes: The Grier service authorization and appeal process for DMRS service denials is depicted in Illustration 2.17.h/a. on page 2-28. The process for termination or reduction of a service is depicted in Illustration 2.17.h/b. on page 2-29 and the process for service delay is depicted in Illustration 2.17.h/c. on page 2-30. The same basic Grier process is followed when a TennCare MCO or BHO initiates adverse actions.

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 27

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 28

2
Appeals Process for Termination/Reduction of Service Illustration 2.17.h/b

DMRS Regional Office notifies enrollee of proposed termination or reduction of service

Service is terminated/reduced

Enrollee does not file appeal

Enrollee submitts Appeal to TennCare

Overturns the termination/ reduction of service. Team notified of decision.

TennCare Solution Unit reviews request for appeal Reconsider

Uphold original decision Overturn original decision. Notify team of decision. TennCare Solution Unit reviews appeal Overturn original decision. Notify team of decision.

Informally resolve

Uphold original decision

Overturn original decision. Notify team of decision.

Administrative Hearing

Team notified of decision.

Uphold original decision

Initial order entered by A.L.J.

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 29

2
Appeal Process for Delays of Service Illustration 2.17.h/c

Team requests service to be funded. Request sent to Regional Office.

Delay Occurs

Regional Office Approves service

Individual and Circle of Support notified of delay

Informally resolve Notify team of decision

RO Reconsideration Explanation

Appeal made to TennCare

Issue directive to supply approved service. Notify team of decision

Uphold original decision

Responses reviewed by TennCare Solutions Unit Uphold RO decision

Overturn original decision Issue a directive. Notify team of directive

Overturn original decision. Notify team of decision

Administrative Hearing Uphold original decision Initial Order entered by A.L.J.

Team notified of decision

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 30

2
2.17.i. Provider Responsibilities in Maintaining Grier Compliance: Providers have the responsibility to maintain compliance with the Grier order by virtue of having a provider agreement with the state which allows provision of Medicaid/TennCare funded services. Provider responsibilities include: 1) Ensuring that appropriate staff have a basic understanding of the Grier order and how it affects the Medicaid waiver service delivery system, particularly in regard to service authorizations (Appropriate staff are, at a minimum, staff involved in ensuring that services are provided consistently and timely, staff responsible for scheduling and employing direct care staff, staff responsible for health care management and oversight and staff involved in obtaining service authorizations); 2) Ensuring that staff involved in accessing TennCare MCO or BHO services have a basic understanding of how the Grier order affects access to health care benefits provided by the TennCare program, such as hospital care, mental health services, medications, physician services, medical equipment and supplies and other professional/clinical services; 3) Ensuring that staff understand their obligation to assist the service recipient in understanding and exercising the right to appeal and request a fair hearing when adversely affected; 4) Ensuring that staff have sufficient knowledge of Grier requirements to assist or obtain assistance for the service recipient with requesting services appropriately, filing an appeal, preparing for appeals hearings, designating a representative for the hearing, understanding notices and/or presenting information at hearings; 5) Ensuring that appropriate staff understand when services requested are timesensitive and warrant requesting an expedited appeal process; 6) Providing all relevant information with service requests and responding promptly to requests for clarification or additional information; 7) Providing documentation and information as necessary to DMRS or TSU staff to ensure timely resolution of appeals; and 8) Ensuring that the DMRS Regional Office is notified a minimum of ten (10) calendar days prior to any denial, reduction, termination, suspension, or delay in providing Medicaid Waiver services. 2.18. Title VI Appeals When a Title VI complaint is filed and not resolved to the complainants satisfaction at the local or regional level, an appeal may be filed with the DMRS Central Office Title VI Coordinator. A copy of the complaint, the findings, the proposed action and the request for appeal must be forwarded to the DMRS Central Office Title VI Coordinator within ten (10) calendar days of the notification of the complainant of the local/regional decision. If the person who filed the Title VI complaint feels that a satisfactory

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 31

2
resolution still has not been achieved with appeal to the DMRS Central Office Title VI Coordinator, the option of appealing to the Commissioner of Finance and Administration, the Tennessee Title VI Compliance Commission or the U.S. Department of Health and Human Services Office of Civil Rights is available (see contact information in Appendix B). 2.19. Service Recipient Responsibilities Related to Participating in a Medicaid Waiver Along with rights, there are certain responsibilities and requirements that service recipients and their families must be advised of and assisted to understand. Regional Office Case Management staff responsible for intake activities provide people receiving services and their families with basic information regarding rights and responsibilities, services, etc. These responsibilities are reflected in DMRS internal operating procedures. The service recipient receiving Medicaid-funded services and the service recipients family or legal representative as applicable should be advised that state and federal Medicaid law specifies that: 1) A physical examination must be completed every one (1) to three (3) years as required; 2) A form must be completed each year to document the need for continuing waiver services (the Annual Reevaluation of Level of Care Form, which is provided in Appendix D); 3) Financial information must be provided each year for annual redetermination of Medicaid financial eligibility; 4) The service recipient and family are required to allow state and federal staff to visit them to look at their home, talk with them and their staff and look at their personal records for the purpose of assessing the quality of services being delivered and the service recipients safety in the community; 5) The service recipient/family will be visited in the home several times a year by the support coordinator/case manager to ensure that the ISP is being implemented; and 6) The service recipient/legal representative as applicable will be asked to participate in selection of Circle of Support Members (see Chapter 3) and will be invited to and encouraged to participate in planning meetings to develop an ISP. 2.20. Service Recipient Responsibilities Related to Participating in DMRS Service Programs In addition to the above requirements for Medicaid waiver service recipients, DMRS requires that a uniform assessment be completed at least every two (2) years for all service recipients receiving services in the DMRS service delivery system. In addition,

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 32

2
DMRS has established requirements for service recipients receiving state-funded services. The service recipient receiving state-funded services and the service recipients family or legal representatives as applicable should be advised that: 1) The service recipient and family may be required to allow state staff to visit the them to look at their home, talk with them and their staff and look at their personal records for the purpose of assessing the quality of services being delivered and the service recipients safety in the community; 2) The service recipient/family will be visited in the home several times a year by the support coordinator/case manager to ensure that the ISP or simplified support plan is being implemented; and 3) The service recipient/family will be asked to participate in selection of Circle of Support Members (see Chapter 3) and will be invited to and encouraged to participate in planning meetings to develop an ISP or simplified support plan. 2.21. Options for Service Recipients Determined Unable to Make Decisions 2.21.a. Durable Power of Attorney: A durable power of attorney is a written document that provides a mechanism for a competent service recipient to designate an individual to act on his/her behalf. The designated individual acts on a service recipients behalf in performing fiduciary duties, such as making decisions about expenditures of assets or management of personal property. A durable power of attorney becomes effective if the service recipient becomes disabled or incapacitated and is no longer able to make his/her own decisions. The competent service recipient will be able to participate in defining the powers granted to the durable power of attorney. TCA 34-6-102 defines the durable power of attorney. 2.21.b. Durable Power of Attorney for Health Care: A durable power of attorney for health care designates an individual to act on a service recipients behalf in making health care decisions (TCA 34-6-201). A durable power of attorney must be in writing with signatures of two (2) witnesses. Signatures must be obtained before a notary public. TCA 34-6-203 specifies the requirements for a durable power of attorney. A person designated by a durable power of attorney for health care has priority over any other person to act for the service recipient in all matters related to health care decisions, including decisions related to end-of-life care. If a guardian or conservator is appointed after a durable power of attorney is executed, the guardian/conservator cannot revoke or replace the durable power of attorney for health care (TCA 334-6-204). A designee specified by a durable power of attorney for health care has the same rights as the service recipient would to access health care records, unless access is limited by the durable power of attorney. Providers must arrange for prompt and orderly transfer of a service

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 33

2
recipient if the provider is unable to implement the health care decisions made by the designated individual acting under a written durable power of attorney (TCA 34-6-214). 2.21.c. District Public Guardians: District public guardians may serve as conservators for service recipients who are sixty (60) years of age or older who have no family members willing and able to act on their behalf. Duties of a district public guardian are specified in TCA 34-7-101 to 105. 2.21.d. Guardians: A guardian is appointed by a court to provide partial or full supervision , protection and assistance of the person or property of a minor (TCA 34-1101). A minor is a person who is not yet eighteen (18) years of age who has not been legally emancipated. Guardians are discussed in greater detail in Chapter 17. 2.21.e. Conservators: A conservator is appointed by a court when an adult is determined disabled as defined in TCA 34-13-101. Any party having knowledge of circumstances necessitating appointment of a guardian/conservator can file a petition for appointment. When a conservator is appointed, the court order will specify the powers removed from the service recipient and vested in the conservator. Conservators are discussed in greater detail in Chapter 17. 2.21.f. Providers and Family Members Serving as Conservators or Guardians or Representing a Service Recipient Under a Durable Power of Attorney: Durable power of attorney, guardianship and conservatorship involve fiduciary responsibilities to the service recipient. Consequently, situations that could be construed as conflict of interest must be avoided. It is improper for an individual acting under a durable power of attorney, guardianship order or conservatorship order to be in a position where he/she is able to profit from decisions made on behalf of the person. Family members who are conservators/guardians will not be paid for providing direct services to a service recipient to whom they also provide guardianship/conservatorship services, unless a court order is obtained expressly allowing them to do so. A provider or employee/contractor of a provider may not make health care decisions on behalf of a service recipient if they are involved in providing health care services to that service recipient. 2.22. Human Rights Committees A Human Rights Committee (HRC) is a group of individuals who meet on a regular basis to review and approve behavior support plans that include restrictive interventions, review psychotropic medication usage and review complaints of rights violations and other rights-related issues.

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 34

2
2.22.a. Regional HRCs: A Regional HRC must be available in each grand region of the state. Regional Directors are responsible for initial appointments of Regional HRC members and for appointment of replacement members based on recommendations from the Regional HRC, from TennCare or from DMRS. Regional HRC members shall be individuals who are familiar with people with disabilities and have relevant professional or personal experience which contributes to their role as an HRC member. Regional HRCs are responsible for hearing appeals of Local HRC decisions. Regional HRCs are also responsible for providing support to local committees and for providing technical assistance to local committees when requested by the Regional Director or designee and when requested by the Local HRC or provider executive director/chief executive director responsible for oversight of the Local HRC. The DMRS Regional Office is responsible for providing adequate staff to administratively support Regional HRCs. DMRS Regional Directors are responsible for operational oversight of Regional HRCs. 2.22.b. Local HRCs: Local HRCs may conduct HRC business for a single provider or a group of providers. Local HRCs must be authorized to perform HRC functions by the DMRS Regional Director. For Local HRCs, the provider executive director(s)/chief executive officer(s) is responsible for appointment of HRC members. Local HRC members shall be individuals who are familiar with people with disabilities and have relevant professional or personal experience which contributes to their role as an HRC member. Provider(s) involved with a Local HRC are responsible for providing adequate staff to administratively support the committee. If a Local HRC has been formed by a single provider, the provider executive director/chief executive officer is responsible for operational oversight and administrative support of the HRC. If multiple providers jointly form a Local HRC, the executive directors/chief executive officers shall determine which of the executive directors/chief executive offers are responsible for operational oversight and administrative support of the HRC. 2.22.c. Authorization of HRCs by the Regional Director: All Local HRCs must be authorized by the Regional Director prior to performing HRC functions for DMRS Service Recipients. The authorization process is as follows: 1) The provider executive director/chief executive officer who will be responsible for operational oversight of the Local HRC will submit a written request for authorization of a Local HRC to the Regional Director, including a roster of proposed committee members; and 2) If all requirements are met, the Regional Director will provide written notification that the Local HRC is authorized to perform HRC functions to the provider executive director/chief executive officer and provide a copy of such notice to Regional HRC chairperson.

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 35

2
2.22.d. Requirements for Maintaining Authorization as a Local HRC: To continue authorization to perform HRC functions, the HRC must: 1) Ensure that the provider executive director/chief executive officer responsible for operational oversight of the HRC provides a roster of HRC membership to the Regional Director at least annually, within thirty (30) days of the beginning of each calendar year; 2) Ensure that the provider executive director/chief executive officer responsible for operational oversight of the HRC notifies the Regional Director of any changes in membership, change of chairperson or change of entity responsible for operational oversight that occurs throughout the year, within thirty (30) calendar days of the change occurring; 3) Ensure that the HRC is duly constituted at all times; 4) Ensure that meeting minutes are provided to the Regional HRC chairperson prior to Regional HRC meetings; and 5) Ensure that all other HRC performance standards and requirements specified in this chapter are met. 2.22.e. Revocation of Authorization to Perform HRC Functions: The Regional Director may revoke a HRCs authorization when: 1) Membership changes result in the HRC not being properly constituted; 2) The HRC consistently fails to meet timeliness standards for completion of HRC functions; 3) The HRC fails to maintain confidentiality; 4) The HRC consistently fails to perform functions required by DMRS policy; 5) The HRC consistently makes decisions that are contrary to DMRS policy; or 6) The HRC consistently fails to act in the best interest of service recipients. 2.22.f. Procedures for Revocation of Authorization to Perform HRC Functions: If one of the situations in Section 2.22.e. occurs, the Regional Director will notify the HRC chairperson and provider executive director/chief executive officer responsible for operational oversight of the HRC of the issues that must be corrected and that the HRCs authorization is in danger of being revoked if a corrective plan that adequately addresses the issues is not submitted within thirty (30) business days. The Regional Director may request recommendations for a course of action from the Regional Committee. Based on such recommendations, the Regional Director may determine that technical assistance and consultation provided by the Regional HRC is warranted. Such technical assistance/consultation could include additional education regarding HRC duties and responsibilities, mentoring by Regional HRC members, internships of Local HRC members or consultation regarding procedural changes. If HRC authorization is revoked

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 36

2
and the unauthorized committee continues to operate, all approvals obtained from the unauthorized committee will be invalid. 2.22.g. Internships With Regional HRCs: Opportunity to complete an internship with a Regional HRC may be provided for new Local HRC members, for members of Local HRCs with identified performance issues or upon request of a Local HRC if Regional HRC resources permit. 2.22.h. Composition of a HRC: All HRCs must have membership including: 1) A community representative who serves as the chairperson; 2) Three (3) community representatives from relevant professions (e.g., clergy, law, psychology, psychiatry, behavior analysis, pharmacy, social work, counseling or medicine), at least one of whom has experience with human rights issues; 3) A minimum of one (1) family member of a person receiving services from a provider in the region or from a provider involved in forming the local committee; and 4) A service recipient receiving services from a provider within the region or from a provider involved in forming the local committee. 2.22.i. Conflict of Interest: Any HRC member who is involved in a matter under review or consideration by the HRC shall not participate in decision-making processes pertaining to that matter. If a conflict of interest involves the chairperson of the HRC, another HRC member must be designated to serve as chairperson while such matter is under review/consideration. Staff employed or contracted by providers shall not be involved in decision making or review of matters concerning service recipients provided services by their employer or concerning other employees of the same agency. Behavior analysts who developed a BSP or who will be responsible for ensuring implementation of a BSP shall not be involved in decision making regarding approval of that BSP. 2.22.j. Functions of a HRC: The functions of a HRC are: 1) Review and approval of behavior support plans (BSPs) that include restrictive interventions; 2) Review of psychotropic medication use; 3) Re-review of BSPs containing restrictive interventions at least annually; 4) Review and evaluation of BSPs utilizing restraint or protective equipment a minimum of every ninety (90) calendar days; 5) Review and approval of any proposed restrictions not contained in a BSP; 6) Review and make recommendations regarding complaints/issues received pertaining to potential human rights violations;

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 37

2
7) Provision of technical assistance to providers regarding policies and procedures affecting the service recipients rights or the ability of service recipients to exercise rights; 8) Review and make recommendations regarding research proposals or academic projects involving service recipients to ensure that implementation of the proposal/project will not result in human rights violations; and 9) Coordination with Behavior Support Committees (see Chapter 12) as needed concerning restrictive interventions, psychotropic medications, research proposals and provider policies. 2.22.k. Timely Processing Requirements: The HRC must address all business issues brought before the committee in a timely fashion. Final determinations must be provided no later than thirty (30) business days following presentation of the issue. 2.22.l. BSP Reviews Requirements: HRC approval must be obtained for all BSPs inclusive of restrictive interventions. Table 2.22.l. provides a description of requirements for approval of initial BSPs and indicators that requirements are met. Table 2.22.l. Requirements and Indicators for BSP Approval Requirements for BSP Approval 1) The service recipient and family members and/or legal representative as applicable provided input or were offered the opportunity to provide input during the development of the BSP. Indicators The assessment section of the BSP or an attachment to the plan will list the names and titles of the individuals who provided input. The author of the BSP will be able to describe efforts made to provide opportunity for input as noted in clinical contact notes. Responses from the service recipient and/or individuals representing the service recipient will be considered.

2) Informed consent was obtained from The signed informed consent will be provided with the service recipient or person with legal the BSP. Any documentation of appointment of a authority to grant consent. legal representative shall be made available to the HRC if necessary for verification of legal authority to provide consent. 3) Behavioral Support approval was obtained. Committee The BSP attachment indicating the date the plan was approved and signed by the Behavior Support Committee chairperson will be made available to the HRC.

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 38

2
Requirements for BSP Approval Indicators 4) Less restrictive interventions were The assessment section of the BSP, including the considered or used and determined to be rationale for selection of specific interventions, contraindicated or ineffective. information about any contraindicated interventions, potential risks and rights restrictions will be provided to the HRC. 5) Restrictive intervention is not being The assessment section of the BSP, including the proposed for the convenience of staff or rationale for selection of specific interventions, as a punishment of the service recipient information about any contraindicated interventions, potential risks and rights restrictions will be provided to the HRC. Complaints or issues presented by the service recipient and/or the service recipients representative will be considered in making this determination. 6)The risk(s) associated with allowing continuation of the behavior issues for which the BSP was developed outweigh the risk(s) associated with implementation of the proposed BSP. The assessment section of the BSP, including the rationale for selection of specific interventions, information about any contraindicated interventions, potential risks and rights restrictions will be provided to the HRC.

2.22.m. Initial BSP Review Process: Initial review of a BSP including restrictive interventions will be conducted as follows: 1) The BSP author will make arrangements to obtain approval of the Behavior Support Committee prior to consideration by the HRC; 2) The plan will be reviewed in accordance with the factors specified in Section 2.21.l; 3) The HRC may approve the plan, conditionally approve the plan or disapprove the plan; 4) If the BSP is approved: The chairperson will sign the BSP approval form (see Appendix D) and ensure that it is attached to the BSP; The HRC will determine when the plan needs to be scheduled for rereview; 5) If the BSP is conditionally approved: The author of the BSP will submit a revised BSP to the HRC chairperson within a specified time period;

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 39

2
The HRC chairperson will review the revised BSP to ensure that revisions made are consistent with revisions agreed upon during the HRC meeting 6) If the BSP is disapproved: The HRC will approve interventions that may be implemented while a new BSP is being developed; A Local HRC decision may be appealed to the Regional HRC; a Regional HRC decision may be appealed to the DMRS Deputy Commissioner or designee. 2.22.n. Annual BSP and Ninety (90) Day Restraint/Protective Equipment Reviews: Annual and ninety (90) day reviews of approved BSPs are required to evaluate whether the approved BSP continues to meet the needs of the service recipient in the least restrictive manner. The HRC must develop a review schedule that ensures that BSPs are reviewed prior to expiration of the approval of the existing BSP. Table 2.21.n. describes the requirements for annual/ninety (90) day reviews and indicators that requirements have been met. Table 2.22.n. Annual/Ninety (90) Day BSP Review Requirements and Indicators Requirements Indicators BSP is of the date of review

1) The review will be completed prior to The BSP approval is extended or a new the expiration of the approval for the approved as necessary before approval existing BSP. existing BSP expires, as evidenced by the the HRC chairpersons signature on the form. 2) The HRC will consider any new risks or rights restrictions resulting from implementation of the plan and will determine if any necessary revisions to the plan have been completed.

The Behavior Support Provider and/or other provider responsible for ensuring implementation of the BSP will provide the assessment section of the Behavior Support Plan which will describe the stage of BSP implementation and BSP effectiveness; any risks or rights issues resulting from implementation of the BSP; benefits noted or outcomes achieved resulting from implementation of the BSP; and recommended plan revisions and rationale for such revisions.

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 40

2
Requirements 3) Request to extend an existing BSP is based upon the assessed need of the service recipient and the level of effectiveness of the current BSP. Indicators The assessment section of the BSP, inclusive of a graphical representation comparing preintervention severity and/or frequency of problematic behaviors to current severity/frequency of problematic behaviors will be provided to the HRC. The Behavior Support Provider and/or other provider responsible for ensuring implementation of the BSP will be able to describe treatment effectiveness and explain data presented during the HRC meeting. The Behavior Support Provider will describe the need for any revisions made, including the rationale for using the selected interventions as noted in the assessment section of the BSP. Complaints or issues voiced by the service recipient and/or the service recipients representative will be considered in making this determination.

4) If the current BSP has been revised, there is a valid treatment rationale for the changes; there is evidence of careful consideration of risks, benefits, level of restrictiveness, rights restrictions, and treatment effectiveness associated with incorporated interventions; and there is no indication that interventions will be used as retribution or for the convenience of staff. 5) The service recipient and family members and/or legal representative as applicable provided input or were offered the opportunity to provide input during the development of the BSP.

The assessment section of the BSP or an attachment to the plan will list the names and titles of the individuals who provided input. The author of the BSP will be able to describe efforts made to provide opportunity for input as noted in clinical contact notes. Responses of the service recipient and/or service recipients representatives will be considered in making this determination.

6) Informed consent was obtained from the The signed informed consent will be provided service recipient or person with legal with the BSP. Any documentation of authority to grant consent. appointment of a legal representative shall be made available to the HRC for verification of legal authority to provide consent.

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 41

2
Requirements 7) Behavioral Support approval was obtained. Indicators Committee The BSP attachment indicating the date the plan was approved and signed by the Behavior Support Committee chairperson will be made available to the HRC.

2.22.o. Requirements for Psychotropic Medication Reviews: The requirements that must be addressed during psychotropic Medication Reviews and indicators that the requirements are met are provided in Table 2.21.o.

Table 2.22.o. Requirements and Indicators for Psychotropic Medication Reviews Requirements Indicators

1) The medication is being used The entity requesting medication approval will provide to address a formal diagnosis. information regarding the current psychiatric diagnosis, other medical diagnoses, the current psychiatric medication and dosage and other medications and dosages to the HRC. 2) The service recipient and family members and/or legal representatives as applicable provided input or were offered the opportunity to provide input during the development of the medication approach. 3) Informed consent was obtained from the service recipient or person with legal authority to grant consent If the medication is incorporated into the BSP, the assessment section of the BSP or an attachment to the BSP will list the names and titles of the individuals who provided input. The author of the BSP will be able to describe efforts made to provide opportunity for input as noted in clinical contact notes. Responses from the service recipient and/or individuals representing the service recipient will be considered in making this determination. The signed informed consent will be provided. Any documentation of appointment of a legal representative shall be made available to the HRC for verification of legal authority to provide consent.

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 42

2
Requirements 4) Medication is not being used in excessive dosages or amounts that interfere with the service recipients quality of life. Indicators The ISP, staff instructions, BSP (if applicable), planning team minutes, responses of the person presenting the information or responses of the service recipient and/or individuals representing the service recipient may be considered in making this determination. If the service recipient attends the HRC meeting and appears lethargic, the HRC should question the cause of lethargy. If the service recipient or person representing the service recipient voices complaints about the negative effects of the medication, the HRC may use this information in reaching a determination. The ISP, staff instructions, BSP (if applicable), planning team minutes, responses of the person presenting the information or responses of the service recipient and/or individuals representing the service recipient may be considered in making this determination.

5) Medication is not being used for the convenience of staff, as a substitute for services or as a punishment of the service recipient

2.22.p. Psychotropic Medication Review Process: When psychotropic medication use is incorporated into a BSP, the BSP review process will apply. However, if the BSP is acceptable, other than requiring resolution of psychotropic medication issues, the BSP can be approved separately to allow expedient implementation while the necessary actions are being taken to resolve medication issues. When it is not necessary to incorporate psychotropic medication use into a BSP, the support coordinator/case manager will submit a copy of the ISP to the HRC. Within the ISP or in an attachment, the type of medication proposed, the current diagnosis and the reason the medication is needed must be provided. A current diagnosis justifying psychotropic medications is considered one that was obtained or recertified within the past three (3) years. The HRC will conduct the medication review in accordance with Section 2.21.o. When review is completed, the HRC chairperson will sign the psychotropic medication review form (see Appendix D) and ensure that the review form is attached to the ISP. The HRC will determine when a subsequent review should be scheduled (required within twelve (12) calendar months). If issues with psychotropic medications are identified, the DMRS Central Office Medical Director will be notified to assist with resolution. 2.22.q. Annual Review of Psychotropic Medications: The HRC shall establish a schedule that ensures that medication reviews are completed within twelve (12) calendar months of initial or previous review.

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 43

2
2.22.r. Review of Restrictive Interventions Not Contained in a BSP: When implementation of restrictive interventions is proposed in the absence of behavior services or is discovered to have been implemented by a provider without proper approval, approval shall be sought from a HRC. The purpose of such review is to determine if the restrictive intervention is warranted and if so, whether behavior services are needed. Such interventions must always be included in the ISP, even if behavior services are declined or determined not to be needed. An example of a restrictive intervention that is sometimes found to be implemented without proper approval is the giving or withholding of an enrollees personal funds. Provider requirements regarding management of service recipient personal funds are described in Chapter 6, Section 6.10. The request to implement or continue such interventions must include a description of the intervention, the plan for implementing the intervention (e.g., the ISP, staff instructions, behavioral intervention guidelines and/or orders from a medical or mental health practitioner) and the plan for removing or lessening the restriction. Such approved interventions shall be reviewed at least annually by a HRC. 2.22.s. Review of Complaints of Human Rights Violations and Issues: Service recipients, family members, legal representatives, advocates, provider staff or other interested parties may contact the HRC chairperson to request information about or review of a potential human rights violation or issue. When a complaint is received, the HRC chairperson or designee is responsible for collection of information necessary to consideration of the complaint. The service recipient involved and the person filing the complaint, if a different person, will be invited to attend the HRC meeting during which the complaint is reviewed. If unable to attend the meeting, the complainant may submit a written description of the complaint or issue to the HRC chairperson. The HRC chairperson is responsible for informing the complainant in writing of the findings and recommendations of the HRC. The Regional Director will receive a copy of the HRCs response. The HRC chairperson is responsible for distributing copies of the response to other individuals such as involved family members, legal representatives or provider executive directors/chief executive officers who are responsible for corrective actions. 2.22.t. Review of Proposed Research or Academic Projects: The HRC shall review all research and academic projects involving DMRS service recipients. The HRC shall determine if the project adequately protects the rights of the service recipients involved. If research/academic projects are approved by the HRC, a written notification shall be provided to the project coordinator prior to initiation of the project. Table 2.21.t. describes requirements for reviews of research/academic projects and indicators that requirements are met.

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 44

2
Table 2.22.t. Requirements and Indicators for Review of Research Projects Element Indicator

The benefits of participation The project description will be provided to the HRC, outweigh any potential risks or including an explanation of any potential risks or rights rights violation. violations. The project protects the The project description will include an explanation of confidentiality of the individuals. how the research data will be collected, tabulated and presented to maintain confidentiality. The project clearly explains the risks The Informed Consent document will be provided to and benefits of participation and the HRC, inclusive of an explanation of risks and allow the person to withdraw from benefits as well as permission to withdraw at any time. the study without any consequences. 2.22.u. HRC Meetings: A quorum, consisting of a simple majority of HRC members, must participate in a meeting for decisions to be made or actions to be taken. Decisions shall be based on the majority opinion of the HRC members participating in the meeting. If a majority decision cannot be made by a Local HRC, the issue will be referred to the Regional HRC for consideration. If the Regional HRC cannot reach a majority decision, the issue will be referred to the DMRS Deputy Commissioner or designee for a decision to be made. Meetings are to be held at a time and place that is conducive to participation by HRC members and that affords reasonable access to providers and individuals bringing business or concerns before the HRC. The presence of the service recipient involved in matters that are considered by the HRC is appropriate and may be beneficial to the HRC in considering the issue(s). The service recipient is to be advised of the date, time and location and supported in participating in HRC meetings, if he/she chooses to attend. The service recipient must be given opportunity to address the HRC or contact the HRC chairperson at any time to provide input or express concerns about a BSP, medication or rights issue. HRC members have a responsibility to keep information discussed during meetings confidential. Aside from HRC members, only those individuals directly involved with the issue being presented to the committee may be present. Arrangements must be made to ensure that individuals attending for issues involving other service recipients do not have inappropriate access to confidential information.

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 45

2
It is permissible for Behavior Support Committees and HRCs to schedule combined meetings as needed to exchange information or facilitate timely review of BSPs. 2.22.v. HRC Meeting Minutes: Meeting minutes must be kept for each HRC meeting. The minutes must include a description of all reviews conducted and all issues discussed. The minutes must also adequately reflect all decisions and recommendations made by the HRC and all actions taken. It must be evident upon reading the minutes and reviewing documentation referenced in the minutes that all requirements for reviews specified in this chapter were met. Members and additional individuals present at HRC meetings must be indicated in the minutes. The minutes are to be produced in a format that allows confidentiality to be maintained when the meeting minutes are distributed. Portions of the minutes regarding individual service recipients can be accessible only to individuals involved with the issue at hand before the HRC for that service recipient. Meeting minutes are to be distributed within thirty (30) days of the meeting date. Distribution of portions of the minutes may be necessary within a shorter time frame if more immediate action(s) are required, such as when follow-up actions must be completed before administration of medications can be initiated. A standard format for HRC meeting minutes has been developed and is provided in Appendix D. 2.22.w. Maintenance of HRC Records: Regional HRC meeting minutes and other records will be maintained at the DRMS Regional Office. Records of Local HRCs will be maintained by the provider in the main administrative office. HRC records are to be maintained separately from service recipient records. To maintain confidentiality, each service recipient who has been involved in a HRC review should have an individual HRC file containing only the portions of the HRC minutes applicable to him/her. If more than one provider is involved with a Local HRC, each provider shall maintain records applicable to the service recipients served. HRC records shall be maintained for a period of five (5) years. Each member of the Regional HRC shall sign a confidentiality agreement that assures compliance with HIPAA requirements, and such signed agreements shall be maintained at the DMRS Regional Office. Each member of a Local HRC shall sign a confidentiality agreement that assures compliance with HIPAA requirements, and such signed agreements shall be maintained by the provider designated to perform administrative support functions for the Local HRC. 2.22.x. Responsibilities of the HRC Chairperson: responsible for: The HRC chairperson is

1) Scheduling meetings; 2) Developing and distributing meeting agendas to committee members;

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 46

2
3) Collecting and distributing copies of materials needed for HRC meetings to committee members and other involved parties; 4) Inviting other individuals who are not HRC members who need to be present during HRC meetings; 5) Ensuring that meeting minutes are recorded and that copies are distributed to committee members and other involved parties (e.g., support coordinators/case managers, other providers, the service recipient, advocates, family members and/or legal representatives); 6) Ensuring that meeting minutes are reflective of the issues discussed, recommendations/decisions made and actions taken during the meeting; 7) Ensuring that meeting minutes include a signature page and that signatures of meeting participants are recorded; 8) Ensuring that the official records of the Regional HRC, including meeting minutes and other documentation are submitted to the DMRS Regional Office to be maintained for a minimum period of five (5) years or ensuring that Local HRC official records are maintained for a period of five (5) years in the providers main administrative office; 9) Ensuring that the Regional Director (for Regional HRCs) or the provider executive director/chief executive officer (for Local HRCs) is provided a copy of the meeting minutes with recommendations made so that follow-up actions/responses can be completed or provided; 10) Arranging for training to be provided to new HRC members and to be repeated as necessary to ensure understanding of HRC functions/responsibilities and confidentiality requirements; 11) Ensuring that all HRC members have signed HIPAA-compliant confidentiality agreements; 12) Ensuring that copies of service recipients records used during HRC meetings are collected at the end of the meeting and properly filed or disposed of; 13) Ensuring that HRC duties are discharged in a timely manner; 14) Ensuring that allegations of possible abuse, neglect, or mistreatment are referred to the appropriate abuse/neglect investigation agency or agencies; and 15) Ensuring that an updated list of HRC members is submitted to the Regional Director at least annually. In addition to the above, Local HRC chairpersons must ensure that the regional committee chairperson receives copies of all meeting minutes for Local HRC meetings. 2.22.y. Relationship Between Local and Regional HRCs: Decisions made by the Regional HRC cannot be overturned by a Local Committee. Regional HRCs are expected to provide support to local committees. Oversight and support includes the following interactions:

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 47

2
1) Provision of consultation and technical assistance enabling local committees to properly discharge their duties when requested by the Regional Director or designee or when requested by the Local HRC or provider executive director/chief executive officer responsible for oversight of the local HRC; 2) Reviewing decisions made by Local HRCs that are appealed to the Regional HRC; 3) Reviewing samples of BSP reviews, medication reviews or other documentation of Local HRC activities as needed to provide support and technical assistance to Local HRCs. Local HRCs are expected to: 1) Review applicable licensure requirements pertaining to rights and rights restrictions (see Section 2.3 and Table 2.3.) and Chapter 2 of this manual annually to ensure that the agency or agencies associated with the Local HRC are compliant with requirements; 2) Provide an annual written report of the activity described in 1) to the Regional HRC chairperson, including what action was taken if non-compliance was identified; 3) Provide documentation of the number of annual and ninety (90) day BSP reviews completed by the Local HRC to the Regional HRC chairperson; 4) Refer service recipients and other individuals to the Regional HRC when they have issues that cannot be resolved by the Local HRC, when the complainant is not satisfied with the Local HRCs resolution of the issue or when the complainant expresses that he/she is not comfortable with the Local HRC addressing the issue or fears retaliation. 2.22.z. DMRS Support of HRCs: DMRS Regional Offices will provide administrative support to Regional HRCs, including, but not limited to, assistance with copying materials for meetings, with procuring meeting space; with maintenance of Regional HRC records, with recording meeting minutes, with distributing materials and with arranging for Regional Behavior Analysts to attend meetings as necessary. DMRS Regional Directors will ensure adequate monitoring and provider response to address Regional HRC concerns. For all HRCs, the DMRS Central Office (including the State Behavior Services Director) and Regional Office staff will be available to HRC chairpersons for consultation regarding potential rights violations or other issues brought before a HRC. The DMRS Central Office Deputy Commissioner or designee will review appeals of Regional HRC decisions.

Provider Manual, Chapter 2 Consumer Rights and Responsibilities Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

2- 48

3
CHAPTER 3 INDIVIDUAL SUPPORT PLANNING AND IMPLEMENTATION

3.1.

Person-Centered Planning Person-centered planning is a process which is focused on service recipients in terms of who they are, what they want in life and how their desired outcomes may be accomplished. Person-centered planning is used in the development and ongoing revision of the Individual Support Plan (ISP). The ISP is person-centered in that it provides an individualized, comprehensive description of a service recipient, as well as, guidance for achieving unique outcomes that are important to the service recipient in achieving a good quality of life in the community. Person-centered planning and the resulting ISP are owned by the service recipient. Consequently, the service recipient is to be encouraged and supported to participate in the planning process to the extent that he/she chooses. The service recipient may be assisted in planning supports and services by a Circle of Support.

3.2.

The Circle of Support The Circle of Support (COS) is a group of individuals who meet or otherwise share information on a regular basis to help a service recipient accomplish personal life goals and become an active member in the community. Members of the COS may engage in social activities with the service recipient; however, the primary purpose of the COS within the DMRS service delivery system is to advise the service recipient and legal representative regarding the planning of services and supports. 3.2.a. COS Membership: The service recipient and/or the service recipients legal representative is in control of who participates as a member of the COS and how the COS functions. The service recipient and/or legal representative may change COS membership at any time. The support coordinator/case manager, as the primary facilitator of the planning process, is to assist the service recipient and/or legal representative in understanding the purpose of the COS, in distributing invitations/meeting announcements and other materials to COS members and in facilitating the planning process during COS meetings. In addition to the service recipient, the legal representative and the support coordinator/case manager, the COS may be comprised of family members, friends, neighbors, or other community members who are chosen by the service recipient and agree to COS membership. COS members are usually involved because they share a

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 1

3
personal relationship with the service recipient and want to make a difference in his/her life. Provider staff must be invited by the service recipient or legal representative to be a member of the COS and/or to participate in Planning Meetings. If provider staff are invited to participate on the COS, their primary focus must be on supporting the individual, not on representing the provider. Situations in which provider staff use the role as a COS member to coerce or influence the selection of service options must be avoided. 3.2.b. COS Functions: The service recipient and/or service recipients legal representative determines how COS members talents and energies are to be employed. COS members are intended to exchange ideas freely with each other and with the professionals who participate with them on the Planning Team. Neither the COS nor the Planning Team is intended to be viewed as a mechanism for over-riding decisions made by a competent individual, by a court-appointed legal representative or parent of a minor child acting in the best interests of the person represented. However, situations may arise where the other members of the COS feel that a court-appointed paid or family legal representative (guardian/conservator) is not acting in the best interests of the service recipient. In such cases, the COS must work with the legal representative to resolve the issue. In some cases, it may become necessary to enlist a neutral external mediator arranged by DMRS (see Chapter 2, Section 2.11.d.) to attempt to resolve the conflict or issue(s). As a last resort, the issues or conflicts may need to be brought to the attention of the court who appointed the conservator/guardian for resolution. The COS is intended to advise and support the service recipient in planning the delivery of services and supports. The COS generally provides support to the service recipient in achieving life goals which may not be achieved without their help. DMRS has no authority over the COS; therefore the information provided in this section is informational, for the purpose of describing the role of the COS for providers who use this manual. The COS may perform the following functions: 1) Encouraging the service recipient to exercise control of his/her life; 2) Encouraging the service recipient to participate in COS meetings/information sharing and Planning Meetings; 3) Assisting the service recipient in understanding responsibilities associated with life choices; 4) Assisting the service recipient in identifying outcomes to be included in the ISP; 5) Assisting the service recipient in identifying options for services or supports to meet identified needs;

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 2

3
6) Assisting the service recipient in making choices about selection of providers; 7) Supporting the service recipient when obstacles present and assisting in identifying ways to overcome obstacles; 8) Assisting the service recipient in identifying and utilizing personal strengths; 9) Assisting the service recipient in keeping the Planning Team centered on action steps and outcomes during Planning Meetings; and 10) Celebrating successes in completing action steps and achieving outcomes with the service recipient. 3.2.c. COS Meetings and Information Sharing: Information may be shared among COS members in a variety of ways, including telephone conversations, written correspondence or meetings. A COS meeting may be requested by any COS member and may occur at any time the service recipient or the service recipients legal representative agrees that a meeting is needed. However, the service recipient and legal representative should be judicious in determining when a meeting is needed. COS meetings are not the appropriate mechanism for resolution of all problems. All service providers are required to have conflict resolution procedures for resolution of issues with service delivery. DMRS compliant resolution processes may also be utilized to resolve problems. COS and Planning Team meetings should be reserved for occasions when the advice/support of COS members is needed or a change in the ISP is required. Support coordinators/case managers are encouraged to convey options for resolution of issues as appropriate when alternatives to COS meetings may be appropriate. COS meetings may include some or all of the COS members. Meetings or other forms of COS information sharing in the absence of the providers involved in service delivery may be determined to be beneficial in allowing COS members to freely exchange ideas and concerns, particularly during the pre-planning period. The service recipient should be informed of and included/involved in all COS meetings and information sharing unless he/she has chosen or requested not to participate or is unable to participate due to health or other valid reasons. COS members must maintain the confidentiality of Protected Health Information (PHI) as required under the Health Insurance Portability and Accountability Act (HIPAA). 3.2.d. Support Coordinator/Case Manager Attendance at COS Meetings: Although the support coordinator/case manager is expected to attend Planning Meetings that are intended to result in development or revision of the ISP, the support coordinator/case manager does not necessarily attend all gatherings of COS members.

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 3

3
3.3. The Planning Team The Planning Team is comprised of Circle of Support members (including the support coordinator/case manager) and other providers involved in implementing the service recipients ISP. It is not necessary for all COS members or providers to be in attendance for a Planning Meeting to occur. However, all parties are to be informed of the meeting time and date, unless the service recipient or legal representative specifically requests that a particular entity not be invited to participate. The service recipient should be informed of and included/involved in all Planning Meetings unless the service recipient has chosen/requested not to participate or is unable to participate due to health or other valid reasons. The purpose of the Planning Team Meeting is to utilize a person-centered planning process to finalize an ISP that reflects the service recipients desired outcomes and defines the services and supports needed to achieve those outcomes. The process of planning services and supports is intended to be a collaborative process, which will frequently require negotiation and consideration of different alternatives for meeting a service recipients needs. Members of the Planning Team are intended to interact and dialog, with the end result being to determine the best possible way to deliver needed services and supports. The service recipient and legal representative always have the legal right to make final determination as to what services are needed. 3.3.a. Roles of Planning Team Members: The roles of Planning Team members during Planning Meetings are as follows: 1) Service Recipient and/or the Service Recipient's Legal Representative: The service recipient and/or the service recipient's legal representative make decisions about the outcomes and action steps that will be included in the final ISP and the services that will be requested to achieve the outcomes. 2) Support Coordinators/Case Managers: Support coordinators/case managers are the facilitators of the person-centered planning process and facilitate the Planning Meeting, unless another facilitator is preferred by the service recipient. Support coordinators/case managers complete the final written ISP. 3) COS Members: COS members are to assist the service recipient in planning services as indicated in Section 3.2.b. If the service recipient is not present during the Planning Meeting, COS members present are to represent the service recipient to the best of their ability based on their personal knowledge of that person, but do not make decisions for the service recipient. 4) Providers: Providers are to offer information regarding the ability to render services in the manner requested by the service recipient and the service recipients legal representative. Providers may also provide alternative suggestions for consideration if there are barriers to delivery of services in the

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 4

3
manner requested. Providers participating in Planning Meetings do not make decisions for the service recipient or legal representative. Providers contribute professional expertise and judgment to the Planning Meeting. Illustration 3.3 (page 3-6) provides a graphic presentation clarifying the roles of the Planning Team and the COS.

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 5

3
CIRCLE OF SUPPORT The service recipient, the service recipient's legal representative (if applicable) and other individuals chosen to assist in making decisions. The COS helps the service recipient and/or the legal representative to make decisions regarding: What the service recipient wants in life; and What outcomes should be included in the ISP to ensure the quality of life desired in the community. PLANNING TEAM The COS plus all providers whom the Individual/Legal Representative selected to provide services. The Planning Team provides an opportunity for service providers to participate in the planning process by: Sharing information/options with the COS for delivering services which will achieve ISP outcomes; Assisting in development of ISP action steps for implementation of the ISP; and Assisting to address individual needs in the ISP and assigning responsibility for completing actions. The Planning Team allows providers to interact with the COS to provide information about: How various service delivery and treatment options could help the service recipient achieve desired life outcomes; and Assessment results and professional recommendations for medical or clinical treatments that, if implemented, could result in progress toward achieving ISP outcomes.

The COS helps the service recipient and/or the legal representative make specific decisions necessary to make outcomes and actions in the ISP operational within the community, such as: Choosing types of services; Choosing providers to implement the ISP; Choosing a home; and Considering medical needs and profesional recommendations in making informed decisions about medical services needed.

The COS has meetings and shares infromation when: A change or an event occurs and COS input is needed to help determine if the ISP must be amended; and Informal social activities are planned that are not related to the planning of paid services, during which COS members act as natural supports for the service recipient.

The Planning Team has meetings during which the COS and providers collaborate to: Develop the initial ISP and update the ISP on an annual basis; Complete ISP amendments between annual updates (Meetings to amend the ISP may only require attendance of Planning Team members who are involved in planning for or rendering services affected by the proposed amendment).

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 6

3
3.3.b. Frequency of Planning Team Meetings: Planning Team meetings are required upon enrollment in service programs for the purpose of finalizing the initial ISP. Planning Team meetings are required at least annually thereafter, or as needed to ensure that the ISP is appropriately updated or amended. 3.3.c. Documentation of Planning Team Meetings: It is not expected that support coordinators/case managers will record minutes to document Planning Team meetings. Planning will be documented in the form of a finalized ISP, ISP update or ISP amendment. 3.4. Responsibility for Developing the ISP Although all providers who deliver services have a responsibility to participate in the planning of services and supports, the primary responsibility for individual support planning for people enrolled in Medicaid waivers rests with the support coordinator. For people who are on the waiting list for services and people enrolled in the Tennessee Self Determination Waiver Program (SDW), a DMRS case manager will have primary responsibility. There are service recipients receiving state-funded services who are currently receiving case management services from providers of day and residential services. It is anticipated that the majority of these service recipients will be moved into one of the waiver programs. For state-funded service recipients receiving services with an annual cost exceeding $20,000 per year, either a support coordinator or DMRS case manager will be assigned or selected. For state-funded service recipients whose annual service cost is $20,000 or less, the residential/day service provider will continue to provide case management services utilizing a simplified care planning process (see Section 3.15.). 3.5. The Role of Assessment in the Person-Centered Planning Process Assessment is a process which allows information to be collected and compiled regarding a service recipients capabilities, needs and desired outcomes for the future. The availability of information gleaned from assessment is crucial in planning services, in that it allows the different people involved in the planning process to determine what things are likely to keep the service recipient healthy and safe, and what things will contribute to the service recipient having a good quality of life in the community. Several different assessment processes contribute to the development of the ISP, including: 1) Conversation(s) with the service recipient, family and/or legal representative to obtain ideas and suggestions about what things the service recipient can and cannot do, what things are important to the service recipient and what things are liked and disliked by the service recipient;

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 7

3
2) A uniform, individual assessment that provides basic information about a service recipients capabilities and service needs; 3) Professional/clinical assessments and evaluations performed to identify clinical service and treatment needs; 4) A risk assessment that identifies the potential risks associated with life in the community, including health risks, risks associated with making choices, etc.; and 5) Medical (including physicians orders), dental and mental health records as applicable, which provide a summary of the service recipients health-related needs. 3.6. The Uniform Assessment Uniform Assessments are required for service recipients in the DMRS system. The uniform assessment will help in identifying the types of services that may be needed, the activities a service recipient may need assistance with and other assessments that may be warranted. The uniform assessment, along with other assessments and documentation, will serve as a way to justify the approval of requested services. The uniform assessment is based on information collected from the service recipient, family members, legal representatives, direct care staff and/or others who know the person very well. 3.6.a. The Uniform Assessment Instrument: DMRS is responsible for identifying the assessment instrument and process used to conduct the assessment. The assessment instrument will be: 1) Comprehensive; 2) Valid and reliable; 3) Conducive to allowing involvement and collection of information from the service recipient being assessed and legal representatives or involved family members; 4) Used to identify service needs and provide systemic information regarding potential service costs associated with differing levels of service need; 5) Used to document descriptive information regarding functional abilities, adaptive skills and health status; 6) Inclusive of training materials/curricula that will be available through DMRS Regional Offices; and 7) Inclusive of a process for requesting that the uniform assessment be revised or redone if there is additional information that contributes to the outcome of the assessment or if there is conflict regarding the results of the assessment between the person who conducted the assessment and the service recipient assessed or a family member or legal representative.

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 8

3
3.6.b. Frequency and Timing of the Uniform Assessment: Following the initial assessment, each service recipient will be assessed at least every two (2) years. The assessment will be conducted more frequently if needed due to a significant change in the service recipients status. A significant change in status could result from a major medical event such as a stroke. Significant change could also result from a major disruption in the service recipients natural support network, such as the death of a primary caregiver. For routine assessments, the assessment should be completed no more than 120 days prior to the ISP effective date. The provider designated by DMRS for scoring the assessment will send the completed, scored assessment to the support coordinator/case manager at least 90 days prior to the ISP effective date. This allows sufficient time for the support coordinator/case manager to share the results with the service recipient assessed and/or legal representative or family and facilitate resolution of any issues related to the results with the person who completed the assessment. 3.6.c. Responsibility for Conducting the Uniform Assessment: Responsibility for conducting the assessment will depend upon the type of services the service recipient receives. The person who completes the assessment must be trained by a DMRSapproved trainer and must meet any training requirements associated with the instrument used and/or other training requirements specified by DMRS. Responsibility for completion of uniform assessments will be distributed as follows: 1) Residential service providers are responsible for people who receive residential services, regardless of what combination of other services is provided with the residential service. If day services are provided with residential services, consultation with day services staff is required to complete the assessment. 2) Day service providers are responsible for people who receive day services and do not receive residential services. 3) Personal Assistance providers are responsible for people who receive personal assistance services and do not receive either residential or day services. 4) Support coordination providers are responsible for people who receive neither residential, day nor personal assistance services. 5) The Regional Office is responsible for people who are not yet receiving community services or have no independent support coordinator. 3.7. Professional/Clinical Assessments and Evaluations 3.7.a. Referrals for Professional Assessments Funded by the Medicaid Waiver or a DMRS State-funded Program: Referrals for professional/clinical assessments or evaluations may be initiated by a physicians order, requested by individuals involved in developing an ISP or requested by the service recipient. Referrals may be initiated if a service recipient experiences a change in status. When the need for a professional/clinical

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 9

3
assessment is determined, sufficient information must be provided to allow the clinician to determine why the assessment is being requested, Clinicians will not be reimbursed for performing assessments prior to receipt of authorization for payment. Nursing assessments may not be billed as a separate service within the DMRS service delivery system.. Payment for clinical assessments is authorized by the DMRS Regional Office via approval of an initial ISP, ISP update or ISP amendment that documents the service recipients need for the identified assessment. Once authorization for payment is received, the written documentation of the assessment must be received by the support coordinator/case manager within thirty (30) calendar days of approval of the service authorization request. 3.7.b. Other Clinical Referrals and Recommendations: All recommendations resulting from professional/clinical assessments or evaluations must be reviewed and considered for inclusion in or amendment to the ISP. This includes assessments and recommendations made by both waiver clinical service providers and those provided by other clinicians whose services are funded by a TennCare MCO/BHO or a private insurance company. 3.8. Vocational Assessments If the service recipient has expressed interest in pursuing employment, a vocational assessment is to be completed and discussed during the Planning Meeting. A vocational assessment may be performed at any time it is needed, but is required at least every three (3) years unless the service recipient does not wish to seek employment and declines the assessment. Vocational assessments are discussed in greater detail in Chapter 10. 3.9. Risk Assessment Risk is a natural part of life. However, for service recipients who receive services and supports through the DMRS system, DMRS must assure that risk factors are identified, managed and reduced to the extent possible. Responsibility for identification and management of risk is shared by DMRS and all providers who render services to a particular service recipient. Risk must be managed both in terms of systemic policy and practice and in terms of individual risk. Systemic risk management at the provider level is discussed in greater detail in Chapter 18, Protection from Harm. 3.9.a. Purpose of the Risk Assessment: Risk assessment provides a process for identifying individualized risk factors. Once individual risk factors are identified, management of individualized risk becomes an integral part of the overall individual support planning process. Risk assessment and planning must be addressed during the

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 10

3
annual ISP update process and as needed throughout the year. The intent of risk assessment and planning is not to limit a service recipients ability to fully experience life in the community. Rather, risk assessment and planning is intended to provide a way to identify individual risk and create an environment which provides appropriate safeguards and necessary supports for risk management while promoting personal growth and independence, as well as, respect of personal choices. 3.9.b. Identification of Individual Risk Factors: For development of the initial ISP and for the required annual update of the ISP, individual risk factors will be identified utilizing the Risk Issues Identification Tool (provided in Appendix D). All providers involved in the provision of DMRS-funded services during the pre-planning phase of the individual support planning process (see Section 3.11.) will be required to document known individual risk factors on this form. The completed form shall be submitted to the support coordinator at least ninety (90) calendar days prior to the ISP effective date. Following receipt of the Risk Issues Identification Tools, the support coordinator/case manager will be responsible for completing the risk identification process by: 1) Requesting any additional information or clarifications needed related to Risk Issues Identification Tool responses; 2) Initiating any professional/clinical assessments warranted based on information provided; 3) Gathering information/documentation pertaining to risk factors from other sources, such as physicians or other professional/clinical service providers; 4) Gathering available assessments completed during the past year that could assist in determining risk factors, such as the Health Risk Screening Tool (Physical Status Review), the most current uniform assessment and/or professional/clinical assessments; 5) Determining if the available information indicates circumstances, conditions, locations or times of the day when risk appears to be increased; 6) Determining if the available information indicates early warning signs that may be related to risk such as specific actions or communications; 7) Reviewing available information and identified risks with the service recipient and/or designated family members/legal representatives; 8) Determining the relevance of the risk(s) identified to the service recipients action steps and outcomes and the service recipients, familys and/or legal representatives level of concern regarding the identified risk(s); and 9) Collecting any additional information that may be provided by the service recipient, designated family members and/or legal representative about risk factors.

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 11

3
3.9.c. Interim Identification of Risk Factors: Risk assessment is an ongoing process. Risk factors that need to be promptly addressed may be identified during the period between annual ISP updates. A number of factors, for example, choices made by the service recipient or incidents that occur, may necessitate risk assessment and planning. When this occurs, the Risk Issues Identification Tool may be completed by any provider and submitted to the support coordinator (if not initiated by the support coordinator) to trigger the risk planning process, potentially resulting in ISP amendment. 3.9.d. Reporting Risk Factors: DMRS will initiate a process of trending the numbers and types of risk factors that are identified within the DMRS system in order to identify provider training needs and develop training curricula targeted at management/prevention of systemic and/or frequently occurring risk factors. Support coordinators and case managers will be required to report risk factors identified in a format and frequency to be established by DMRS in collaboration with community stakeholders. 3.10. The Individual Support Plan (ISP) 3.10.a. Purpose of the ISP: A plan of care is required for all Medicaid waiver participants. The ISP is Tennessees format for the federally required plan of care. The ISP is the roadmap to implementing services that meet a service recipients unique needs. The ISP also serves as the vehicle for justifying the service recipients need for services so that services can be authorized by the DMRS Regional Offices. The ISP is to clearly describe needs and the services and supports required to meet those needs. 3.10.b. Standardized ISP Format: With assistance from stakeholders, a standardized ISP format has been developed that is inclusive of all required elements. This format must be used in the development of an ISP for every Medicaid waiver participant. The same ISP format is used in other DMRS-funded programs, with the exception of Family Support, Consumer Directed Services and Early Intervention. An ISP is not required when a state-funded service recipient is not assigned to a support coordinator or DMRS case manager and requires services with a cost of $20,000 per year or less. An ISP is also not required when state-funds are used to purchase one-time services (such as a piece of equipment) or emergency services that are time-limited (such as respite while a caregiver is in the hospital for a short-term illness). DMRS is finalizing written guidelines for completion of the ISP format. These guidelines, along with the ISP form, will be posted on the DMRS website and will be available upon request from DMRS offices. 3.10.c. Addressing Personal Funds Management in the ISP: Personal funds are individual financial resources used by or on behalf of an enrollee to pay for necessary

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 12

3
personal expenses. The ISP shall address the following elements in regard to personal funds management: 1) How the enrollees personal funds will be managed; 2) The enrollees capabilities and desires regarding personal funds management; 3) Any training or assistance needed to support the enrollee in managing personal funds or to develop skills needed to increase independence with managing personal funds; 4) The extent to which the provider agency (or the conservator if applicable) is entrusted with management of personal funds (i.e., earned funds and unearned funds, including trust funds); 5) Goals and objectives involving usage of the enrollees personal funds; and 6) Any health, safety or exploitation issues involving the enrollee that require limitations on access to personal funds and strategies to remove limitations at the earliest possible time. 3.10.d. Timeframes for Completion and Review of the ISP: When a service recipient is enrolled in services, the initial ISP must be developed within thirty (30) calendar days from the date of enrollment. The date of enrollment for people enrolled in a Medicaid waiver is the date that services initially begin as shown on the Department of Human Services Form 2362. Support coordination services are typically the first services to be initiated for people enrolled in existing waiver programs. The initial ISP must include, at a minimum, those services necessary to ensure the service recipients health, safety and welfare. The initial ISP must also identify any assessments/clinical evaluations that are needed to further determine the service recipients needs. As assessment results become available and more information is learned about the service recipient, this information must be reviewed and considered for incorporation into the ISP as necessary. Revisions that occur after the initial ISP is finalized are referred to as ISP amendments. For people enrolled in the Medicaid waivers, the ISP must be reviewed and amended as needed, but no less frequently than monthly, as specified in the TennCare rules. The initial ISP can be used for a period of one (1) calendar year from the effective date listed on the form. During that time period, changes in the ISP may be accomplished through ISP amendments. The ISP is considered expired after a one (1) year period and must be updated. An ISP update refers to the annual process of systematically reviewing the entire ISP with the Planning Team and making revisions to reflect any changes that have occurred during the past year. 3.10.e. Effective Date of the ISP: The initial ISP effective date is the date the plan is to be implemented. The effective date will be thirty (30) days from the date of enrollment listed on the DHS Form 2362 for Medicaid-eligible service recipients. When services are state-funded, the initial ISP is due thirty (30) days from the date of enrollment in

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 13

3
services. The effective date is used to determine when annual updates are due. The effective date of a new plan can be no more than one (1) calendar year from the effective date of the previous plan. 3.10.f. ISP Amendments: An amendment to the ISP may result from the regular monthly review of the ISP done by the support coordinator/case manager. An ISP amendment may also be initiated by the service recipient, legal representative, other individuals involved in the service recipients life or by other providers who are involved in implementing the ISP. All other providers are responsible for contacting the support coordinator/case manager to initiate ISP amendments. The service recipient or service recipients legal representative will determine if a meeting is needed to change the ISP. The ISP must be amended when: 1) 2) 3) 4) 3.11. The action steps and outcomes change; Services or service providers change; There is a significant change in overall service and support needs; or The ISP no longer reflects the service recipients preferred lifestyle.

Preplanning Activities: Preplanning activities are those activities that are performed prior to the Planning Meeting either at a Circle of Support Meeting or through individual contacts to allow development of the initial draft of the ISP and to schedule the ISP meeting. 3.11.a. Preplanning Activities for the Initial ISP: Preplanning activities can be broken down into four areas of responsibility for actions that must be completed or facilitated by the support coordinator/case manager prior to the ISP meeting: obtaining and compiling information; developing a draft ISP; providing information to the service recipient, family or legal representative; and making meeting arrangements. Developing a draft of the ISP includes: 1) Obtaining information from the service recipient, the service recipients legal representative, the service recipients family members (if the service recipient wants family members to be involved and the family members are agreeable) and any other individuals the service recipient identifies and wants to be involved in planning; 2) Informing the service recipient, legal representative and/or family of the need for assessments to occur and the relevance of different assessments to the personcentered planning process; 3) Requesting authorization for assessments as needed and ensuring that assessments are completed timely;

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 14

3
4) Reviewing the uniform assessment and any other available assessments to ensure that the assessment is consistent with the service recipients overall condition/situation and to identify service/support needs that must be included in the ISP draft; 5) Summarizing risk factors (see Section 3.9.) identified on a single Risk Issues Identification Tool and completing the section of the Risk Analysis and Planning Tool titled Prior to the Planning Meeting (form provided in Appendix D); 6) Gathering and reviewing available relevant medical records, including doctors orders; 7) Determining if additional assessments are needed based on doctors orders or on the service recipients overall status and ability to progress toward achieving desired outcomes; 8) Circle of Support meetings as determined necessary by the support coordinator/case manager and/or Circle members. Developing a draft of the ISP includes: 1) Drafting the Personal Focus portion of the ISP, which describes the service recipients current situation, including: How the service recipient communicates and makes decisions; What risk factors exist in the service recipients life; What is important to the service recipient; What the service recipient likes and dislikes; and What things the service recipient wants to change about his/her life related to home, work, relationships, community membership and health status. 2) Drafting the Action Plan portion of the ISP, which outlines the action steps that must be accomplished to meet the service recipients individual needs. The Action Plan must address any needs identified in completing the Personal Focus section of the ISP. The Action Plan includes: Personal outcomes and action steps; Needs, barriers and risks to be addressed; Mechanisms to address, manage, alleviate or minimize risk; Supports needed to complete routine daily living activities; Supports needed for events that vary from the service recipients regular routine, such as hospitalizations; and Additional services, equipment or assistive technology needed.

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 15

3
Information to be provided to the service recipient, legal representative and/or family includes: 1) General information, including service options, about the DMRS program through which the service recipient will receive services (e.g. the Medicaid Waiver); 2) A list of available providers and information regarding the right to choose any willing, available provider; 3) The rights and responsibilities of a service recipient, including appeal rights and complaint resolution processes; 4) Information about risk factors identified (see Section 3.9.); and 5) The process for changing services, service levels and providers. Activities required to arrange the Planning Meeting include: 1) Scheduling a date, time and location for the meeting (attention must be given to arranging a time, date and location that is convenient for the service recipient and family); 2) Determining issues to be discussed at the Planning Meeting; 3) Providing information regarding the date, time and location of the meeting to individuals who may attend the Planning Meeting; and 4) Distributing the draft ISP for review to all individuals who may attend the ISP meeting. 3.11.b. Preplanning Activities for Updating the ISP: The requirement for an annual Planning Meeting and ISP update ensures routine review of the effectiveness of the ISP. The support coordinator/case manager must complete or facilitate an annual ISP review with the Planning Team, which may include members of the service recipients Circle of Support to address the following: 1) Reviewing the right to select services in a waiver program or Intermediate Care Facility for the Mentally Retarded (see Chapter 4, Section 4.7.c) with the service recipient and legal representative and obtaining a signed Freedom of Choice Form (see form in Appendix D); 2) Reviewing Title VI rights with the service recipient and legal representative (see Chapter 2, Section 2.7.; 3) Reviewing the previous years ISP; 4) Reviewing the most current uniform assessment and other available assessments; 5) Identifying any new risks that are present in the service recipients life (see Section 3.9.);

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 16

3
6) Considering information obtained through conversation with or observation of the service recipient, as well as, information provided by other individuals involved in planning; 7) Considering whether outcomes were reached and why or why not; 8) Considering the appropriateness and effectiveness of services and supports in completing/achieving action steps and outcomes; 9) Considering the effectiveness of providers in completing/achieving action steps and outcomes; and 10) Identifying aspects of the ISP and service provision that require change/revision. The support coordinator/case manager must then: 1) Draft any revisions needed to update all parts of the ISP; 2) Discuss any new risk factors identified (see Section 3.9.) 3) Determine if provider changes are desired and if so, provide appropriate provider lists and facilitate choice of new provider(s); 4) Provide information and answer any questions pertaining to the service program through which services are received; 5) Review service recipient rights and responsibilities, including appeal rights and complaint resolution procedures; and 6) Make arrangements for the ISP meeting, distribute information about the ISP meeting and distribute draft ISP revisions/updates. 3.11.c. Providing Notice of the Planning Meeting: The support coordinator or case manager will send out copies of the draft ISP to Circle of Support members who will participate in the planning or as requested by the service recipient, prior to the meeting date. The draft ISP will serve as an invitation to the meeting and as notice to providers that the services they provide have been requested to be initiated or considered for continuation. The draft ISP should be sent out as far in advance as possible to allow sufficient time for the Planning Team to prepare for the meeting. Consideration should be given to the amount of time needed to review materials that will be discussed during the meeting and the amount of time the service recipient or family may need to make such arrangements as baby-sitting services, time off work, etc. 3.11.d. Provider Role in the Preplanning Process: Active and full cooperation and participation in the pre-planning process by all DMRS service providers is critical and mandatory for ensuring a successful plan for the person. Providers must ensure the timely completion and obtaining of information for planning purposes. Examples of such information may include the service recipients annual physical and dental exams, vocational assessments, recent evaluations, housing assistance budgets, etc. Providers must forward this information to the service recipients support coordinator/case manager

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 17

3
within 90 days prior to the effective date of the upcoming, annual ISP. Once the ISC distributes the pre-meeting ISP draft, providers are responsible for carefully reviewing the ISP and notifying the support coordinator/case manager of any inaccurate, conflicting or missing information so that corrections may be made prior to the Planning Meeting. 3.12. The (ISP) Planning Meeting 3.12.a. The Purpose of the (ISP) Planning Meeting: The purpose of the Planning Meeting is to allow the individuals involved in planning and the providers involved in implementing service delivery to finalize the ISP, including: 1) Discussing any changes made to the draft after dissemination; 2) Correcting any inaccurate, conflicting or missing information; 3) Finalizing the services/supports that will be requested, including amount, frequency, and duration; 4) Finalizing strategies to address, manage, alleviate or minimize identified risks; and 5) Obtaining the necessary approval signatures on the finalized plan. 3.12.b. Risk Planning: During the Planning Meeting, the Risk Issues Identification Tool and the Risk Analysis and Planning Tool will be used to facilitate and document completion of the risk planning process. Goals of risk planning include: 1) Planning Team members will gain common understanding of risks identified through presentation of information gathered during the pre-planning phase and through discussion of risk factors during the Planning Meeting; 2) For Planning Meetings held to develop the initial ISP, risk planning will result in determination of actions/outcomes and supports/services intended to address identified risk(s); 3) For Planning Meetings held to update or amend the ISP, risk planning will result in determination as to whether current supports and services are adequate in addressing identified risks or as to whether the ISP must be modified to include additional action steps/outcomes and/or additional supports and services to adequately address individual risk management.; and 4) The Planning Team will identify and take steps to ensure initiation of any additional training or education needed by the service recipient or by provider staff supporting the service recipient that could result in improved risk management. Discussions of why, when, where and how the risk to health or safety may occur are expected to occur during the Planning Meeting. Planning Team members must be

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 18

3
prepared to provide/discuss information specific to the service recipient which may include: 1) Ability to understand potential risks; 2) Decision-making history and past experiences with risk-taking; 3) Skills and abilities that may impact health and safety, including communication skills, coping skills, physical abilities, social interaction skills, self-preservation skills and etc.; 4) Preferences related to leisure activities; 5) Work-related issues that may impact health and safety; 6) Personal relationships; and 7) Recent or predictable changes that may result in temporary increase in risk factors or level of risk. 3.12.c. Incorporating Risk Management into the ISP: Risk planning tools are intended to be used for the purpose of guiding and documenting the risk planning process. Action steps/outcomes and services/supports that are to be implemented to address identified risk factors must be included in the ISP. Each provider is responsible for developing any necessary staff instructions that are needed to implement the ISP. If the Planning Team determines that an identified risk should not be addressed in the ISP, the reason/explanation must be documented on the final Risk Analysis and Planning Tool. 3.12.d. Interaction of Participants in the Planning Meeting: The Planning Team members who attend a Planning Meeting may have diverse backgrounds and different types of relationships with the service recipient. Consequently, members of the team may disagree about what is best for the service recipient. The support coordinator/case manager is to act in a leadership capacity in attempting to bring the group to consensus. The support coordinator/case manager is to facilitate free discussion of options and the pros and cons of each, enabling the team to make informed choices. If, however, there is disagreement between the service recipient or the service recipients legal representative and other members of the group, consideration must be given to the fact that the service recipient or the legal representative have legal authority to make the final decision regarding the outcomes and action steps that will be included in the ISP and the services that will be requested. Family members who are part of the Circle of Support will participate in making such decisions to the extent specified by the service recipient and/or the service recipient's legal representative. The service recipient and legal representative are intended to carefully consider the opinions and professional advice of other members of the Planning Team in making decisions regarding services and supports. Such orders may be limited in nature; consequently, Planning Team members should be aware of the legal representatives scope of authority in making decisions on behalf of the service recipient. Such information can be provided during Planning Team meetings by the legal

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 19

3
representative. Planning Team members can obtain a copy of applicable court orders pertaining to the appointment of legal representatives from the court or the legal representative if questions related to decision making authority arise. The service recipient should be informed of and included/involved in all Planning Meetings unless participation has been declined or is not in the service recipients best interests due to health or other valid reasons. Providers are expected to participate in Planning Meetings as needed to ensure that services are integrated with other services the service recipient is receiving. Providers are expected to send a representative to Planning Team meetings who has the authority to make decisions on behalf of the provider organization. Attending Planning Meetings is considered a provider administrative expense that is included in the provider rate. Extra or additional payment is not available for time required to participate in Planning Meetings. During the Planning Meeting, the purpose of the provider being present is to provide input as to whether a service or strategy being requested can be carried out by the provider, and if not, why. The provider may also be able to provide alternative ideas for consideration. A provider may be required to explain why a particular service is recommended and how it is expected to result in the persons ability to progress toward completion or achievement of action steps and outcomes. The Planning Meeting shall not result in a debate or vote between the service recipient and COS and the providers of services. Rather, the Planning Meeting is to be a free exchange of ideas as to how the action steps and outcomes identified in the ISP can best be achieved. 3.12.e. Signatures on the ISP: To the extent possible, planning decisions are to be made during the planning meeting to allow the ISP to be finalized and approved as quickly as possible. The signatures of the individuals attending the Planning Meeting should be obtained on the ISP to indicate attendance at the meeting and participation in development of the ISP during the meeting. If the service recipient does not attend the planning meeting, his/her signature must be obtained if able to sign. Changes discussed during the Planning Meeting will appear in the final ISP or ISP amendment. 3.12.f. Maintaining Documentation of the Planning Meeting: All documentation used and/or generated during the planning process is to be maintained by the support coordinator/case manager as a part of the support coordination/case management record. 3.12.g. ISP Requirements Specific to Day Services: Every service recipient receiving residential services must also have access to day services appropriate to their needs. A service recipient may refuse day services; however, there must be clear documentation that the opportunity to receive a day service was offered. For each individual receiving DMRS-funded day services, the ISP will describe:

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 20

3
1) The type of day services to be provided, such as services that enable an individual to sustain supported or competitive employment, services that facilitate participation in community activities and utilization of community resources, services that facilitate participation in retirement activities and services that provide skill acquisition training; 2) The specific day activities that are appropriate, purposeful and suitable in accordance with the persons age and desired life style; 3) The individual needs being addressed with provision of day services, such as the need for supervision, the need for assistance with activities of daily living, the need to acquire or maintain independence or the need to acquire or maintain skills or functions; 4) The location where the day services will be provided, such as the persons home, a day services facility, a job site or another community location; and 5) The amount of time the service recipient will require support for day service activities, in accordance with the service recipients interest and capabilities. 3.12.h. ISP Requirements Specific to Follow-Along Services: For follow-along services, the ISP is to include outcomes related to how the service recipients employment experience will be enhanced through provision of the service. Examples of outcomes that may be addressed include obtaining a promotion, increasing work hours or improving work attendance. Any employment-related assessments known to be needed for the following year should be addressed in the ISP. 3.12.i. Planning for Possible Admission for In-Patient Services: For those individuals who have had a history of admissions to medical or psychiatric facilities, the support coordinator/case manager should facilitate the development of the Individual Support Plan (ISP) to include clear information about planning for situations that require inpatient admissions. For service recipients with no prior history of admissions to such facilities, the Circle of Support may choose to provide similar planning information as part of the ISP or may choose to rely on the generalized crisis management approaches used within the provider agency. Continuity of care related to inpatient hospitalization is discussed in Chapter 11, Section 11.16. and Chapter 12, Section 12.9. 3.13. Ensuring That Other Alternatives for Services are Exhausted Prior to Requesting DMRS Services To ensure that TennCare Managed Care Organization (MCO) benefits are exhausted prior to accessing Division of Mental Retardation Services (DMRS) services, the service recipient must request the needed services that are covered in accordance with the TennCare contract for managed care and behavior health organizations and, if denied,

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 21

3
exhaust appeal rights before the service can be approved to be reimbursed through the waiver (appeals procedures are discussed in Chapter 2, Section 2.17.). 3.14. Use of the ISP for Service Authorization Following the Planning Meeting, the support coordinator/case manager will submit the ISP to the DMRS Regional Office for review and approval (see contact information in Appendix B). DMRS Regional Office staff will review the ISP to determine if it is complete, if services are appropriate to the service recipients identified needs and if sufficient justification is present to authorize the services requested for the service recipient. The ISP Review Checklist that will be used in review of ISPs is included in Appendix D. The ISP must be submitted to the DMRS Regional Office at least twentyone (21) days prior to the effective date. Services must be preauthorized by the appropriate DMRS Regional Office before payment will be made. Sanctions may be applied when the Support Coordination provider fails to submit the ISP in a timely manner and reimbursement for services to other providers is delayed. Providers of services included in the ISP are not expected to provide services that have not been authorized by DMRS, with exception of those services that are being continued as a result of an appeal request. When continuation of services not approved by DMRS is required, providers will be paid for services rendered. 3.15. Distribution of the Final ISP The original ISP is kept in the support coordination/case management file. Upon DMRS approval of the ISP, copies of the final ISP are to be distributed to: 1) 2) 3) 4) The service recipient; The service recipient's legal representative; Providers responsible for implementing the plan; Family or friends designated by the service recipient or the service recipients legal representative; and 5) All providers involved in implementing the ISP that were not in attendance at the Planning Meeting. Upon receipt of the final ISP, Planning Team members are expected to confirm that changes made are consistent with the changes that were agreed upon during the Planning Meeting. If there is a discrepancy, the support coordinator/case manager shall be notified. The support coordinator/case manager shall respond to reports of discrepancy by consulting with the service recipient or legal representative as necessary, then either amending the ISP as necessary or notifying the reporting party of why an amendment was not completed.

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 22

3
3.16. Appeals of Service Denials When services are denied, Medicaid or other appeal rights may be applicable. A discussion of appeal rights is provided in Chapter 2. Support coordinators/ case managers must assist service recipients as needed in exercising appeal rights. 3.17. Provider Responsibilities for Implementation of the ISP: Support coordination/case management responsibilities are addressed throughout this chapter and in Chapter 4. Other providers are responsible for effectively training direct support staff to carry out the ISP. Although written staff instructions are not required, providers are encouraged to develop and utilize staff instructions when it is determined that written instructions would be beneficial in ensuring that staff consistently and accurately deliver services and supports to a particular service recipient. Providers are required to document progress in completing action steps and achieving outcomes for which they are responsible. 3.17.a. Residential, Day and Personal Assistance Provider Responsibilities: Residential, day and personal assistance providers who employ direct support staff are required to cooperate with therapists and other clinical service providers in developing and implementing staff instructions related to therapy services, when such staff instructions are necessary to complete therapy-related ISP action steps. Residential, day and personal assistance providers are also required to designate a trainer if it is determined that it is appropriate for staff training to be provided by someone other than a licensed therapist. Such determinations are to be made jointly by the therapy and residential, day or personal assistance providers (see Chapter 13, Section 13.13.d.). 3.17.b. Clinical Service Provider Responsibilities: Clinical providers are responsible for documenting the period of time during which services were provided by recording time in and time out notations as indicated in Chapter 13, Section 13.14.a. 3.18. Monthly Reviews Providers are responsible for completing and documenting monthly reviews, which provide a summary of the progress in meeting action steps and outcomes. Each provider is responsible for submitting monthly reviews describing progress related to the services they are responsible for providing. For example, residential providers are responsible for reporting progress made towards completion of any therapy-related ISP action steps or outcomes that direct support staff are responsible for carrying out, but are not responsible for reporting progress related to therapy services directly provided by the therapist or therapy assistant. Evaluation of risk management strategies is to be incorporated into the monthly review process. Monthly reviews are to be kept in the provider record and a

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 23

3
copy is to be submitted to the support coordinator or case manager by the twentieth (20th) day of the month following the month for which the monthly review is being completed. 3.18.a. Basic Requirements for Contents of Monthly Reviews: Monthly reviews must include: 1) 2) 3) 4) The name of the service recipient; The dates of services provided; The service recipients response to the service; A description of any staff training or changes in written staff instructions intended to alter the provision of direct support services since the previous month including the reasons such alterations were made; 5) Any recommendations for changes to the ISP; 6) Any significant health-related or medical events occurring since the last review; and 7) The signature and title of the person completing the monthly review, with the date the monthly review was completed. 3.18.b. Additional Requirements for Clinical Service Monthly Reviews: Clinical staff who are providing services as an independent provider or an employee of an agency licensed as a home care organization professional support services provider are required to provide written progress reports to the service recipients support coordinator/case manager monthly and to the service recipients primary care physician annually [Department of Health Rules 1200-8-34-.06 (1)]. Clinical service monthly reviews must contain the following information, as applicable to the clinical service being provided, in addition to the basic requirements listed in Section 3.14.a.: 1) The number of visits scheduled for the month and the number of visits that actually occurred; 2) An explanation of the reason for any missed visits or units of services that were approved but not used; 3) Conclusions as to whether the clinical service plan of care is meeting the service recipients needs; 4) Recommendation to either continue to implement clinical services without change or to initiate revision, modification or amendment to the ISP and clinical service plan of care; 5) Recommendations for continuation, reduction or increase in service units or discharge from clinical services as appropriate; 6) Documentation of any staff training provided during the month and/or planned for the following month; and

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 24

3
7) The clinical service practitioner signature and credentials with the date the monthly review was completed. 3.19. The Support Planning Process for State-Funded Service Recipients Not Receiving Support Coordination or DMRS Case Management Services For service recipients who receive ongoing DMRS state-funded services with an annual cost of less than $20,000, an ISP is not required. A simplified support plan must be developed in accordance with requirements specified in this section. 3.19.a. Responsibility for Development of Simplified Support Plans: Responsibility for development of a simplified support plan is distributed in the following manner: 1) For people receiving residential services, the residential provider is responsible. If day services are provided by a different day service provider, the residential provider must consult with the day service provider in planning and managing services. 2) For people receiving day services and not receiving residential services, the day service provider is responsible. 3) For people receiving personal assistance and not receiving day or residential services, the personal assistance provider is responsible. 3.19.b. Simplified Support Plan Requirements: A simplified support plan must meet the following requirements: 1) It must be developed prior to the initiation of services; 2) It must be developed with input from the service recipient, the legal representative as applicable, involved family members and any other persons identified to be included in planning by the service recipient and/or legal representative; 3) It must be approved by the service recipient and legal representative as appropriate; 4) It must address abilities, needs and preferences; and 5) It must identify services and supports that will be provided to the service recipient and the staff person or entity responsible for providing the supports and services. 3.19.c. Monitoring and Review of Community Support Management Plans: The provider responsible for developing the simplified support plan must document support summaries in accordance with licensure requirements for the service provided or at least quarterly. Summaries may be required to be completed more frequently if needed to address the service recipients needs. The simplified support plan must be reviewed and

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 25

3
revised at least annually and more frequently if needed to address the service recipients needs. 3.20. Planning for Transition from a Developmental Center to the Community A developmental center is an Intermediate Care Facility for the Mentally Retarded that is owned and operated by the state. Facilitating moves from the developmental centers to the community has been a major focus in the Arlington Remedial Order and the Clover Bottom/Green Valley Settlement Agreement. 3.20.a. Required Meetings During the Transition Process: A series of meetings are required during the transition process, including: 1) The Initial Support Coordination Meeting; 2) The Transition Plan Meeting; and 3) The Closure Meeting. 3.20.b. The Initial Support Coordination Meeting: The initial meeting between the selected support coordinator is important to establishing an effective relationship with service recipients, their legal representatives and/or involved family members. The purpose of this meeting is to get to know service recipients and involved legal representatives and family members and to gather information that will be used in the planning process, including: 1) The service recipients desired outcomes for the transition process; 2) Where the service recipient may want to live and what type of living arrangements could meet identified needs; 3) The type of housemate(s) the service recipient might want to live with; and 4) The types of providers the service recipient may need. 3.20.c. The Transition Meeting: The primary focus of the Transition Meeting is the finalization of the Individual Transition Plan (ITP). Activities that occur during the Transition Meeting include: 1) Meeting participants will make recommendations as to the adequacy of the draft ITP; 2) Meeting participants share any known information that could effect the success of the transition; 3) Any needed revisions to finalize the ITP will be made; and 4) The target date of the transition/move will be identified.

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 26

3
3.20.d. The Closure Meeting: The final meeting required during the transition process is the Closure Meeting. The purpose of this meeting is to: 1) Review the ITP to ensure that all assigned tasks have been completed; 2) Develop a schedule for visitation and monitoring post-transition. 3.20.e. Role of the Support Coordinator in Planning and Facilitating Developmental Center to Community Transitions: Service recipients who move from a developmental center to the community are generally enrolled in a Medicaid waiver. A support coordinator must be selected to participate in the transition process prior to the anticipated transition date. This allows the support coordinator to get to know the service recipient and his/her family and/or legal representative prior to the actual move date. It also allows the support coordinator to become involved in planning the transition. The support coordinator has the following responsibilities prior to the move: 1) Making arrangements for the initial support coordination meeting; 2) Assisting the service recipient, legal representative and/or family in visiting/interviewing potential providers and collecting information about these providers (i.e. brochures, survey documents, etc.); 3) Working with Regional Office transitions staff to assist in identifying service needs and developing a draft ITP; 4) Assisting the Regional Office transitions staff in obtaining any information needed to facilitate the transition process; 5) Assisting with selection of providers; 6) Assisting in making arrangements for the Closure Meeting; 7) Assisting the Regional Office transitions staff in completing the Pre-Move Checklist (see form in Appendix D) within 5 days of the target transition date and facilitating correction of any remaining items or issues that must be resolved prior to the move; 8) Assisting in monitoring implementation of the cross-training section of the ITP; 9) Assisting with documentation of the completion of all tasks, such as home modifications, prior to the targeted transition date; and 10) Attending the Closure Meeting to assist in developing a schedule of the posttransition monitoring visits. 3.20.f. Role of the Community Provider in Planning and Facilitating Developmental Center to Community Transitions: Potential providers approached to provide services to service recipients moving out of a developmental center must determine if they have the capability of meeting the individuals needs. They must also provide information and meet with the service recipient and/or the service recipients family and legal

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 27

3
representatives as necessary to assist in selecting providers. Providers have the following responsibilities: 1) Reviewing and responding to the service recipients Individual Profile provided by Regional Office staff; 2) Working with the Regional Office staff to schedule visits to the developmental center to meet the service recipient; 3) Working with the Regional Office staff to make arrangements for the service recipient or the service recipients legal representative or family (as appropriate) to visit the provider; 4) Attending the Transition and Closure Meetings (if selected as one of the service recipients providers) to assist in development and implementation of the ITP and establishment of the targeted transition date; 5) Completing all assigned tasks specified in the ITP, including completion of any home modifications needed; 6) Notifying the Regional Office transitions staff of any barriers or issues that need to be resolved to enable completion of assigned tasks; 7) Ensuring that staff who will provide direct support services are available and trained in accordance with DMRS policy prior to the targeted transition date; and 8) Beginning authorized services on the date of transition. 3.21. Community Transition Planning for Residential Services The community transition process described in this section is the process by which a service recipient changes the community place of residence, the type of residential service received and/or the residential services provider. A community transition may occur as a result of : 1) A service recipient or legal representative requesting to move to another more favorable site; 2) A service recipient or legal representative requesting a change in residential service providers or a change in the type of residential service received; 3) A situation where the current provider is no longer available to provide services, such as termination of a provider agreement or the provider being unable to assure the health and safety of the service recipient due to a significant change in medical condition. 3.21.a. Initiating a Community Transition Involving a Change in Service Providers: A change in service providers may or may not involve a change of residence, depending on the type of residential services received. There are different ways a community transition involving a change in service providers may be initiated:

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 28

3
1) A service recipient or legal representative may contact the support coordinator/case manager to request the change in providers; 2) A provider may notify the service recipient and DMRS of being no longer capable of meeting the service recipients needs; or 3) The DMRS Regional Office may notify the service recipient and legal representative of the need to change service providers due to termination of a provider agreement or a determination that the current service provider is unable to meet the health/safety needs of a particular service recipient. 3.21.b. Development of the Community Transition Protocol: The Community Transition Protocol is used by the DMRS Regional Office to monitor the transition process when a community transition occurs. Each step in the transition process identified in the Community Transition Protocol will be assigned to a Planning Team member, whose task will be to assure that the transition step is completed in a timely manner. All steps must be completed prior to the specified transition date. Planning steps identified in the Community Transition Protocol must include: 1) Notification of all parties involved if the transition involves housemate changes, including housemates in the old home and their representatives, as well as, potential housemates in a new home and their representatives; 2) Completion of a Residential Service Provider Community Transition Pre-Move Checklist: Home Site Assessment (see form in Appendix D), if moving to a new residence is required; 3) Submission of the dated Residential Service Provider Community Transition Pre-Move Checklist: Home Site Assessment to the support coordinator/case manager and the DMRS Regional Office, including recommendations for any changes that must be made to the proposed residence prior to the service recipient moving; 4) Completion of a Residential Service Provider Community Transition: Acknowledgement of Receipt of Personal Possessions Form (see form in Appendix D); 5) Submission of the dated Residential Service Provider Community Transition: Acknowledgement of Receipt of Personal Possessions Form to the support coordinator/case manager and the DMRS Regional Office; 6) Completion of any Special Site Assessments by appropriate clinical service providers; and 7) Completion of any modifications that must be made to the residence as identified during application of the Residential Service Provider Community Transition Pre-Move Checklist: Home Site Assessment or completion of Special Site Assessments;

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 29

3
3.21.c. Role and Responsibilities of DMRS Regional Office Staff in Facilitating Community Transitions: Regional office staff will: 1) Assist with selection of a provider or identification of a community residence as needed; 2) Ensure that the ISP submitted by the support coordinator/case manager is approved to authorize services in a timely manner; 3) Participate in transition planning meetings as needed; 4) Assist the support coordinator/case manager in developing a Community Transition Protocol which outlines the steps to be completed for successful transition to occur; 5) Review the Residential Service Provider Community Transition Pre-Move Checklist: Home Site Assessment with the support coordinator/case manager to ensure that the potential residence meets the service recipients needs; 6) Assure that adequate records are transferred to the receiving provider or new place of residence on the transition date; 7) Assure that the service recipients personal funds are transferred in adequate amounts; 8) Otherwise assist as needed in implementing the Community Transition Protocol; 9) Conduct quarterly sample reviews of transitions that have occurred utilizing the Regional Office Verification Checklist; and 10) Conduct quarterly sample reviews of transitions that have occurred utilizing the DMRS Performance Assessment Review for Community-Based Transition Program. 3.21.d. Roles and Responsibilities of the Support Coordinator/Case Manager in Facilitating Community Transitions Involving a Change in Providers: The support coordinator/case manager must work expediently and cooperatively with the DMRS Regional Office to facilitate smooth and safe community transitions. The following activities, as applicable, must be completed by the support coordinator/case manager prior to the transition date: 1) Notify the appropriate DMRS Regional Office (see contact information in Appendix B) that the service recipient or legal representative has requested a community transition; 2) Notify the DMRS Regional Office if a new provider has been selected, and if not, work with Regional Office staff to assist the service recipient in selecting a new provider; 3) Work with the DMRS Regional Office to develop a Community Transition Protocol;

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 30

3
4) Coordinate visits/interviews with potential providers and arrange visits to potential new homes to assist the service recipient and legal representative and/or designated family members in making an informed choice in selecting a new residential provider or new residence; 5) Collect information about potential housemates and/or coordinate meetings between the service recipient and potential new housemates (including legal representatives and family members involved in the service recipients life) to evaluate compatibility; 6) Facilitate COS and Planning Team meetings as needed; 7) Initiate appropriate amendments/updates to the ISP as needed; 8) Submit the amended/updated ISP to the Regional Office for approval and provide any additional information requested by the Regional Office in a timely manner; 9) Analyze and address any risks identified by the COS or Planning Team that are associated with transferring to a new provider or residence or receiving a different type of residential services; 10) Arrange for the service recipient to participate in visits to the new home prior to moving, if needed/requested; 11) Ensure the development of a personal budget that shows the availability of funds for payment of expenses pertaining to support of a new household; 12) Ensure that any personal fund balances, food stamp electronic bank transfer (EBT) cards, etc. are transferred to the new provider in the appropriate amount; and 13) Ensure, with assistance from the Regional Office, as needed, that all tasks assigned to be completed and all issues to be addressed prior to the move are actually completed and addressed before the transition date. 3.21.e. Continuation of Services during Transition: If a residential provider change is requested, the transferring provider must continue to provide services until the transition date unless otherwise directed by the DMRS Regional Director, Assistant Commissioner of Facility and Community Services or Deputy Commissioner. Termination of services of the transferring provider may be directed in situations where continuation of services is likely to result in serious health and safety issues. In such instances, DMRS will assume responsibility for placing the service recipient in respite care or arranging alternate service provision until such time as a new provider is identified. 3.21.f. Transferring Residential Provider Responsibilities: In addition to continuation of authorized services, a transferring residential provider must: 1) Initiate contact with the support coordinator /case manager upon learning of the impending transition;

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 31

3
2) Attend all transition Planning Meetings to assist in developing the Community Transition Protocol and any needed ISP amendments/updates, unless the service recipient or legal representative objects; 3) Provide transportation needed for the service recipient to interview prospective providers, visit possible new homes, meet potential roommates and make visits to the new home as needed; 4) Identify a mechanism for making training records available for any direct support staff who are to transfer to the new provider with the service recipient to ensure that training already provided does not have to be unnecessarily repeated (training records may be provided to the staff person or to the DMRS Regional Office); 5) Assist in providing cross-training to receiving provider staff as necessary; 6) Obtain a release of information signed by the service recipient or the service recipients legal representative which allows records to be transferred to the receiving provider; 7) Ensure that the record is copied and given to the designated person for transfer to the receiving provider on the transition date; 8) Ensure that an adequate supply of medical supplies, equipment and medications are available for use by receiving provider staff; 9) Develop or update a list of personal property and make sure the actual property is accounted for (if property is missing, an investigation will be initiated in accordance with policy specified in Chapter 18); 10) Pack and move the service recipients belongings to the new home if moving is involved in the transition; and 11) Close out personal accounts in accordance with Chapter 6, Section 6.10.f. 3.21.g. Receiving Residential Provider Responsibilities: A receiving provider must: 1) Attend any transition Planning Meetings to assist in developing the Community Transition Protocol and any needed ISP amendments/update; 2) Analyze and address any risks identified by the COS or Planning Team that are associated with transferring to a new provider or residence or receiving a different type of residential services; 3) Assist the service recipient and the legal representative and/or family in locating a new home, if a new home is indicated; 4) Complete a Residential Service Provider Community Transition Pre-Move Checklist: Home Site Assessment ensuring that the new home meets basic safety requirements and service recipient needs; 5) Submit a dated copy of the Residential Service Provider Community Transition Pre-Move Checklist: Home Site Assessment to the DMRS Regional Office and the support coordinator/case manager; 6) Develop a cross-training plan for new staff;

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 32

3
7) Establish new checking/savings accounts as needed and verify that the transferring provider has transferred appropriate amounts of funds into accounts and provided the correct amount of cash on hand; 8) Verify that belongings listed on the transferring providers inventory of personal property are present and complete a Residential Service Provider Community Transition: Acknowledgement of Receipt of Personal Possessions Form; 9) Submit a dated copy of the Residential Service Provider Community Transition: Acknowledgement of Receipt of Personal Possessions Form to the support coordinator/case manager and the DMRS Regional Office; 10) Verify that adequate medical supplies and equipment are on hand and obtain any items that are needed; 11) Verify that adequate medication supplies are on hand and make arrangements to refill any medications as needed; 12) Ensure that utilities are connected and functioning, that adequate furniture and functional appliances are present and that an adequate food supply appropriate to the service recipients diet is on hand; and 13) Begin provision of authorized services on the date of transition. 3.21.h. Site to Site Residential Transitions Within the Same Agency: A service recipient may request a move to a new location or the move may be prompted by a number of other reasons. Change of residence may be necessitated by changes in lease requirements, rent increases that make the home unaffordable, sale of a home, roommate incompatibility or inadequacies in the home environment that affect health and safety and cannot be corrected with home modifications. 3.21.i. Support Coordination/Case Management Responsibilities for Site to Site Transitions: When a service recipient moves to a new home but keeps the same residential provider, the support coordinator or case manager is responsible for: 1) Consulting with COS members regarding whether the move is compatible with the service recipients needs and outcomes as identified in the ISP; 2) Completing a Risk Assessment to determine if the move will result in increased risk factors that must be addressed in the ISP; 3) Arranging to meet with the Planning Team as needed to complete any necessary changes to the ISP; 4) Submitting the ISP to the Regional Office if amendments are made and/or notifying the Regional Office of the new address when available; 5) Working with the provider to identify a targeted move date; 6) Notifying other providers of the address change; 7) Coordinating visits to potential new homes to assist the service recipient and legal representative (if applicable) in selecting a new home;

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 33

3
8) Collecting information about potential housemates and/or coordinate meetings between the service recipient and potential housemates (including legal representatives and family members when appropriate) to evaluate compatibility; 9) Arranging for the service recipient to participate in visits to the new home prior to moving, if needed/requested; 10) Ensuring that any necessary therapeutic visits to the home by clinical/professional staff are completed and recommendations accepted by the COS are implemented prior to the move; 11) Ensuring that any needs identified in completing the Pre-move Checklist or therapeutic site visits are incorporated into the ISP; 12) Ensuring that an inventory of all personal belongings is available prior to the move and that all personal belongings are accounted for following the move; 13) Ensuring that food stamp electronic bank transfer (EBT) cards, cash on hand, etc. are transferred to the new home in the appropriate amount; and 14) Ensuring, with assistance from the Regional Office as needed, that all tasks assigned to be completed and all issues to be addressed prior to the move are actually completed and addressed before the moving date. 3.21.j. Residential Provider Responsibilities: The residential provider is responsible for: 1) Assisting the service recipient, with the legal representative or family as appropriate, in locating a new home, ensuring that the new home meets applicable building codes and standards and making any necessary modifications to the home selected prior to the move; 2) Notifying the Support Coordinator or case manager of the anticipated move; 3) Attending any Planning Meetings held to develop a Community Transition Protocol and address ISP amendments/updates that are needed as a result of relocation to the new home; 4) Providing transportation needed for the service recipient to visit possible new homes, meet potential roommates and make visits to the new home as needed; 5) Coordinating the development of a personal budget that shows the availability of funds for payment of expenses pertaining to support of the new household; 6) Assisting in cross training receiving staff as necessary; 7) Completing a Residential Service Provider Community Transition Pre-Move Checklist: Home Site Assessment, ensuring that the new home meets basic safety requirements and service recipient needs; 8) Submitting a dated copy of the Residential Service Provider Community Transition Pre-Move Checklist: Home Site Assessment to the DMRS Regional Office and the support coordinator/case manager;

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 34

3
9) Ensuring that adequate medical supplies and equipment are on hand at the new residence; 10) Verifying that adequate medication supplies are on hand at the new residence; 11) Ensuring that the personal record is transferred to the new home on the transition date; 12) Developing or updating a list of personal property and making sure the actual property is accounted for and transferred to the new home (if property is missing, an investigation will be initiated in accordance with policy specified in Chapter 18) and completing a Residential Service Provider Community Transition: Acknowledgement of Receipt of Personal Possessions Form; 13) Submitting a dated copy of the Residential Service Provider Community Transition: Acknowledgement of Receipt of Personal Possessions Form to the support coordinator/case manager and DMRS Regional Office; 14) Ensuring that bank access cards, checkbooks, food stamp EBT cards, bank books, etc. and available cash on hand are transferred to the new residence; 15) Ensuring that utilities are connected and functioning, that adequate furniture and functional appliances are present and that an adequate food supply appropriate to the service recipients diet is on hand at the new residence; and 16) Packing and moving the service recipients belongings to the new home. 3.22. Transition Process for Non-Residential Services 3.22.a. Support Coordination/Case Management Responsibilities: When providers are changed for services other than residential services, the support coordinator/case manager is responsible for coordinating the transition to ensure that there is no interruption in services and to ensure that sufficient information is available to the receiving provider. Support coordination/case management responsibilities include: 1) Obtaining information and/or coordinating visits/interviews with potential providers to assist the service recipient and/or legal representative in making an informed choice in selecting a new provider; 2) Requesting assistance as needed from the DMRS Regional Office (see contact information in Appendix B) to identify potential new providers; 3) Facilitating any needed Planning Team meetings; 4) Completing and submitting any ISP amendments or updates required to transfer service provision to the selected receiving provider; 5) Updating the risk analysis for the purpose of addressing any risks associated with changing providers; 6) Notifying the transferring and receiving providers of the date that services will be discontinued by the transferring provider and assumed by the receiving provider; and

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 35

3
7) Facilitating communication between providers and the transfer of records as needed. 3.22.b. Continuation of Services during Transition: In the event that a provider change is initiated, the transferring provider must continue to provide services until the transition date unless otherwise directed by the DMRS Regional Director, Assistant Commissioner of Facility and Community Services or Deputy Commissioner. Termination of services of the transferring provider may be directed in situations where continuation of services is likely to result in serious health and safety issues. 3.22.c. Transition Requirements for Non-Residential Transferring Providers: Requirements include: 1) Attending any scheduled Planning Meetings to assist in amending/updating the ISP, unless the service recipient or legal representative objects; 2) Assisting in providing cross-training to receiving provider direct support staff as needed; 3) Obtaining a release of information signed by the service recipient or the service recipients legal representative which allows essential records to be transferred to the receiving provider if the transferring provider has responsibility for maintaining the comprehensive record; and 4) Ensuring that the record is copied and given to the designated person for transfer to the receiving provider on the transition date. 3.22.d. Transition Requirements for Non-Residential Receiving Providers: Requirements include: 1) Attending any scheduled Planning Meetings to assist in amending/updating the ISP; 2) Ensuring that staff are adequately trained prior to assuming services; and 3) Beginning provision of authorized services on the date of transition.

Provider Manual, Chapter 3 Individual Support Planning and Implementation Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

3- 36

5
CHAPTER 5 APPLICATION FOR PROVIDER STATUS

5.1.

Introduction Business entities (provider agencies) or individual practitioners who want to provide and directly bill for services within the Division of Mental Retardation Services (DMRS) system must undergo an approval and orientation process. Participant directed providers (e.g., personal assistance providers) who provide services under the self-direction of the participant through the Tennessee Self-Determination Waiver Program, as well as microboards, which are waiver service agencies that serve only one service recipient, shall also be required to sign a provider agreement and undergo the approval process. This process involves submission of an application form (available in Appendix D) accompanied by supplemental documentation demonstrating that all requirements are met for participation. There are several different types of application forms for different types of services. Different application forms (see Appendix D) include: 1) The Long Term and Respite Supports Application for residential, day, respite, behavioral respite and personal assistance service providers; 2) The Support Coordination Application for support coordination service providers; 3) The Behavior Services Application for behavior service providers; 4) The Clinical Services Application for nursing providers; physical therapy providers; occupational therapy providers: speech/language/hearing providers: nutrition providers; orientation and mobility providers: environmental accessibility modifications providers: vehicle accessibility modifications providers and specialized medical equipment and supplies and assistive technology service providers; 5) The Credentialing Form for Dentistry and Vision Providers; and 6) The General Services Provider Application for individual transportation providers, personal emergency response systems providers, supports brokerage providers, financial administration entities and all other service providers. Providers who want to provide different types of services are required to submit the applications for all the different types of services intended to be provided. For instance, a provider wanting to provide residential habilitation, supported living, behavior services

Provider Manual, Chapter 5 Application For Provider Status Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

5-1

5
and nursing services would need to submit the Long Term and Respite Supports Application, the Behavior Services Application and the Clinical Services Application. Once the provider is approved to participate in the DMRS provider network, a three-way provider agreement between DMRS, the Bureau of TennCare and the provider must be fully executed before the provider can be reimbursed for services rendered. 5.2. Obtaining an Application Packet Provider application packets may be obtained from the DMRS Central Office. As soon as is feasible, application packets will be available to prospective providers on the DMRS website. Contact information for obtaining an application packet is provided in Appendix B. 5.3. Submission of New Provider Applications 5.3.a. Requirements for Submission of Provider Applications: Provider applications are required when: 1) Approval as a new provider of services is needed; and 2) An existing provider undergoes a change of ownership. 5.3.b. Completing and Submitting the Application: The application packet contains a cover letter identifying DMRS staff to call with questions regarding completion of the application, an application form, instructions for completing the application form and a description of policies and other attachments that must be included with the completed application. Copies of the different types of DMRS application packets are provided in Appendix D. Applications are to be submitted to the DMRS Central Office where they will be routed to the appropriate staff for processing. Contact information for DMRS Central Office staff involved in processing applications is provided in Appendix B. 5.4. Processing Provider Applications Provider applications are processed by the appropriate DMRS Central Office Director or designee. For example, applications submitted by a potential provider of residential services are processed by the DMRS Residential Services Director or designee. When multiple services of different types are proposed, the potential provider is required to submit applications for each type of service being proposed. If the appropriate applications have not been submitted, the provider applicant will be contacted and asked to submit the additional application(s) needed. The application review process generally takes sixty (60) to ninety (90) calendar days, but could take longer if a provider applicant

Provider Manual, Chapter 5 Application For Provider Status Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

5-2

5
delays responding to requests for additional or corrected information. The application review process is as follows: 1) The application is received by the DMRS Central Office and routed to the appropriate Director; 2) The application is reviewed for completeness by the DMRS Central Office Director or designee and additional information is requested as needed via written correspondence to the provider applicant; 3) The provider applicant will have a maximum of six (6) months to respond to requests for additional information, at which time DMRS will send written notice indicating that the application process has been terminated due to failure to respond; 4) The results of a criminal background check completed by the Tennessee Bureau of Investigation (TBI), Federal Bureau of Investigation (FBI) or a state licensed private investigation company must be submitted to designated DMRS Central Office staff before the application can be processed; 5) Reference and background checks are completed/reviewed by the DMRS Central Office Director of Residential Services or designee; 6) Verification is obtained that the provider applicant has not been terminated, barred or suspended from participation in the Medicare or Medicaid program; 7) If the provider applicant currently operates or has recently operated in another state, information about the provider applicants performance history in that state is requested from the primary state agency that provides services to people with developmental disabilities and from the state Medicaid agency; 8) The completed application and supporting documentation is submitted to the appropriate DMRS Regional Office(s) for review and analysis; 9) A joint decision is made by appropriate DMRS Central and Regional Office staff on the basis of whether the application and supporting documentation contains information sufficient to determine that criteria for approval are met; 10) A recommendation for approval or denial of the provider application is made to the DMRS Deputy Commissioner; 11) Provider applicants approved are provided with a written notice of approval to provide services pending execution of a provider agreement; and 12) Provider applicants denied are provided with written notice of denial, including an explanation of the reasons for denial and a description of the opportunity to reapply. 5.5. Provider Approval Criteria 5.5.a. Basic Criteria for Provider Approval: The following criteria are applicable to any provider applicant, regardless of the type of services provided:

Provider Manual, Chapter 5 Application For Provider Status Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

5-3

5
1) The provider and/or the proposed executive director/chief executive officer must be of sound and reputable character and in good professional standing as determined by obtaining positive results from the following: The criminal background check; Verification of business license; Verification of required professional license(s); The Department of Health Elderly or Vulnerable Abuse Registry check(s); The Sexual Offender Registry check(s); The DMRS Substantiated Abuse and Neglect List check(s); and Personal reference checks (a minimum of three (3) references are required). 2) The provider applicant must have acceptable qualifications to provide the services proposed to people with developmental disabilities (see Table 5.5); 3) The provider applicant must not be terminated, barred or suspended from participation in the Medicare or Medicaid program; 4) There must be evidence of mechanisms to ensure that provider staff are qualified to deliver the proposed services, including verification of licensure/certification for any licensed/certified staff employed; 5) The provider must have general liability insurance; and 6) If transportation services are provided, the provider must ensure automobile liability insurance for any provider- or staff-owned vehicles used to transport service recipients. 5.5.b. Additional Criteria for Approval of New Long Term and Respite Supports Provider Applicants: In addition to the basic provider approval criteria listed in Section 5.5.a., the following criteria will apply when considering approval of residential, day, respite, behavioral respite or personal assistance provider applicants: 1) The providers philosophy of service provision must be consistent with that of DMRS; 2) The provider must demonstrate that the proposed organizational structure is sufficient to manage the proposed services; 3) There must be acceptable written policies submitted in accordance with DMRS requirements for provider policies (see Chapter 6); 4) The provider and/or proposed executive director/chief executive officer must have a successful history of providing similar services to people with developmental disabilities; 5) The provider and/or proposed executive director/chief executive officer must have knowledge of Social Security rules governing representative payees and must have experience in personal funds management;

Provider Manual, Chapter 5 Application For Provider Status Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

5-4

5
6) The provider must demonstrate the financial capacity to operate the services proposed with a minimum of two (2) months operational reserves or sufficient line of credit; 7) The provider must have a history of financial stability or the proposed executive director/chief executive officer must have a history of managing a similar business with a history of financial stability; 8) The provider must have formed or have plans to form a Board of Directors or Advisory Group comprised of local individuals residing in the state of Tennessee; and 9) There must be an acceptable Provider Administrative Plan that is inclusive of an internal quality assurance plan, a prevention plan, a management plan and a supervision plan. 5.5.c. Additional Criteria for Approval of Clinical Service and Behavior Service Providers: In addition to meeting basic criteria listed in Section 5.5.a., the following additional criteria must be met: 1) The providers philosophy of service provision must be consistent with that of DMRS; 2) The provider must demonstrate that the proposed organizational structure is sufficient to manage the proposed services; 3) There must be acceptable written policies submitted in accordance with DMRS requirements for provider policies (see Chapter 6); and 4) Any clinical service staff employed to provide services must not be listed on the Department of Health Elderly or Vulnerable Abuse Registry, the Sexual Offender Registry or the DMRS Substantiated Abuse and Neglect List. 5.6. Disposition of Provider Applications 5.6.a. Conditions of Approval: The applying provider may be approved for all services requested on the application or may be partially approved. Partial approval will be based upon information obtained in the application process, such as the amount of experience in providing similar services, the experience level of the executive director/chief officer or past performance in other states. Partial approval may involve approval of some, but not all of the services requested on the application. Partial approval may also involve approval in a limited geographical area or approval to provide services to a limited number of service recipients. Providers approved to provide residential and/or day services are automatically approved to provide transportation services unless they specifically indicate on the application that

Provider Manual, Chapter 5 Application For Provider Status Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

5-5

5
there is no intent to provide transportation services other than those that are required to be provided as a component of the residential/day service. 5.6.b. Denial of Applications Due to Unacceptable Executive Directors/Chief Executive Officers or Board Members: DMRS will not approve any provider application when the identified executive director/chief executive officer or any identified board member is an individual who has: 1) Been found guilty of criminal offenses adversely affecting a DMRS service recipient or other disabled person; 2) Been found to have a history of being directly responsible for retaliation against a service recipient, family member or staff member for reporting or being involved in a complaint, investigative or appeal process; 3) Been found to be directly responsible for Medicaid fraud or fraudulent activities against a state or federal agency; and 4) Been found to be directly responsible for a providers closure or termination of a DMRS provider contract due to negligence in performance of duties in a similar position of administrative responsibility. 5.6.c. Responding to Denial of an Application: Provider applicants will be afforded the opportunity to apply twice within a one year time period, beginning with the date of receipt of the initial application. DMRS decision in regard to denial of an application is final and cannot be appealed. 5.7. Requests for Expansion of Services 5.7.a. Expansion to a New Geographic Area: When providers initially request operation in one geographic area of the state or are limited to one region during the DMRS provider approval process, expansion to other regions may be requested at a later date. In such circumstances, reapplication will not be required, but approval must be obtained from DMRS. A letter of interest requesting expansion to a new region must be submitted to the DMRS Central Office (contact information provided in Appendix B). The providers performance history will be jointly reviewed by appropriate DMRS Central and Regional Office Staff. Based upon the review, recommendation will be made for approval or denial of the expansion request to the DMRS Deputy Commissioner. The performance history review will encompass any available DMRS or TennCare Quality Assurance (QA) survey reports, complaint and investigations data, licensure survey reports and financial audit reports. The provider will be notified in writing of the approval or denial of the expansion request.

Provider Manual, Chapter 5 Application For Provider Status Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

5-6

5
5.7.b. Expansion to Provide Additional Services: A provider with an existing provider agreement may be approved to provide additional services by submitting a letter of interest to the DMRS Central Office (contact information provided in Appendix B). Approval will be based on the providers performance history determined through review of any available DMRS and TennCare Quality Assurance (QA) survey reports, complaint and investigations data, licensure survey reports and financial audit reports. 5.7.c. Expansion of Home Care Organization Services: Licensed Home Care Organizations approved to provide professional services such as nursing or therapy services may request to provide personal assistance services by submitting a letter of interest to the DMRS Central Office (contact information provided in Appendix B). 5.7.d. Required Contents/Attachments to be Included with Letters of Interest for Expansion of Services: The following information must be included in the letter of interest or provided in an attachment: 1) Updated information regarding operational reserves; 2) Definitions of proposed services involved in the expansion request; 3) A development plan, including the geographic area within which services are to be offered, the new services to be offered, and/or the number of additional people to be served; 4) Revised supervision and quality assurance plans; 5) A list of current services provided; 6) A revised organizational chart; and 7) Job descriptions for new services. 5.7.e. Review of Expansion Requests: Expansion requests will be jointly reviewed by the Central and Regional Offices utilizing the DMRS Review of Expansion Requests Checklist (provided in Appendix D). In addition to reviewing the information submitted in and with the letter of interest, the review will include analysis of the providers quality assurance survey history, results of any fiscal or contract compliance reviews and information about complaints filed and investigations conducted involving the provider. 5.8. Licensure Requirements For new providers, DMRS provider approval may be required by the licensing entity before licensure can be obtained. In such circumstances, DMRS approval will be granted pending establishment of a provider agreement. Appropriate licensure must be obtained and verified by DMRS prior to establishing a provider agreement and rendering services. All provider types requiring licensure are licensed by either the Department of Mental

Provider Manual, Chapter 5 Application For Provider Status Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

5-7

5
Health and Developmental Disabilities or the Department of Health. Licensure requirements for different provider types are shown in Table 5.5 beginning on page 5-10. 5.9. Revoking a Provider Approval DMRS reserves the right to revoke a provider approval prior to executing the provider agreement. Revocation may occur if: 1) Evidence is discovered to support that false information was relied upon to approve the application; 2) Additional information is presented that affects the determination that any of the criteria for approval were met; or 3) The approved provider fails to obtain licensure within a year of the date provider approval was granted. Providers will receive written notice if approval is revoked, including an explanation of why the revocation is warranted. 5.10. Establishing a Provider Agreement 5.10.a. Establishing a New Provider Agreement: Once the provider application has been approved and any required licensure obtained, the provider must contact the appropriate DMRS Central Office Contract Services Unit to initiate development of the provider agreement. The provider cannot be paid for services rendered prior to the date the provider agreement is executed. The provider agreement is executed when all required signatures are obtained. The process for completing the provider agreement is as follows: 1) The provider agreement will be signed by DMRS and mailed to the provider for signature with forms that must be completed in order for the provider to bill for services rendered. The signed provider agreement must be returned to the DMRS Central Office Contract Services Unit by the provider with the completed forms, proof of licensure and a voided, blank check which is required to set up direct deposit of reimbursement. 2) All new providers are required to register on-line at the Service Provider Registry website (see contact information in Appendix F). 3) DMRS will obtain the remaining signatures needed from the Bureau of TennCare Deputy Commissioner and the Commissioner of the Department of Finance and Administration.

Provider Manual, Chapter 5 Application For Provider Status Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

5-8

5
4) DMRS will return a copy of the fully executed provider agreement to the provider. A copy of the provider agreement must be maintained on file at the providers main administrative office within the state of Tennessee. 5.10.b. Amending an Existing Provider Agreement: When a provider discontinues the provision of certain services or obtains approval to offer additional services before it is time to renew the current provider agreement, the provider agreement will be amended to correctly reflect the services being provided. Amendments to the provider agreement must be kept on file with the original provider agreement. 5.10.c. Referrals Following Establishment of a Provider Agreement: A provider agreement with DMRS and the Bureau of TennCare does not guarantee referrals to provide services to DMRS service recipients. DMRS service recipients have the right to choose any qualified provider of services with an executed provider agreement if the provider is willing and able to provide the needed services. DMRS service recipients may change providers at any time. 5.11. Provider Orientation 5.11.a. Provider Orientation for Independent Support Coordination and Long Term and Respite Supports Providers: A systems orientation program for new independent support coordination, residential, day and personal assistance providers is presented by DMRS Central Office staff. In addition, a regional provider orientation program is presented by staff in each Regional Office. It is required that the provider executive director, chief executive officer or other administrator responsible for executing contracts and board chair (as applicable) attend both the regional and systems orientation programs. A video presentation of the Central Office Provider Orientation is being developed to make board chair attendance more convenient. Central Office Provider Orientation is held every ninety (90) days. DMRS sends out written invitations to all providers who have been approved since the previous orientation session. Existing providers who wish to attend may contact the DMRS Central Office Director of Residential Services for information. 5.11.b. Provider Orientation for Clinical Service, Behavior Service, Respite/Crisis Respite and Other Providers: New providers of nursing, nutrition, behavioral, therapy services, respite/crisis respite or other services are invited to attend the Regional Office Provider Orientation presentation, which includes a Medicaid Waiver Overview developed by DMRS Central Office staff for presentation by the Regional Office. Attendance is mandatory. Regional Office Provider Orientation is scheduled as needed depending upon the number of providers approved in each region since the last orientation. Approved providers will receive an invitation with information about the

Provider Manual, Chapter 5 Application For Provider Status Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

5-9

5
time, date and location of Regional Office Provider Orientation. The Regional Offices also provide required orientation sessions for new behavior service providers. New behavior service providers are to contact the Regional Office Behavior Service Director to schedule this orientation session.

Provider Manual, Chapter 5 Application For Provider Status Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

5 - 10

Table 5.5
SERVICE Behavior Services PROVIDER TYPE Behavior Analyst LICENSURE Must be licensed by the Department of Mental Health & Developmental Disabilities, if applicable (TCA Title 33 Chapter 2) Must be licensed by the Department of Mental Health & Developmental Disabilities, if applicable (TCA Title 33 Chapter 2) Must be licensed by the Department of Mental Health & Developmental Disabilities, if applicable (TCA Title 33 Chapter 2) Must be licensed to practice in Tennessee (TCA Title 63 Chapter 6) Must be licensed to practice in Tennessee (TDH Rules 1180-1 and 1180-2; TCA Title 63 Chapter 11) Must be licensed by the Department of Mental Health and Developmental Disabilities (TCA Title 33 Chapter 2) Must be licensed by the Department of Mental Health and Developmental Disabilities (TCA Title 33 Chapter 2) Must be licensed to practice in Tennessee (TDH Rules 0460-1 and 0460-2). CERTIFICATION OTHER STANDARD

Behavior Specialist

Also see Provider Qualifications Section C entitled "Provider Requirements Applicable to Each Service.

Waiver Service Agency

Psychiatrist Psychologist

Day Services

Waiver Service Agency Individual (for staff-supported employmnet) Dentist (individual, group, or dental service agency) Individual carpenter or craftsman (including a family member) Waiver Service Agency Building Supplier Durable Medical Equipment Supplier

Dental Services

Environmental Accessibiliity Modifications

Modifications requiring the skill of a carpenter, electrician, plumber, or other craftsman must be made by persons with sufficient skills and training to meet state and local building codes and standards. Must have a business license in Tennessee.

Provider Manual, Chapter 5 Application For Provider Status Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

5 - 11

Table 5.5
SERVICE Environmental Accessibiliity Modifications Family Model Residential Support Individual Transportation Services PROVIDER TYPE Other Retail Business Local Contractor Waiver Service Agency Individual (including a family member) Waiver Service Agency Commercial Transportation Agency LICENSURE Must have a business license in Tennessee. Must be licensed by the Department of Mental Health & Developmental Disabilities (TCA Title 33 Chapter 2) Must have a valid driver's license for transport in Tennessee. All drivers must have a valid driver's license for transport in Tennessee. Must have a business license. All drivers must have a valid driver's license of appropriate type (e.g., personal, commercial) for transport in Tennessee. Must be licensed by the Department of Mental Health & Developmental Disabilities (TCA Title 33 Chapter 2) Must be licensed by the Department of Health (TDH Rule 1200-8-34); must be licensed to practice in Tennessee (TDH Rule 1000-1 and 1000-2). Must be licensed by the Department of Health (TDH Rule 1200-8-34). Must be licensed by the Department of Health (TDH Rule 1200-8-34). Must have a valid license to practice in Tennessee (TDH Rule 0470-1). Must have a valid license to practice in Tennessee (TDH Rule 0470-1). Must be licensed as a home health agency in Tennessee (TDH Rule 1200-8-8-.01). Must be licensed by the Department of Health (TDH Rule 1200-8-34). CERTIFICATION OTHER STANDARD

Must maintain acceptable liability insurance and have a safe driving record.

Medical Residential Waiver Service Agency Services Nursing Services Registered Nurse

Nutrition Services

Home Health Agency Waiver Service Agency Dietitian Nutritionist Home Health Agency Waiver Service Agency

An LPN must work under the supervision of a licensed RN.

Provider Manual, Chapter 5 Application For Provider Status Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

5 - 12

Table 5.5
SERVICE Occupational Therapy PROVIDER TYPE Occupational Therapist

Orientation and Mobility Training

Personal Assistance

OTHER LICENSURE STANDARD CERTIFICATION Must be licensed by the Department of Health (TDH Rule 1200-8-34); must have a valid license to practice in Tennessee (TDH Rule Occupational therapist assistants must 1150-2). work under the supervision of a Home Health Must be licensed by the Department of Health licensed occupational therapist. Agency (TDH Rule 1200-8-34). Waiver Service Must be licensed by the Department of Health Agency (TDH Rule 1200-8-34). Certified Orientation Must be licensed by the Department of Mental & Mobility Specialist Health & Developmental Disabilities (TCA Academy for Certification of (COMS) Title 33 Chapter 2) Vision Rehabilitation and Waiver Service Must be licensed by the Department of Mental Education Professionals. Agency Health & Developmental Disabilities (TCA Title 33 Chapter 2) Individual (as Must be licensed by the Department of Mental permitted by federal Health & Developmental Disabilities, if regulations) applicable (TCA Title 33 Chapter 2) Home Health Agency Waiver Service Agency Must be licensed as a home health agency in Tennessee (TDH Rule 1200-8-8-.01). Must be licensed by the Department of Mental Health & Developmental Disabilities (TCA Title 33 Chapter 2) Must have a business license in Tennessee.

Personal Emergency Personal Emergeny Response Response System Vendor System

All devices must meet Federal Communications Commission, Underwriters' Laboratory, or other equivalent standards and must be monitored by trained professionals.

Provider Manual, Chapter 5 Application For Provider Status Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

5 - 13

Table 5.5
SERVICE Physical Therapy PROVIDER TYPE Physical Therapist LICENSURE Must be licensed by the Department of Health (TDH Rule 1200-8-34); must have a valid license to practice in Tennessee (TDH Rule 1150-1). Must be licensed by the Department of Health (TDH Rule 1200-8-34). Must be licensed by the Department of Mental Health & Developmental Disabilities (TCA Title 33 Chapter 2) Must be licensed by the Department of Mental Health & Developmental Disabilities (TCA Title 33 Chapter 2) CERTIFICATION OTHER STANDARD

Residential Habilitation Respite

Home Health Agency Waiver Service Agency Waiver Service Agency Waiver Service Agency Medicaid-certified ICF/MR Licensed Respite Care Facility Individual Waiver Service Agency

Physical therapist assistants must work under the supervision of a licensed physical therapist.

Self-Determination Training & Consumer Education

Must have a high school diploma or GED. Must be licensed by the Department of Mental Health & Developmental Disabilities (TCA Title 33 Chapter 2)

Educational Facility Operated by the Department of Education Specialized Medical Durable Medical Equipment Supplier Equipment and Other Retail Supplies and Business Assistive Waiver Service Technology Agency

Any individual who is employed by, or under contract with, the waiver service agency to provide this service must have a high school diploma or GED.

Must have a wholesale or retail business license in Tennessee to sell equipment, supplies, etc.

Must honor relevant manufacturer's warranties or guarantees. Repairs must be made by persons with sufficient skills and training to perform the repairs in accordance with manufacturer's standards.

Provider Manual, Chapter 5 Application For Provider Status Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

5 - 14

Table 5.5
PROVIDER SERVICE TYPE Speech, Language & Speech Language Pathologist Hearing Services Audiologist Home Health Agency Waiver Service Agency Individual Support Coordinator Waiver Service Agency Individual Waiver Service Agency Auto Customization Shop or Repair Shop Mechanic Ophthamologist Optometrist Dispensing Optician Retail Business Selling Eyeglasses, Frames, or Lenses Must be licensed to practice in Tennessee (TCA Title 63 Chapter 6). TDH Rule 1045-2. Must be licensed to practice in Tennesee (TDH Rule 0480-1). Must have a business license in Tennessee. LICENSURE Must be licensed to practice in Tennessee (TDH Rule 1370-1); must be licensed by the Department of Health (TDH Rule 1200-8-34). CERTIFICATION

5
OTHER STANDARD An individual who is registered with the Tennessee Board of Communication Disorders and Sciences as currently completing the speech language pathology or audiology clinical fellowship year must work under the supervision of a licensed speech language pathologist or audiologist, as applicable. Also see Provider Qualifications Secton "C" entitled "Provider Requirements Applicable to Each Service".

Must be licensed by the Department of Health (TDH Rule 1200-8-34).

Support Coordination

Supported Living

Must be licensed by the Department of Mental Health & Developmental Disabilities (TCA Title 33 Chapter 2) Must have a business license in Tennessee. Any modification shall be made by individuals who possess sufficient skills and training to complete the modification.

Vehicle Accessibility Modifications Vision Services

Provider Manual, Chapter 5 Application For Provider Status Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

5 - 15

6
CHAPTER 6 GENERAL PROVIDER REQUIREMENTS
6.1. Introduction This chapter provides information about requirements that are applicable to providers rendering services within the Division of Mental Retardation Services (DMRS) service delivery system. Provider records and training are covered in individual chapters that follow, as the volume of information to be covered is more extensive than that related to the topics covered in this chapter. 6.2. Licensure Requirements Chapter 5 indicates that all providers who require licensure must obtain the appropriate license prior to establishing a provider agreement with DMRS. Required licensure for different provider types is listed in Table 5.5. It is required that providers maintain licensure for services offered at all times while services are being rendered within the DMRS system. Providers who have allowed licensure to lapse will not be reimbursed for services provided during the lapsed period. Providers will be required to show proof of current licensure during DMRS annual quality assurance surveys and during TennCare Quality Assurance surveys. Proof of licensure may be required during other external reviews or surveys, such as those conducted by the Centers for Medicare and Medicaid Services (CMS), the Tennessee Office of the Comptroller or the Tennessee Department of Health. 6.3. Personnel Requirements 6.3.a. Required Personnel Policies: Personnel policies are required if staff are employed by a provider. Personnel policies are not required of independent providers or when services are provided only by contracted staff in accordance with a DMRS approved subcontract. The following basic personnel policies are otherwise required to be submitted to DMRS before a provider receives initial approval to enter into a provider agreement. Basic personnel policies must be updated, maintained and implemented while a DMRS provider agreement remains in effect. Required personnel policies must address: 1) Procedures for hiring staff, including minimum staff qualifications for each staff position;

Provider Manual, Chapter 6 General Provider Requirements Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

6-1

6
2) Development and communication of job descriptions for each staff position; 3) Procedures for initiating and resolving employee complaints; 4) Requirements pertaining to utilization of employee-owned vehicles to transport service recipients, if applicable; 5) Procedures for initiating/employing progressive employee disciplinary actions, including, but not limited to, those related to Title VI non-compliance, drug-free workplace violations, and substantiation of staff abuse/neglect/exploitation of service recipients; 6) Procedures for staff termination, suspension and placement on the Department of Healths Tennessee Abuse Registry; 7) Procedures for tuberculosis testing in accordance with current Department of Health policy (see current Policy in Appendix I). 8) Procedures pertaining to drug-free workplace requirements. 6.3.b. Staff Requirements: The approved waiver documents list general requirements that are applicable to all provider-employed staff, subcontractors and their staff or independent providers. DMRS utilizes the same requirements for providers and staff and subcontractors rendering state-funded services. The general requirements are: 1) Staff must be at least eighteen (18) years of age; 2) Staff who have direct contact with or direct responsibility for service recipients must be able to effectively read, write and communicate verbally in English and must be able to read and understand instructions, perform record-keeping and write reports; 3) Staff responsible for transporting a service recipient must have a valid drivers license and automobile liability insurance of the appropriate type; 4) Staff who have direct contact with or direct responsibility for service recipients shall pass a criminal background check performed in accordance with Title 33; and 5) Staff who have direct contact with or direct responsibility for service recipients must not be listed on the Tennessee Abuse Registry, the Tennessee Sexual Offender Registry, or the Tennessee Felony Offender List. 6.3.c. Title 33 Requirements for Background Checks: In accordance with Title 33 (T.C.A. 33-2-1202), each provider must have a process for ensuring that statewide criminal background checks are performed for each employee, volunteer or subcontractor employee having direct contact with or direct responsibility for service recipients. The employee/job applicant or volunteer must be told that a criminal background check will be conducted. Prior to assignment or change of responsibilities involving direct contact with or direct responsibility for service recipients, certain information must be obtained from the employee/job applicant or volunteer and required information must be submitted

Provider Manual, Chapter 6 General Provider Requirements Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

6-2

6
to the entity conducting the criminal background check. Information to be obtained from the employee includes: 1) A work history inclusive of a continuous description of activities during the past five (5) years; 2) At least three (3) personal references, with one of the references having known the employee for at least five (5) years; 3) A release of investigative records to the provider for the purpose of verifying the accuracy of criminal violation information stated on the employment application; and 4) Either fingerprint samples for a criminal history background check conducted by the Tennessee Bureau of Investigation (TBI) or Federal Bureau of Investigation (FBI) or information for a criminal background investigation conducted by a Tennessee-licensed private investigation company. The TBI is now offering The Tennessee Applicant Processing Services System through Sylvan/Identix Fingerprint Systems. Interested providers should contact the TBI for additional information about this option. A current list of licensed private investigation companies in Tennessee can be accessed via the internet. Please see Appendix F for the current website address. 6.3.d. Additional DMRS Requirements Pertaining to Background Checks: In addition to Title 33 requirements for criminal background checks, DMRS requires the following pertaining to job applicants/employees and volunteers: 1) For any employee that has lived in Tennessee for one (1) year or less, a nationwide background check is required; and 2) Employees must be directly supervised and not left alone with service recipients until such time as background check results are available to the provider. 6.3.e. Reimbursement for Criminal Background Checks: criminal background checks will be made as follows: Reimbursement for

1) The provider requesting that a background check be conducted will pay the TBI, the FBI or the Tennessee licensed private investigation company. The TBI and FBI will be paid in accordance with the amounts established by T.C.A. 38-6103. 2) DMRS will provide reimbursement of criminal background checks only when: The provider has a current, signed DMRS Provider Agreement and is licensed by the Department of Mental Health and Developmental Disabilities;

Provider Manual, Chapter 6 General Provider Requirements Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

6-3

6
Background checks are done for employees whose responsibilities include direct contact with or direct responsibility for DMRS service recipients; Background checks are completed by the TBI, FBI or a Tennessee licensed private investigation company; The employee is hired by the provider to provide services funded by DMRS; and Funding is available for DMRS to provide payment up to the published maximums.

6.3.f. Title 33 Requirements for Employee Reference Checks: Work and personal references must be checked prior to employment of a job applicant. Requirements for reference checks are as follows: 1) At a minimum, the provider must directly communicate with the most recent employer and any employer who employed the job applicant for more than six (6) months within the past five (5) years; and 2) At a minimum, the provider must directly communicate with at least two (2) of the personal references provided by the job applicant. 6.3.g. Requirements Pertaining to the Continued Employment of Provider Staff: Requirements include: 1) The provider must employ a process for periodically evaluating the performance of staff; and 2) The provider must implement a written policy that ensures that employees do not continue to provide direct services or have direct responsibility for service recipients when the employee is convicted of criminal activity during employment (e.g., fraud, misappropriation of funds, breach of fiduciary duty) or if an employee is placed on the Department of Healths Tennessee Abuse Registry; 6.4. Provider Conflict Resolution Procedures Title 33 (TCA 33-2-602) requires that all providers licensed by the Department of Mental Health and Developmental Disabilities (DMHDD) develop and implement clear, written conflict resolution procedures. DMRS requires that conflict resolution procedures be developed for all providers who execute a DMRS provider agreement. Conflict resolution procedures are intended to address disputes that service recipients, families or legal representatives may have with the provider. Conflict resolution policies and procedures must be communicated to service recipients, family members, legal representatives, advocates, support coordinators/case managers and others who may initiate conflict resolution on behalf of the service recipient. Providers may not cease to provide services

Provider Manual, Chapter 6 General Provider Requirements Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

6-4

6
while conflict resolution is pending unless the service recipient agrees to select a new provider. Conflict resolution policies are to include: 1) A means to resolve conflict informally; 2) A description of the review process initiated when a conflict is identified or a complaint is presented; 3) Identification of staff responsible for decision making at each level of conflict resolution; 4) The time frames involved in each level of conflict resolution; and 5) The rights and responsibilities of the parties involved in the conflict resolution procedure. 6.5. Required Provider Policies In addition to the basic personnel policies listed in Section 6.3.a., certain other policies are required before approval can be granted for a DMRS provider agreement to be executed. These policies must be updated, maintained and implemented while a provider agreement with DMRS is in effect. Required policies must address: 1) Showing respect to service recipients during service delivery; 2) Protecting service recipients rights; 3) Using positive approaches with service recipients (required only if staff are responsible for direct support and supervision of one or more service recipients); 4) Obtaining emergency and/or urgent health care for service recipients (required only if staff are responsible for direct support and supervision of one or more service recipients); 5) Addressing health care needs specified in the individual transition plan (ITP) or individual support plan (ISP) (required only if staff are responsible for direct support and supervision of one or more service recipients); 6) Serving as an advocate for the service recipient and referring to external advocacy services as needed; 7) Taking appropriate action in emergency situations; 8) Maintaining a sanitary and safe environment, including fire safety precautions in provider offices, individual homes and other sites where services are delivered (required only if the service provider is responsible for maintaining a service delivery site or an office space visited by service recipients); 9) Managing and accounting for service recipient personal funds (required only if a provider manages service recipient funds); 10) Maintaining a well-trained workforce; 11) Managing and reporting incidents (see Chapter 18); 12) Maintaining Title VI compliance (see Chapter 2, Section 2.7.); and

Provider Manual, Chapter 6 General Provider Requirements Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

6-5

6
13) Maintaining and monitoring service recipients records, including compliance with confidentiality requirements and the Health Insurance Portability and Accountability Act (HIPAA) standards (see Chapter 8), supervisory reviews of records and organization/storage locations for record components (supervisory reviews of records are required only for providers responsible for maintaining the comprehensive and/or residential record). 6.6. The Provider Management Plan Providers of residential services, day services and/or personal assistance services are required to complete and follow a management plan. The management plan is a formal, written plan that describes how the provider conducts business to ensure successful operation and compliance with applicable program requirements. The plan describes how the provider implements policies and procedures to assure the health, safety and welfare of service recipients. 6.6.a. Required Components of a Management Plan: The required components of a Management Plan may differ depending upon the type of services provided. Basic components of the Management Plan include: 1) The providers mission statement and philosophy of service delivery; 2) An organizational chart if two (2) or more service recipients are provided services; 3) A description of service(s) offered by the provider; 4) Demographic information about the providers service recipient population; 5) Any criteria employed by the provider in determining whether services to a service recipient will be refused or terminated due to inability to ensure safe provision of services; 6) A list of any fees charged, categorized by service; 7) A staffing plan for each location (see Chapter 9, Section 9.8. for staffing plan requirements for residential providers and Chapter 10, Section 10.4.d. for staffing plan requirements for day service providers); 8) The geographic location where services are available; 9) A description of the Board of Directors or Local Advisory Group, including the composition of the board/advisory group, the names and occupations of board/advisory group members, the number of representatives from each geographic area served, the length of board/advisory group terms and the number of consumers/family member representatives; 10) Complaint resolution (grievance) procedures for service recipients and legal representatives/family members;

Provider Manual, Chapter 6 General Provider Requirements Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

6-6

6
11) A description of how service recipients health care needs will be managed (see Chapter 11); 12) A description of the providers process for self-assessment to determine strengths and weakness in delivery of services (see Section 6.6.b.); 13) A description of the providers internal quality assurance/quality improvement plan (see Section 6.6.c.); and 14) Policies and procedures targeted toward ensuring prevention of harm to service recipients (i.e. Prevention Plans in accordance with Chapter 18, Section 18.2). 6.6.b. Management Plan Components Applicable Only to Certain Provider Types: Additional Components of a Management Plan required for certain providers include: 1) For providers of transportation services or providers of services that include transportation as a component of the service, a description of the providers transportation system, including service recipient access to transportation (e.g., a description of how service recipients will be provided adequate access to transportation for medical appointments and other activities that may specified in the ISP); 2) For providers, including providers of paid conservatorship services, who assist in personal funds management or who manage funds on behalf of a service recipient(s), a description of how personal funds management policies are implemented to account for and prevent misuse of service recipients personal funds (see Section 6.10.); 3) For support coordination providers and other providers who employ staff who are responsible for supervision of a service recipient, a Supervision Plan (see Section 6.6.e.); 4) For providers who utilize unlicensed direct support staff to administer medications, a medication administration policy approved by DMRS. 6.6.c. Provider Self-Assessment: A providers self-assessment process ensures that an internal mechanism exists for ongoing review of the effectiveness of services provided. Self-assessment allows a provider to identify systemic issues and initiate corrective actions before such issues are discovered by the state and federal agencies responsible for monitoring service provision. Each provider is responsible for completion of selfassessment activities identified in the management plan and for evaluation/revision of self-assessment processes. The following components must be included in selfassessment activities completed throughout the year between DMRS annual QA surveys: 1) Monthly reviews to determine staff performance in assisting service recipients to complete action steps and/or progress toward outcomes; 2) Review of processes for updating service recipient records in a timely manner;

Provider Manual, Chapter 6 General Provider Requirements Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

6-7

6
3) Review of trends related to service recipient and family satisfaction with services provided; 4) Review of incident trends, including those related to medication errors and other health and safety factors; 5) Review of external monitoring reports for the previous twelve (12) month period; 6) Review of any sanctions imposed during the previous twelve (12) month period; 7) Review of personnel practices, including staff recruitment and hiring, staff training, and staff retention/turnover; 8) Review of processes intended to ensure timely access to health-related interventions, such as health care appointments and follow-up activities; 9) Review of trends related to high risk reviews; 10) Review of current policies and management plan(s), including success in implementing policies/plans and the degree to which policies/plans ensured compliance with program requirements; 11) Application of the current DMRS Quality Assurance Survey Tool to a sample of service recipients; and 12) Evaluation of the effectiveness of the management plan and modification as needed to achieve quality assurance and compliance outcomes.

6.6.d. Provider Internal Quality Assurance/Quality Improvement Plans: The quality assurance/quality improvement (QA/QI) plan is the mechanism for addressing the issues identified during the self-assessment process. The QA/QI plan is to be focused on resolution of systemic issues at the provider level. Systemic issues are those that affect or have the potential to affect a number of service recipients. The QA/QI plan specifies how any necessary systemic improvements will be made through a process which includes: 1) Analysis of the cause of any serious issues/problems identified (serious issues/problems are those that impact multiple service recipients or those that have health and safety consequences requiring medical treatment of one or more service recipients); 2) Development of observable/measurable quality outcomes related to resolving the causal factors; 3) Establishment of reasonable timeframes for implementation of quality initiatives; 4) Assignment of staff responsible for completion of actions and achievement of quality outcomes; and 5) Modification of policies, procedures and/or the management plan (potentially including the QA/QI plan) to prevent recurrence of issues/problems that were resolved.

Provider Manual, Chapter 6 General Provider Requirements Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

6-8

6
All provider staff should have access to the QA/QI plan and have a basic knowledge of what is included in the plan to ensure that implementation occurs from the direct service level all the way up to and including top management. 6.6.e. Evaluation of Provider Self-Assessment Activities and QA/QI Plans: DMRS will evaluate provider self-assessment processes and QA/QI plans based on: 1) Whether the required components of the self-assessment process were completed within the timeframe between annual QA surveys; 2) Whether self-assessment activities result in timely identification and correction of issues/problems; 3) Whether the QA/QI plan is clearly related to the issues and causal factors identified during self-assessment; 4) Whether the QA/QI plan is revised to address identified issues/problems in a timely manner; 5) Whether there is evidence that staff at all levels of the provider organization have access to and knowledge of the components of the QA/QI plan; 6) Whether staff are held responsible for completing assigned self-assessment and QA/QI activities and duties; and 7) Whether the results of the self-assessment activities and the QA/QI plan are made available in an understandable format to staff, service recipients, family members, the provider governing body and to other interested parties who request the information. 6.6.f. Supervision Plans: A supervision plan is required when a provider employs staff who are responsible for direct supervision of service recipients. Supervision plans address how the provider accomplishes major supervisory functions, including: 1) Ensuring that staff understand their job duties and performance expectations; 2) Ensuring that staff acquire the knowledge and skills needed to complete job duties and meet performance expectations; 3) Monitoring staff performance to ensure that performance issues are promptly identified and rectified by requiring or providing additional training, increased supervision, counseling, and/or appropriate disciplinary action; 4) Ensuring that a minimum of three (3) unannounced supervisory visits are conducted at each service site during each calendar month, including visits that monitor staff performance during sleep hours, on weekends and on holidays; 5) Developing and implementing policies that effectively control the incidence of employees having visitors, including family members, in a service recipients home that are not present based on the wishes of the service recipient(s);

Provider Manual, Chapter 6 General Provider Requirements Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

6-9

6
6) Developing and implementing policies that prevent employees from conducting personal business, such as running errands or attending to their children or other family members while on duty; and 7) Developing and implementing policies that ensure that service recipients homes are safe, clean and appropriately furnished. Providers are required to evaluate the effectiveness of the supervision plan and revise as necessary. 6.7. Provider Governance Not-for-profit providers are required to be governed by a board of directors. For-profit providers are required to have a local advisory group that provides input regarding the policies and procedures employed to direct the provision of services. 6.7.a. Requirements for Not-For-Profit Provider Boards of Directors: An appointed board of directors is expected to follow all applicable state and federal laws pertaining to not-for-profit corporations (Title 48 Chapters 51-68, accessible via a link on the DRMS website version of the manual). 1) If the Board of Directors is made up of out of state members, a local advisory group must be established that is comprised of Tennessee residents; 2) Minutes to all Board meetings will be recorded, inclusive of names of those present and description of all actions taken at the meeting; 3) Board meetings will be held at least quarterly and more frequently if needed to effectively discharge Board duties; 4) A quorum of Board members must be present for Board business to be conducted during a Board meeting; 5) Board members will be required to sign confidentiality agreements and the provider will be responsible for maintaining HIPAA compliance in presentation of information to board members; 6) Board members will be regularly provided with current information pertaining to: Provider fiscal status; Development and revision of operational policies, procedures and plans; Results of internal self-assessment activities; and Reports of compliance reviews conducted by external monitoring entities; 7) The board will be composed of individuals representing different community interest groups, including persons with disabilities and/or family members of people with disabilities;

Provider Manual, Chapter 6 General Provider Requirements Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

6-10

6
8) Board minutes will reflect presentation of service recipient/family input and consideration of the information presented in revising provider operational policies, procedures and plans as appropriate; 9) New Board members will attend an orientation within ninety (90) calendar days of appointment for the purpose of receiving information pertaining to: The duties and responsibilities of Board members; An introduction to the provider agency, including services provided and an overview of the providers mission, purpose, and operational goals/objectives; 10) All Board chairs will attend DMRS new provider orientation or view a DMRS orientation videotape presentation within ninety (90) calendar days of assuming office; 11) Policies will be developed and implemented to address conflict of interest between board members and the provider; 12) Board minutes will reflect that Board members are provided with a copy of the Title 48 requirements pertaining to conflict of interest or a copy of provider policies that reflect Title 48 conflict of interest requirements; 13) The Board will review, recommend revisions and approve the providers charter, bylaws, purpose, mission statement, goals/objectives and operational policies/procedures as needed; 14) The Board will review and take action to resolve in a timely manner any fiscal issues identified in provider financial statements (financial statements must be reviewed by the Board at least quarterly); 15) The Board will review and take action to resolve any issues identified through provider self-assessment or through external compliance/quality monitoring at least annually or more frequently if needed to ensure continued operation of the provider; and 16) The Board will appoint a chief executive officer to whom the Board will delegate the responsibility and authority to implement Board-approved policies/procedures/plans, direct provider day-to-day operations (e.g. personnel management and authorization of expenditures) and conduct annual selfassessment of provider performance. 6.7.b. Requirements for For-Profit Provider Local Advisory Groups: For-profit providers of residential, day, personal assistance and support coordination services must have a local advisory group. Requirements include: 1) Minutes to all advisory group meetings will be recorded, inclusive of the names of those present and a description of issues discussed and recommendations made; 2) Advisory group meetings will be held at least quarterly and more frequently if determined necessary to complete duties;

Provider Manual, Chapter 6 General Provider Requirements Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

6-11

6
3) The advisory group will be composed of individuals representing different community interest groups, including persons with disabilities and/or family members of people with disabilities; 4) Provider policies will support persons with disabilities and/or family members in attending advisory group meetings; 5) Advisory group members will be required to sign confidentiality agreements and the provider will be responsible for maintaining HIPAA compliance in presentation of information to advisory group members; 6) Providers will develop mechanisms for presenting input from service recipients and family members to advisory group members; 7) Advisory group meeting minutes will reflect presentation of service recipient/family input and consideration of the information presented in revising provider operational policies, procedures and plans as appropriate; 8) Advisory members are encouraged to attend orientation that includes an overview of provider operations and a description of the duties and responsibilities of advisory group members; 9) Advisory group members will be advised of the need to revise operational policies, procedures and plans and asked to provide input regarding changes; and 10) Providers will provide response to advisory group recommendations by incorporating recommendations into operational policies, procedures or plans or by documenting the reasons that recommendations were not acted upon. 6.8. Assuring Staff Sufficient to Provide Services and Adhering to Service Schedules Any provider who agrees to provide a direct service such as residential services, day services, personal assistance services, nursing services or therapy services must ensure that sufficient qualified and trained staff are available to provide the service in accordance with the staffing schedule or appointment time arranged. This applies to independent providers of service as well as providers who employ a number of staff for service provision. Provisions must be made for coverage of services and supervision of staff as required when independent providers or employees take periods of extended leave, when staff resign from employment or when staff are sick or are otherwise unable to come to work due to unexpected events or circumstances. The service recipients support coordinator or case manager and caregiver (as applicable) must be notified with as much advance notice as possible any time that a provider anticipates that expected/scheduled direct support staff services, such as personal assistance, may not be available. It is anticipated that provider and service recipient schedules may unexpectedly change for a number of reasons. Common courtesy should be observed in notifying the appropriate parties of such changes to avoid the frustration and cost associated with

Provider Manual, Chapter 6 General Provider Requirements Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

6-12

6
missed appointments. For instance, clinical and other service providers must ensure that provider direct support staff and/or family caregivers at the service recipients home or day service site are notified if services are to be rescheduled for a different time or date. Conversely, the service recipients direct support staff provider and/or family caregivers are expected to notify clinical and other service providers if an appointment needs to be rescheduled due to a change in the service recipients schedule. Notifications related to changes in provider or service recipient schedules should occur as soon as possible after the need to reschedule has been identified. 6.9. Provider Subcontracts Providers with an executed DMRS provider agreement must develop written subcontracts when any part or requirement of a service as defined by the service definition and provider agreement is rendered by individuals who are not directly employed (either as paid or volunteer staff) by the provider. DMRS providers must hold any subcontractor(s) to the same terms and conditions specified in the DMRS Provider Agreement. Providers relying upon subcontracted entities for the provision of services are fully responsible for any services provided by or with the assistance of the subcontractor. Provider subcontracts are to be submitted to DMRS Central Office for approval. Provider subcontracts are also subject to TennCare approval. A subcontract is provided in Appendix D. DMRS is currently finalizing a standard subcontract format which, once approved by TennCare, will be required to be used by DMRS providers when subcontracts are established. 6.10. Provider Responsibilities Pertaining to Personal Funds Management 6.10.a. Personal Allowance Funds: A service recipients personal allowance is that portion of personal funds that is reserved for the service recipients use for the purchase of personal items and that may not be applied to the cost of services. Personal allowance funds belong to the service recipient and are kept in the service recipients home. Personal allowance funds may be used to purchase clothing, grooming supplies, entertainment equipment, leisure activities refreshments during community activities or other personal items desired by the enrollee. DMRS provider requirements related to personal allowances include: 1) Providers will ensure that service recipients have access to personal funds at all times unless limitations to access are specified in the ISP; 2) Providers will encourage use of personal allowance funds to purchase personal items needed or desired by the service recipient; 3) Providers will ensure that personal allowance funds will not be allowed to accumulate in the service recipients home in excess of $100;

Provider Manual, Chapter 6 General Provider Requirements Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

6-13

6
4) Providers will assist in establishing checking or savings accounts for deposit of funds as requested by the service recipient in the service recipients name in a bank chosen by the service recipient; 5) Providers will monitor for and advise the service recipient or entity that assists with management of personal funds of accumulations of personal allowance funds that could result in loss of benefits (e.g., Medicaid or Social Security); 6) Providers will ensure that personal allowance funds transactions are posted no later than midday on the day following the date of the transaction; and 7) Providers will ensure that personal allowance records are reconciled on a monthly basis. 6.10.b. Responsibilities Related to the Support of Service Recipients in Managing Personal Funds: In accordance with TennCare policy, which specifies provider requirements related to personal funds management, provider responsibilities include: 1) Supporting service recipients who are capable of managing personal funds to the extent necessary; 2) Providing appropriate personal funds management training in accordance with the ISP for service recipients who desire greater involvement in management of personal funds but have skills deficits; 3) Assisting service recipients who are unable to manage personal funds to select another person to act on their behalf (e.g., enrollees receiving Social Security may complete forms to designate a Representative Payee); and 4) Assisting legal representatives of service recipients in making an informed decision regarding whether to manage the service recipients personal funds or select a person or entity to act in the service recipients behalf. 6.10.c. Provider Responsibilities Related to Selecting and Serving as a Service Recipients Representative Payee: In accordance with TennCare policy which specifies provider requirements related to personal funds management, provider responsibilities include: 1) Making a reasonable effort to identify a responsible Representative Payee who is a family member or friend; 2) Agreeing to serve as a service recipients Representative Payee only if another responsible party cannot be identified; 3) Refraining from requiring an enrollee to designate the provider as Representative Payee for any reason, including requiring such designation as a condition of providing services; 4) Refraining from charging a funds management fee when selected as a service recipients Representative Payee; and

Provider Manual, Chapter 6 General Provider Requirements Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

6-14

6
5) Including the name of the legal representative and the circumstances of appointment on the Social Security Administration application form (Form SSA11, page 1, item 5) so the legal representative may be contacted if necessary. 6.10.d. Requirement for Development of Personal Funds Management Policies: In accordance with TennCare policy, providers, including providers of paid conservatorship services, who assist in management of personal funds or manage personal funds on behalf of any service recipient shall develop and implement written policies and procedures to protect personal funds. Policies shall indicate that the ISP will specify the extent to which a provider is entrusted with management of personal funds. 6.10.e. Provider Prohibitions Related to Personal Funds Management: Provider prohibitions include: 1) Providers and their employees, representatives, and subcontractors and paid conservators are prohibited from illegally obtaining or otherwise misusing personal funds, including but not limited to: Borrowing personal funds from the service recipient; Using a service recipients personal funds for staff benefit (e.g., purchasing premium cable channels for staff entertainment or purchasing tickets for staff attendance to activities or events selected based on staff preference rather than the service recipients preference); Using a service recipients personal funds for provider benefit such as using service recipient funds to pay for maintenance or repair of property such as buildings, building grounds, equipment, or appliances owned by the provider, for telephone charges other than those attributed to the service recipients personal phone use, or for office space intended for provider use; Using one enrollees funds for the benefit of another person; Using personal funds for any medical supplies, services or equipment covered by TennCare, Medicaid, Medicare or other health insurance; Giving or withholding an enrollees personal funds for the purpose of rewarding or punishing the enrollee unless specifically approved by a human rights committee and specified in the Independent Support Plan; and Otherwise using an enrollees personal funds for purposes that do not benefit the enrollee; 2) Providers are prohibited from commingling personal funds belonging to different service recipients; 3) Providers are prohibited from allowing negative bank balances to occur for service recipient accounts;

Provider Manual, Chapter 6 General Provider Requirements Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

6-15

6
4) Providers are prohibited from the purchase of insurance policies with service recipient funds when the insurance policies are not for the sole benefit of the enrollee; and 5) Providers are prohibited from requiring the purchase of home liability insurance policies as a condition of receiving services. 6.10.f. Provider Requirements Pertaining to Personal Funds Management: Provider requirements include: 1) Providers will reimburse service recipients for telephone or other utility expenses attributable to agency administrative use; 2) Providers will have written policies addressing how personal funds will be maintained, secured and safeguarded, including limitations on staff access to personal funds; 3) Providers will ensure that individual personal allowances kept in the home are maintained separately and are not treated as household petty cash (If a single locked box is used, the personal allowances must be kept in separate labeled envelopes within the box.); 4) Providers will ensure that separate ledgers are kept for each service recipient, including beginning and ending balances for each month and description of any expenditures (with supporting receipts for expenditures exceeding $4.99); 5) Providers will ensure maintenance of separate bank accounts for each service recipient; 6) Providers will ensure documentation of monthly reconciliation of bank statements, checks and deposits; 7) Providers will ensure timely reimbursement (not to exceed thirty (30) calendar days) to the service recipient following identification of a financial loss to the service recipient caused by the action or inaction of the provider or the providers employee, representative or subcontractor, including but not limited to: Loss of Social Security funds due to the providers negligence in allowing countable assets to exceed the countable asset limit; Payment of bank fees for insufficient funds that result from provider negligence; Late payment penalties to utilities; and Payment of expenses that do not directly benefit the enrollee; 8) Providers will develop and implement adequate accounting procedures for management of service recipients personal funds to assure consistent availability of current information involving: The amount of financial resources available to each service recipient for basic living expenses and for personal spending;

Provider Manual, Chapter 6 General Provider Requirements Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

6-16

6
The amount of total countable assets (For Medicaid funded service recipients, personal assets exceeding maximum resource limits must be reported to the Department of Human Services); and Documentation (e.g., receipts, monthly billings, checkbook ledgers) of expenditures made on behalf of the service recipient, including justification that the purchase was appropriate and in accordance with the service recipients needs; 9) Providers will ensure that service recipient protections are developed and implemented to prevent improper expenditures of personal funds for insurance policies; 10) Providers will ensure that all personal funds and personal property are appropriately inventoried or accounted for, including: Initial inventories of personal property compiled as of the date the provider began providing services; Timely updating of inventories of personal property to indicate personal property removed from or brought into the home, including dated signatures of the individuals who purchased or supplied the personal property; and Timely updating of personal fund or personal allowance ledgers to indicate funds provided to the service recipient by others, including dated signatures of the individuals who supplied the funds; 11) Providers will ensure that personal property and personal funds are efficiently and effectively transferred in a timely manner to the new provider when a change of providers occurs (e.g., due to provider agency closure), including but not limited to the following: The transferring provider shall reconcile records pertaining to personal funds management (e.g., personal allowance ledgers for petty cash, checkbooks, etc.); Except as otherwise required by social security requirements, the transferring provider shall forward any personal allowance cash balances to the receiving provider within five (5) business days (If the 5th working day falls on a state or federal holiday, transfers shall be completed on the next business day.); The transferring provider shall provide the receiving provider with an inventory of the enrollees personal property, as well as the actual personal property if a change in location is necessary; The receiving provider shall conduct an initial inventory of all personal property received and shall immediately notify the transferring provider and the support coordinator/case manager if there are any discrepancies between personal property received and personal property noted on the transferring providers inventory;

Provider Manual, Chapter 6 General Provider Requirements Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

6-17

6
Except as otherwise required by the Social Security Administration, the receiving provider shall complete arrangements to transfer benefit payments (e.g., food stamp payments) within five (5) business days (If the 5th working day falls on a state or federal holiday, transfers must be completed on the next business day.); and If applicable, the receiving provider must complete and submit documents necessary to establish the receiving provider as the representative payee within thirty (30) calendar days (If the 30th day falls on a federal holiday, submission may occur on the next business day.).

6.11.

Implementation of the Individual Support Plan (ISP) Providers are required to implement the ISP, including ensuring staff training as needed to ensure appropriate implementation. Providers who employ direct support staff are required to ensure that such staff implement any staff instructions necessary to the completion of ISP action steps or achievement of ISP outcomes, even if such staff instructions are primarily written by other providers (i.e. therapists or behavior service providers). It is expected that when staff instructions are determined necessary, providers will collaborate/cooperate in developing staff instructions and providing training/support to ensure that staff appropriately implement the instructions provided. Providers are required to document implementation of the ISP, including progress in completing action steps and achieving outcomes. Providers are expected to take advantage of teachable moments that occur during the course of daily life. Teachable moments are opportunities to include the service recipient in meaningful activities that occur throughout the day that may or may not be detailed in the ISP. Examples of such activities may include assisting staff to prepare meals or plan menus, assisting staff with household duties such as washing clothing or helping to schedule activities.

6.12.

Notification of DMRS of Changes in Provider Information Providers are required to notify the DMRS Central Office of : 1) 2) 3) 4) 5) Change in provider office address, telephone or fax numbers; Change of provider chief administrative officer; Change of Board chair; Changes in services offered; and Changes of address for service recipients (applicable only to the provider identified as being the primary provider).

Provider Manual, Chapter 6 General Provider Requirements Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

6-18

6
6.13. Electronic/Computer Capability Requirements and Considerations 6.13.a. Provider Requirements: It is DMRS intention to conduct business with providers through electronic means to the extent possible. Consequently, providers are required to: 1) Maintain e-mail accounts that, at minimum, is accessible to the executive director/chief executive officer and Board Chair (if applicable); 2) Have access to the internet, at least at the providers administrative office(s); 3) Provide basic computer skills training to any staff who will be expected to communicate electronically or provide or access electronic information to or from DMRS; 4) Submit required reports, data, forms, billing documents and other information electronically through business applications/systems provided or designed by DMRS; and 5) Maintain an electronically secure environment in compliance with the Security Rule of HIPAA (CFR, Title 45, Parts 106 and 164), including ensuring that email communications and attachments containing personal health information are encrypted when transmitted across the Internet. 6.13.b. Electronic Signatures: Electronic signatures are not acceptable at this time on records pertaining to service recipients enrolled in a Medicaid waiver.

Provider Manual, Chapter 6 General Provider Requirements Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

6-19

7
CHAPTER 7 GENERAL PROVIDER REQUIREMENTS PROVIDER TRAINING

7.1.

Introduction Provider staff must have adequate and appropriate training to ensure efficient management and operation as a business entity, to implement staff instructions, to complete Individual Support Plan (ISP) action steps, to assist the service recipient to achieve ISP outcomes and to ensure the general health, safety and welfare of service recipients. DMRS has standardized training requirements and developed training programs intended to enhance the quality of services and supports. The training requirements specified in this chapter apply to all providers who contract with DMRS to provide waiver or state-funded services, unless otherwise specified. Training for Family Support and Early Intervention providers is not addressed in this manual. The DMRS Training Plan contains information regarding the specific requirements for each training curriculum. The Training Plan is available on the DMRS website (see website address in Appendix F) Each DMRS training curriculum includes a course guideline that addresses: 1) 2) 3) 4) 5) 6) Course objectives; Training methodology; Training hours required for course completion; Documentation requirements; Testing methodology; and Course evaluation requirements.

7.2.

General Provider Training Requirements 7.2.a. Training Phases and Timeframes: There are three phases of minimum required training that must be completed by staff involved in the provision of services to service recipients. The three training phases are: 1) Phase 1 (Pre-service Training): Phase 1 or Pre-service Training is the initial training that must be completed within thirty (30) days of employment and before

Provider Manual, Chapter 7 Provider Training Division of Mental Retardation Services , State of Tennessee Published March 15, 2005

7-1

7
working alone with any service recipient. Prior to completion of Pre-Service Training, the newly-employed staff person must be accompanied by a trained staff person who assumes the responsibility for providing direct services. A person who has completed CPR (cardiopulmonary resuscitation) training must be readily available and accessible at all times. Pre-Service Training courses are shown in Table 7.2. 2) Phase 2 (Core Training): Phase 2 or Core Training must be completed within sixty (60) days of employment. Staff may work alone with service recipients while completing Core Training courses; however, staff are not to administer medication until Medication Administration training is completed. Core training courses are shown in Table 7.2. 3) Phase 3 (Refresher Training): Phase 3 or Refresher Training must be completed annually, to ensure that staff maintain current knowledge of the content offered in certain required training programs. Refresher courses are shown in Table 7.2. Table 7.2. Training Phases and Required Courses Training Phase 1. Pre-Service Training Courses 1) 2) 3) 4) 5) 6) 7) 8) 1) 2) 3) 4) 5) CPR First Aid Fire Safety and Evacuation Abuse Prevention Protection from Harm Introduction to MR/DD Training Specific to the Needs of the Individual Universal Precautions

2. Core

Independent Support Coordination Individual Rights and the ADA ISP Overview ISP Implementation Medication Administration (for staff expected to administer medications) 6) Quality Behavioral Health Supports 7) Sensitivity Training 8) Title VI Training

Provider Manual, Chapter 7 Provider Training Division of Mental Retardation Services , State of Tennessee Published March 15, 2005

7-2

7
Training Phase 3. Refresher (Annual) Training Courses 1) 2) 3) 4) 5) 6) CPR First Aid Abuse Prevention Protection From Harm Sensitivity Training Title VI Training

7.2.b. Training Specific to the Needs of the Individual: Providers are responsible for providing training specific to the needs of each service recipient. This training is required initially during Pre-service Training; however, ongoing training is expected as the service recipients needs change. The focus of initial training is the provision of specific information that staff must know about the service recipient to be able to provide services and supports in the most effective manner. It is crucial that staff be given basic information about the service recipients interests, fears, preferences and communication style, as well as, the supports needed to perform daily activities. It is equally important that staff acquire any skills training needed to provide services. The specific skills needed are unique for each person and will be specified in the ISP. Ensuring staff proficiency in performing skills could necessitate training related to implementing mealtime practices or positioning techniques, using assistive devices or specialized equipment, completing health monitoring procedures or preventative health measures and/or implementing a behavior support plan or providing positive behavior supports. Ongoing training involves making staff aware of changes in ISP outcomes and action steps and providing revised staff instructions as needed. Ongoing training also involves ensuring that any skills training is provided as needed for staff to implement new/revised action steps or staff instructions. 7.2.c. Other Required Trainings: Table 7.4. lists a number of required training programs in a category titled Other, including the following: 1) 2) 3) 4) 5) 6) Challenges in Physical Management; Mealtime Challenges; Enhancing Independence Through Physical Management; Enhancing the Mealtime Experience; Job Coach Training; and Central and Regional Office Orientation.

Provider Manual, Chapter 7 Provider Training Division of Mental Retardation Services , State of Tennessee Published March 15, 2005

7-3

7
Job Coach Training is required only for direct support staff who work in the role of a job coach. Training must be completed prior to a direct support staff person performing job coaching duties independently. Challenges in Physical Management, Mealtime Challenges, Enhancement in Physical Challenges and Enhancement in Mealtimes are required for clinical service practitioners who provide direct therapy and other clinical services. These training courses are required to be completed within sixty (60) calendar days of employment. 7.2.d. Successful Completion of Training Courses: Training required by DMRS is competency based. This means that the staff person completing the training course has to demonstrate knowledge of the content offered during the training by passing a test or demonstrating the ability to perform a task. Tests that must be passed are referred to as course evaluations. A person must complete course evaluations with a minimum score of 80%. If the minimum score is not achieved, retraining and retesting are required. Unless specifically required to maintain compliance with the Americans with Disabilities Act (ADA), staff shall not train and test for the same course on more than two (2) occasions within a one (1) year period. 7.2.e. Completing Training Within Required Time Frames: For purposes of determining whether training was provided on a timely basis, the employment date will be the first day the employee is paid for either attending required training courses or performing work duties. For Refresher Training, the date training is due is calculated from the date of the initial or most recent date of training for each of the required courses. 7.3. Provider Business Entities and Staff Titles Providers may operate as different types of business entities in providing services within the DMRS system. The titles of staff performing basically the same functions may differ, depending upon the type of business entity with which they are employed. For instance, a person who assists with activities of daily living such as eating, bathing, dressing, etc., may be called a direct support staff person by a residential provider and be called a Certified Nursing Assistant (CNA) by a home care organization. Provider business entities may be called: 1) Service Agencies (including Microboards and Respite Care Providers); 2) Independent Support Coordination Agencies; 3) Home Care Organizations (including Home Health Agencies or Professional Support Services Agencies); or 4) Independent Providers.

Provider Manual, Chapter 7 Provider Training Division of Mental Retardation Services , State of Tennessee Published March 15, 2005

7-4

7
7.3.a. Service Agencies: Service agencies, typically provide residential and/or day services. In addition to residential and/or day services, service agencies may also provide a number of ancillary services, such as nursing services, therapy services, nutrition/dietary services, environmental modifications and/or behavior services. Such ancillary services may be provided by staff employed by or contracted with the service agency. Some service agencies may also provide a single service within the DMRS system, such as orientation and mobility training. Microboards are a type of non-profit service agency that is set up to manage and provide services to one service recipient. Microboards are typically set up by service recipients and their family members. Microboard members are generally the service recipient, family and friends and others from the community that are asked to participate. A microboard can be described as being somewhat like having a Circle of Support that is in charge of operating and managing all services needed by the service recipient. Microboards must meet the same training and other requirements as other service agencies. Microboards may hire staff directly to meet the service recipients needs or may contract with other providers for provision of some or all of the services needed. A respite care provider is an individual or agency who provides short term services (thirty days or less for standard respite) for the purpose of relieving a family member or other caretaker when events/activities are scheduled or when emergency situations arise. Respite care providers may operate as a service agency providing only respite services; however, that is generally not the case. Typically, a service agency will obtain several different types of licensure allowing provision of an array of service options, including respite. A service agency may then utilize existing direct support staff or initiate a shortterm contract with a family member or other individual within the community to provide respite in a service recipients usual residence when needed. The service recipient may also need respite in a different location provided by a respite care provider contracted with or employed by a service agency or respite care provider. Behavioral respite services may be provided when the service recipient experiences a behavioral crisis that necessitates removal from the current residential setting in order to resolve the behavioral crisis. Behavioral respite services may be provided in an ICF/MR, in a licensed respite care facility or in a home operated by a licensed residential provider. 7.3.b. Independent Support Coordination Agencies: Independent support coordination agencies function for the purpose of providing support coordination as defined in Chapter 4. State-employed case managers will be required to complete the same training courses specified for support coordinators.

Provider Manual, Chapter 7 Provider Training Division of Mental Retardation Services , State of Tennessee Published March 15, 2005

7-5

7
7.3.c. Home Care Organizations: The term home care organization, may be used to refer to a agency that provides home health, hospice or home medical equipment services to Medicaid and Medicare recipients, including Medicaid waiver service recipients. A home care organization may also be licensed as a professional support services agency that provides nursing and therapy services within the DMRS system. Home care organizations may also provide personal assistance and respite services as defined in Chapter 16. 7.3.d. Independent Providers: Independent providers typically are licensed professionals who obtain professional support services licensure to practice independently or establish contracts with other providers licensed to provide professional support services to render a specific type of service. Independent providers may be registered nurses, personal assistants, orientation and mobility clinicians, speech/hearing/language therapists, physical therapists, occupational therapists, nutritionists/dieticians or behavioral analysts/specialists. Independent providers may also be direct support staff employed by service recipients in the Tennessee Self Determination Waiver Program. 7.4. Staff Categories and Training Requirements Staff will be described in terms of functional responsibilities for purposes of describing training requirements. Staff will be considered to fall within one of the following categories: 7.4.a. Direct Support Staff: Direct Support Staff are staff who provide direct, face-toface assistance to service recipients as specified in ISP action steps or individualized staff instructions on a routine or as needed basis. Personal assistants perform the same basic functions as direct support staff, but rather than being employed by a service agency to provide day or residential services, a personal assistant may work for a service agency or home care organization to provide personal assistant services to service recipients living in a family home. A Personal Assistant who works for a home health agency is generally called a Certified Nurse Aid or Technician (CNA/CNT). Direct Support Staff job titles/positions may include: 1) 2) 3) 4) 5) 6) 7) 8) Personal Assistant; Job Coach or Employment Support Staff; Relief, Floating, Temporary or Substitute Staff; Day or Residential Direct Support Staff or Direct Support Professionals; Certified Nurse Aid or Technician (CNA, CNT); Family-based Provider; Respite Care Provider or Staff; or Van Driver or Transportation Staff.

Provider Manual, Chapter 7 Provider Training Division of Mental Retardation Services , State of Tennessee Published March 15, 2005

7-6

7
Training requirements for direct support staff are shown in Table 7.4.a. Training requirements other than training specific to the needs of the individual are not applicable in situations where emergency respite or behavioral respite must be arranged due to sudden and unexpected absence of a caregiver (e.g., due to death, hospitalization, desertion, etc.); there is no trained respite provider or staff available; and a family member, neighbor or friend must be engaged to provide immediate one-time, short-term respite services. Table 7.4.a. Direct Support Staff Training Requirements Training Phase Pre-Service (within 30 days of employment) Training Course CPR (including Heimlich) First Aid Fire Safety and Evacuation Abuse Prevention Protection from Harm Introduction to MR/DD Training Specific to the Needs of the Individual Universal Precautions ISP Implementation ISP Overview Individual Rights and the ADA Medication Administration (cannot administer medication until training is complete) Quality Behavior Health Supports Sensitivity Training Title VI CPR (including Heimlich) First Aid Abuse Prevention Protection from Harm Sensitivity Training Title VI Job Coach (only if providing Job Coach services)

Core (within 60 days of employment)

1) 2) 3) 4) 5) 6) 7) 8) 1) 2) 3) 4) 5) 6) 7) 1) 2) 3) 4) 5) 6) 1)

Annual Refresher

Other

Provider Manual, Chapter 7 Provider Training Division of Mental Retardation Services , State of Tennessee Published March 15, 2005

7-7

7
7.4.b. Provider Administrative or Managerial Staff: Administrative/Managerial Staff are staff whose responsibilities include management of all aspects of the business entity providing services. Job titles include 1) 2) 3) 4) Executive Director; Chief Executive Officer; Principle Administrator; or Chief Financial Officer.

Administrative/managerial staff training requirements are shown in Table 7.4.b. Table 7.4.b. Administrative/Managerial Staff Training Requirements Training Phase Pre-Service (within 30 days of employment) Core (within 60 days of employment) Annual Refresher Training Course Fire Safety and Evacuation Abuse Prevention Protection from Harm Individual Rights and the ADA Sensitivity Training Title VI Abuse Prevention Protection from Harm Sensitivity Training Title VI Central Office Orientation Regional Office Orientation

Other

1) 2) 3) 1) 2) 3) 1) 2) 3) 4) 1) 2)

7.4.c. Program Support Staff: Program Support Staff responsibilities do not necessarily include the provision of direct services, but do include the oversight, supervision or support of staff with direct support responsibilities. Program Support Staff job titles may include: 1) 2) 3) 4) 5) 6) Residential, House or Group Home Manager; Social Worker or Case Manager; Residential Coordinator; Supported employment or Follow-Along coordinator; Assistant director; Program coordinator;

Provider Manual, Chapter 7 Provider Training Division of Mental Retardation Services , State of Tennessee Published March 15, 2005

7-8

7
7) Workshop supervisor; or 8) Incident Management Coordinator. Training requirements for program support staff are shown in Table 7.4.c. Table 7.4.c. Program Support Staff Training Requirements Training Phase Pre-Service (within 30 day of employment) Training Courses Fire Safety and Evacuation Abuse Prevention Protection from Harm Universal Precautions ISP Overview (as Social Worker or Case Managers) ISP Implementation Individual Rights and the ADA Quality Behavior Supports Sensitivity Training Title VI Abuse Prevention Protection from Harm Sensitivity Training Title VI

Core (within 60 days of employment)

Annual Refresher

1) 2) 3) 4) 1) 2) 3) 4) 5) 6) 1) 2) 3) 4)

7.4.d. Administrative Support Staff: Administrative support staff typically perform functions necessary to the operation of the provider business entity that do not involve direct contact with service recipients. Administrative support staff job titles may include: 1) 2) 3) 4) 5) Cook or Dietary Staff; Maintenance Staff or Custodian; Personnel Director; Bookkeeper or Accountant; or Secretary or Administrative Assistant.

Training requirements for administrative support staff are shown in Table 7.4.d.

Provider Manual, Chapter 7 Provider Training Division of Mental Retardation Services , State of Tennessee Published March 15, 2005

7-9

7
Table 7.4.d. Administrative Support Staff Training Requirements Training Phase Pre-Service (within 30 day of employment) Core (within 60 days of employment) Annual Refresher Training Courses Fire Safety and Evacuation Abuse Prevention Individual Rights and the ADA Sensitivity Training Title VI Abuse Prevention Sensitivity Training Title VI

1) 2) 1) 2) 3) 1) 2) 3)

7.4.f. Clinical Services Staff: Clinical services staff are professional and/or licensed staff who are either employed or contracted by a provider to provide professional/clinical services to service recipients. Clinical services staff may be a sole independent provider licensed as a professional support services agency or may be professional staff contracted or employed by a service agency or home care organization. Such clinicians/professionals may include: 1) 2) 3) 4) 5) 6) Physical or Occupational Therapists; Speech Language Pathologists or Audiologists; Orientation and Mobility Specialists; Nutritionists or Dietitians; Behavior Specialists or Analysts; and Registered or Licensed Practical Nurses.

Training requirements for clinical services staff are shown in Table 7.4.f. Table 7.4.f. Clinical Services Staff Training Requirements Training Phase Pre-Service (within 30 day of employment) Core (within 60 days of employment) Training Courses Abuse Prevention Protection from Harm ISP Overview Sensitivity Training Title VI

1) 2) 1) 2) 3)

Provider Manual, Chapter 7 Provider Training Division of Mental Retardation Services , State of Tennessee Published March 15, 2005

7 - 10

7
Training Phase Annual Refresher 1) 2) 3) 4) 1) 2) 3) 4) Training Courses Abuse Prevention Protection from Harm Sensitivity Training Title VI Challenges in Physical Management Mealtime Challenges Enhancing the Mealtime Experience Enhancing Independence Through Physical Management

Other Discipline Specific

Other Required Training By Specific Discipline Training Phase Occupational Therapy Physical Therapy Speech and Language Training Courses Challenges in Physical Management Mealtime Challenges Challenges in Physical Management Mealtime Challenges Mealtime Challenges Enhancing Independence Through Physical Management 1) Enhancing the Mealtime Experience 2) Enhancing Independence Through Physical Management 1) 2) 1) 2) 1) 2)

Dietitian Orientation and Mobility

7.4.e. Support Coordinators: Independent Support Coordinators (ISC) are staff employed by a support coordination provider to perform functions as specified in the Support Coordination definition provided in Chapter 4. Training requirements for support coordinators are shown in Table 7.4.e. Table 7.4.e. Training Requirements for Administrative/Managerial Staff in Independent Support Coordination Agencies Training Phase Pre-Service (within 30 day of employment) Core (within 60 day of employment) Training Courses Introduction to MR/DD Abuse Prevention Protection from Harm Independent Support Coordination Individual Rights and the ADA

1) 2) 3) 1) 2)

Provider Manual, Chapter 7 Provider Training Division of Mental Retardation Services , State of Tennessee Published March 15, 2005

7 - 11

7
Training Phase 3) 4) 5) 6) 1) 2) 3) 4) 1) 2) Training Courses ISP Implementation Quality Behavior Health Supports Sensitivity Training Title VI Abuse Prevention Protection from Harm Sensitivity Training Title VI Central Office Orientation Regional Office Orientation

Annual Refresher

Other

Training Requirements for Independent Support Coordinators Training Phase Pre-Service (within 30 day of employment) Core (within 60 days of employment) Training Course Introduction to MR/DD Abuse Prevention Protection from Harm Independent Support Coordination Individual Rights and the ADA ISP Implementation Quality Behavior Health Supports Sensitivity Training Title VI Abuse Prevention Protection from Harm Sensitivity Training Title VI

Annual Refresher

1) 2) 3) 1) 2) 3) 4) 5) 6) 1) 2) 3) 4)

Training requirements for staff categories for each type of provider business entity are summarized in Table 7.4. beginning on page 7-15. 7.5. Information Specific to Particular Training Courses and Provider Categories The following information is provided to further clarify or explain requirements for particular training courses: 1) All CPR courses must include training in implementation of the Heimlich maneuver. 2) Fire Safety and Evacuation training must occur in the primary environment(s) where services are provided.

Provider Manual, Chapter 7 Provider Training Division of Mental Retardation Services , State of Tennessee Published March 15, 2005

7 - 12

7
3) For support coordinators and case managers, individual support plan training and ISC certification must be completed in accordance with Chapter 4, Section 4.4.. A trained support coordinator or case manager with at least six (6) months experience must mentor the new employee during support coordination/case management training and until certification is achieved. Mentoring includes ensuring proper completion of all Independent Support Plans (ISP) and proper documentation of support notes. A mentor-qualified support coordinator/case manager must sign all Independent Support Plans written by the new employee until certification is achieved. 4) For support coordinators and case managers, training specific to the needs of the individual shall include reading the current ISP, support notes for the past year, and Individual Transition Plans, if one was produced during the past year. Special skills may be necessary for the support coordinator or case manager if special skills are required to complete support coordination functions or otherwise meet the service recipients needs. 5) For Home Care Organization personal assistance staff and respite providers, a CPR and first aid training certification received through training provided by the American Heart Association or American Red Cross (Basic CPR training is requiredtraining targeted to health care clinicians is not required for direct support staff) must be maintained. 6) When personal assistant services are provided in a family home, Fire Safety and Evacuation training may be provided by appropriate agency staff or by family members who serve as primary caregivers. 7) For staff employed as direct support staff, respite providers or personal assistants, First Aid training provided in the CNA or CNT certification process is sufficient to meet DMRS First Aid training requirements. A CNT/CNA certificate maintained in the employees personnel file will be accepted as documentation. 8) For staff employed as job coaches, a four (4) hour job coach training course is required in addition to the direct support staff training required. 9) For a direct support staff person or personal assistant to assist with administration of medications to service recipients within the DMRS system, certification must be obtained following completion of a DMRS-approved medication administration training course. Following initial certification, re-certification must be obtained every two (2) years via completion of a DMRS-approved medication administration refresher course. 7.6. Training of Developmental Center Staff Employed by Providers in the Community A person recently employed by a Tennessee state developmental center who is hired by a community provider may request that the developmental center issue a training history summary report. The summary report will be issued to the provider by the Staff

Provider Manual, Chapter 7 Provider Training Division of Mental Retardation Services , State of Tennessee Published March 15, 2005

7 - 13

7
Development Director at the developmental center and will include the persons name, the name of the training course completed, the course evaluation score and the date the course was taken. The actual scored course evaluation form will not be provided. Not all training courses taken at the developmental center are community-based; therefore, additional training may be required when staff transfer from a developmental center to a community provider.

Provider Manual, Chapter 7 Provider Training Division of Mental Retardation Services , State of Tennessee Published March 15, 2005

7 - 14

SERVICE AGENCIES Administrative Managerial Staff Direct Support Staff Program Support Staff Administrative Support Staff Respite Care Providers & Staff Physical Therapists Occupational Therapists Orientation/Mobility Nurse Speech/Hearing/Language Therapist Nutritionist/Dietitian Behavior Analyst/Behvaior Specialist Introduction to MRDD Protection From Harm Training Specific to the Needs of the Individual Universal Precautions Independent Support Coordination Sensitivity Title VI CPR (Upon Expiration) Incident Management Protection From Harm Sensitivity Title VI First Aid (Upon Expiration) Job Coach Training (Only Required if Job Coaching) Challenges in Physical Management Mealtime Challenges Enhancement in Physical Challenges Enhancement in Mealtimes Individual Rights and ADA ISP Implementation Individual Support Planning ISP Overview Medicaiton Administration (Only if Administering Meds) Quality Behavioral Health Supports Incident Management Central Office Orientation Regional Office Orientation Fire Safety and Evacuation First Aid CPR

Provider Manual, Chapter 7 Provider Training Division of Mental Retardation, State of Tennessee Published March 15, 2005

TRAINING REQUIREMENTS FOR PROVIDER STAFF CATEGORIES Table 7.5

PRE-SERVICE CORE ANNUAL OTHER

7 - 15

ISC AGENCIES Administrative Managerial Staff Independent Support Coordinator HOME CARE AGENCIES Administrative Managerial Staff Personal Assistant Respite Care Providers & Staff Physical Therapists Occupational Therapists Orientation/Mobility Nurse Introduction to MRDD Protection From Harm Training Specific to the Needs of the Individual Universal Precautions Independent Support Coordination Individual Rights and ADA ISP Implementation Individual Support Planning Title VI CPR (Upon Expiration) Incident Management Protection From Harm Sensitivity Title VI First Aid (Upon Expiration) Job Coach Training (Only Required if Job Coaching) Challenges in Physical Management Mealtime Challenges Enhancement in Physical Challenges Enhancement in Mealtimes ISP Overview Medicaiton Administration (Only if Administering Meds) Quality Behavioral Health Supports Sensitivity Incident Management Central Office Orientation Regional Office Orientation Fire Safety and Evacuation First Aid CPR

Provider Manual, Chapter 7 Provider Training Division of Mental Retardation, State of Tennessee Published March 15, 2005

TRAINING REQUIREMENTS FOR PROVIDER STAFF CATEGORIES Table 7.5

PRE-SERVICE CORE ANNUAL OTHER

7 - 16

7
TRAINING REQUIREMENTS FOR PROVIDER STAFF CATEGORIES Table 7.5
PRE-SERVICE CORE ANNUAL OTHER

Medicaiton Administration (Only if Administering Meds)

Job Coach Training (Only Required if Job Coaching)

Training Specific to the Needs of the Individual

Enhancement in Physical Challenges

Quality Behavioral Health Supports

Challenges in Physical Management

Independent Support Coordination

Individual Support Planning

First Aid (Upon Expiration)

Speech/Hearing/Language Therapist Nutritionist/Dietitian Behavior Analyst/Behvaior Specialist INDEPENDENT PROVIDERS Administrative Managerial Staff Direct Support Staff Physical Therapists Occupational Therapists Orientation/Mobility Nurse Speech/Hearing/Language Therapist Nutritionist/Dietitian Behavior Analyst/Behvaior Specialist

Provider Manual, Chapter 7 Provider Training Division of Mental Retardation, State of Tennessee Published March 15, 2005

7 - 17

Regional Office Orientation

Individual Rights and ADA

Fire Safety and Evacuation

Enhancement in Mealtimes

Central Office Orientation

CPR (Upon Expiration)

Protection From Harm

Protection From Harm

Introduction to MRDD

Universal Precautions

Incident Management

Incident Management

Mealtime Challenges

ISP Implementation

ISP Overview

Sensitivity

Sensitivity

First Aid

Title VI

Title VI

CPR

7
7.7. Training Requirements for Volunteers DMRS appreciates the volunteers who provide supports to service recipients and encourages the development of these supports. Providers have an obligation to provide appropriate information and/or skills training to volunteers as necessary to protect the immediate health and safety of the service recipient. 7.7.a. Volunteers: Volunteers are unpaid individuals who provide services and supports to service recipients. Volunteers do not typically work alone with people and may not be counted as staff the provider uses to fulfill staffing obligations. 7.7.b. Information Shared with Volunteers: The training a provider is required to complete with volunteers will vary depending upon the nature of the support being provided. The provider must ensure that the volunteer has the necessary information and skills to provide the support safely and effectively. Information in the ISP describing the service recipients communication skills, preferences, interests, fears, likes and dislikes is to be provided if the volunteer does not already know the service recipient well enough to have this information. Consent must be obtained from the service recipient or the service recipients legal representative before any personal information is shared. 7.7.c. Skills Training for Training Volunteers: Volunteers may be trained to perform skills necessary to assist with meals, assist with positioning, assist with use of assistive devices, implement behavior-related staff instructions or initiate individual emergency/crisis plans. Volunteers must be trained by appropriate and qualified professionals or designated provider trainers in the same manner utilized to train employed direct support staff. Training provided should focus only on those skills necessary to maintain the health and safety of the service recipient. The person and the persons legal representative are to be involved in the decision of which skills are appropriate for volunteers to perform. 7.8. Training Available to Natural Supports Natural supports, sometimes called generic supports, are people, places and support mechanisms that already exist or can be created to provide supports that are not funded by DMRS or other public health care systems. Natural supports are often available through connections and relationships with other people or organizations in the community, such as churches or other community organizations. A provider may be asked to supply or may feel it prudent to offer information and skills training as necessary to enable natural supports to provide support safely and effectively. Consent must be obtained from the service recipient or the service recipients legal representative before any personal information is shared.

Provider Manual, Chapter 7. Provider Training Division of Mental Retardation, State of Tennessee Published March 15, 2005

7 - 18

7
7.9. Documenting Staff Training Providers must maintain a training file for each employee that contains documentation to verify that required training courses have been successfully completed in a timely manner. Course evaluations (i.e. the test or examination form), including the employees name, the course instructors name, the training course completed, the date of the training course and the course evaluation score will be accepted as verification of training. A developmental center training history summary report will also be accepted as verification of training. Table 7.9. shows documentation that is acceptable as verification of specific training courses. Standardized forms for documenting required training are provided in Appendix D. Table 7.9. Documentation of Required Training Courses Training Course CPR First Aid Fire Safety and Evacuation Incident Management Introduction to MRDD Protection from Harm Documentation Accepted Copy (front and back) of current certification card Copy (front and back) of current certification card Course evaluation or answer sheet Course evaluation or answer sheet Course evaluation or answer sheet Copy of signature sheet containing the trainees name, date of training and instructors name/ DMRS-approved documentation form Course evaluation or answer sheet Course evaluation or answer sheet Course evaluation or answer sheet Course evaluation or answer sheet Course evaluation or answer sheet Course evaluation or answer sheet

Training Specific to the Needs of the Individual Universal Precautions ISP Implementation Independent Support Coordination Individual Rights and the ADA Individual Support Planning ISP Overview

Provider Manual, Chapter 7. Provider Training Division of Mental Retardation, State of Tennessee Published March 15, 2005

7 - 19

7
Training Course Medication Administration Quality Behavioral Health Supports: Core Training Sensitivity Training Title VI Training Annual Refresher CPR Documentation Accepted Course evaluation or answer sheet Course evaluation or answer sheet Course evaluation or answer sheet Course evaluation or answer sheet Copy (front and back) of current certification card Copy (front and back) of current certification card Course evaluation or answer sheet

First Aid Refresher Course (every 2 years) Annual Refresher Incident Management Annual Refresher Protection from Harm Annual Refresher Sensitivity Training Annual Refresher Title VI Training Challenges in Physical Management Mealtime Challenges Enhancement in Physical Challenges Enhancement in Mealtimes Central Office Orientation Regional Office Orientation

Copy of signature sheet containing the trainees name, date of training and instructors name Course evaluation or answer sheet Course evaluation or answer sheet Course evaluation or answer sheet Course evaluation or answer sheet Course evaluation or answer sheet Course evaluation or answer sheet DMRS Central Office will maintain sign-in sheets for each orientation session DMRS Regional Office will maintain sign-in sheets for each orientation session

Provider Manual, Chapter 7. Provider Training Division of Mental Retardation, State of Tennessee Published March 15, 2005

7 - 20

7
7.10. Documenting Training Provided to Volunteers Providers must maintain a general personnel file or files containing documentation of training offered and/or provided to volunteers and natural supports. Specific descriptions of training provided by professionals, such as therapists or nurses, should be maintained in the professionals records. Documentation must include the name of the person trained, the name of the person providing the training, a brief description of the reason training was needed, a brief description of the training provided and the date the training was provided. 7.11. Provider Trainers Train-the-trainer courses are offered by DMRS to provide a mechanism for providers to develop the resources needed to deliver quality training to employed staff. Providers are required to designate a staff person(s) to serve as a trainer. After successful completion of train-the-trainer courses, the trainer will provide required training courses to other provider staff. Provider trainers may not train other trainers. DMRS must provide trainer courses and certify all provider trainers. 7.11.a. Certification Requirements for Provider Trainers: The Regional Training Coordinator will maintain a roster of all DMRS-certified trainers. Certification requirements are as follows: 1) Train-the-trainer courses must be successfully completed for each DMRSrequired training course that will be taught by the trainer; 2) The DMRS course titled Effective Training Techniques must be successfully completed; and 3) Licensure requirements applicable to the training course to be taught must be met. 7.11.b. Train-the-Trainer Documentation to be Maintained in Personnel Files: Upon successful completion of train-the-trainer courses, DMRS will award a certificate. A copy of the DMRS certificate or the scored course evaluation/answer sheet will be accepted as documentation of qualification to serve as a provider trainer. Documentation must be maintained to verify completion of the DMRS course titled Effective Training Techniques. Current documentation must be maintained to verify completion of trainer courses for each DMRS-required training provided to other provider-employed staff. 7.11.c. Provider Trainers for Continuation of Therapy, Behavior, Nutrition, and Other Clinical Service Plans of Care: Occasions may arise when a service recipient has received maximum benefit from clinical services and it is determined that such services should be appropriately discontinued. When such situations occur, there will often be maintenance/discharge instructions that must be followed by a service recipients direct

Provider Manual, Chapter 7. Provider Training Division of Mental Retardation, State of Tennessee Published March 15, 2005

7 - 21

7
support staff. Residential, day or personal assistance providers may also collaborate with a clinical service provider in determining that it is safe, appropriate and cost effective for an agency trainer to assume the responsibility for training direct support staff to implement ISC actions or staff instructions related to clinical services. When appropriate for an agency trainer to assume direct support staff training responsibilities, the residential, day or personal assistance provider will be responsible for designating a trainer to be trained by the clinical service provider. Following such training, the designated trainer will be responsible for ensuring that new staff are appropriately trained to perform special skills or implement actions as indicated in the clinical service maintenance/discharge instructions and/or the ISP.

Provider Manual, Chapter 7. Provider Training Division of Mental Retardation, State of Tennessee Published March 15, 2005

7 - 22

8
CHAPTER 8 CREATION AND MAINTENANCE OF PROVIDER RECORDS

8.1.

Introduction The purpose of this chapter is to outline requirements for a functional method of creating and maintaining records pertinent to the provision of services to the Division of Mental Retardation Services (DMRS) service recipients. Records serve many important purposes, including: 1) Documentation of the service-related activities that occurred and the service recipients response to such activities; 2) Documentation of the provision of services in accordance with applicable requirements to support reimbursement of the service; 3) Communication of significant events that occurred in a service recipients life to subsequent staff who provide services; 4) Documentation of actions taken and communication initiated with other providers for the purpose of resolving problems and issues affecting service delivery; 5) Collection of data and information enabling evaluation and revision of the various plans that guide staff in providing services to a service recipient; and 6) Documentation of the qualifications, training and supervision of staff providing services to service recipients.

8.2.

General Records Requirements for Service Recipient Records 8.2.a. Requirements Applicable to Creation of Records: Requirements applicable to all providers creating service recipient records include: 1) Each provider must create a record containing documentation of services provided for each service recipient; 2) Information contained in service recipient records must be clear, concise, complete and current; 3) Information recorded in service recipient records must be factual and absent of any fabricated or falsified data or narratives; 4) Information and documents included in service recipient records must be organized in a systematic and chronological format; 5) Information documented in service recipient records must be written in ink or recorded in a typed/printed format;

Provider Manual, Chapter 8 Creation and Maintenance of Provider Records Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

8- 1

8
6) Correction fluid, correction tape or similar appliances must not be used to correct errors in the record; 7) Errors are to be corrected by marking through the incorrect entry with a single line and recording the date and initials of the person correcting the entry; 8) Information documented in service recipient records must be legible; 9) Information documented in service recipient records must be dated and authenticated by the signature and title of the person recording each entry; 10) Abbreviations, acronyms and symbols other than those listed as acceptable standard abbreviations (see Appendix A) either must not be used, or if used, must be spelled out in complete form followed with the abbreviation, acronym or symbol in parenthesis; 11) Information entered into the record must be recorded in a timely manner, as soon as possible following the completion of the event or activity described by the entry; 8.2.b. Requirements Applicable to Maintenance of Service Recipient Records: Requirements applicable to all providers maintaining service recipient records include: 1) Providers must implement written policies pertaining to records maintenance, including identification of the location of required components of the record and identification of staff responsible for records maintenance; 2) All service recipient records must be stored in a manner that maintains the confidentiality of the information contained by preventing inappropriate access to the records; 3) Records must be maintained by providers for a period of ten (10) years in accordance with the Department of Mental Health and Developmental Disabilities (DMHDD) licensure standards (TCA 33-4-102), whether or not the provider is licensed by DMHDD; 4) Department of Health professional support services licensure rules require maintenance of records for people with developmental disabilities for ten (10) plus one (1) years; 5) Records maintained in the home of the service recipient must be regularly purged to ensure usability of the record for direct support staff and to protect the confidentiality of the records; 6) Providers are to maintain original documents for the services provided by employed staff; 7) Providers are to maintain copies of required documentation obtained from contracted staff and other providers; 8) Records must be maintained by the provider in a manner that ensures that the records are accessible and retrievable within a reasonable time period (see

Provider Manual, Chapter 8 Creation and Maintenance of Provider Records Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

8- 2

8
subsequent sections for more specific information about what is considered to be a reasonable time period); 9) If records are maintained on an electronic system, the provider must implement a routine procedure for backup of files. 8.2.c. Requirements Applicable to Maintenance of Incident Reports: Providers must maintain incident reports relative to the service(s) provided for a period of ten (10) years. Incident reports are to be maintained in an administrative file separate from service recipient records. 8.3. Confidentiality of and Access to Service Recipient Records 8.3.a. Confidentiality of Records: All providers must sign a provider agreement to receive reimbursement for services funded by DMRS. The provider agreement contains requirements regarding the confidentiality of service recipients personal information. All records and information obtained and/or created by the provider, regardless of whether the information is kept and/or shared as a paper document, as an electronic record, as a verbal report or by any other means must be kept confidential in accordance with applicable state and federal laws, rules, regulations, policy and ethical standards. In practical terms, this means that the provider must safeguard against personal information being disclosed to or seen by inappropriate persons or entities who could use the information in a manner that is not in a service recipients best interests. 8.3.b. Access to Service Recipient Records: Service recipient records are to be made available, following verification of identity of the person requesting access, to: 1) The service recipient; 2) The service recipients legal representative(s); 3) Family members or other individuals who have obtained appropriate consent for access to the record or parts of the record from the service recipient or the service recipients legal representative; 4) Service providers involved in the provision of services specified in the ISP, including those who may not be employed or contracted with the provider responsible for maintaining a particular record, such as support coordinators/case managers or clinical service providers; 5) DMRS and TennCare staff or designees conducting monitoring or other related activities; and 6) Staff of other state and federal agencies with authority to conduct monitoring or other related activities, such as the Tennessee Office of the Comptroller, the Centers for Medicare and Medicaid Services (CMS), the Office of the Inspector General (OIG) and the Office of Civil Rights.

Provider Manual, Chapter 8 Creation and Maintenance of Provider Records Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

8- 3

8
8.4 The Health Insurance Portability and Accountability Act (HIPAA) The DMRS provider agreement requires that providers who sign the agreement assure the state of knowledge of HIPAA requirements and of HIPAA compliance during the term of the provider agreement. HIPAA is a federal law that pertains to the privacy and security of individual health records. HIPAA specifies requirements pertaining to the use, maintenance, transmission and deletion of protected health information, including personal records created, obtained and maintained by DMRS and the DMRS provider network. Protected health information (PHI) is any individually identifiable information (past, present or future) related to the physical or mental health/condition of an individual, the provision of health care to an individual or payments made for health care services. Providers in the DMRS system may meet the HIPAA definition of a business associate and may be required to sign a business associate agreement. 8.4.a. Business Associate/Provider Requirements: Providers generally meet the HIPAA definition for business associate and may be required to sign a business associate agreement. A DMRS provider business associate must implement written policies and procedures that are HIPAA compliant. DMRS providers must: 1) Refrain from use or disclosure of PHI except as permitted by the provider agreement or allowed/required by law; 2) Safeguard PHI in the course of daily operations; 3) Report to DMRS any use or disclosure of PHI prohibited by the provider agreement or applicable law when such use or disclosure is initially discovered; 4) Ensure that any agents, including subcontractors, to whom PHI is provided to or received from, or who create protected health information, agree to the same restrictions and conditions that apply to the DMRS provider business associate; 5) Designate a Privacy Officer, responsible for development and implementation of HIPAA-compliant policies and procedures and for responding to HIPPA-related complaints; 6) Identify the level of access to protected health information necessary for each staff person to complete designated job responsibilities; 7) Train staff regarding HIPAA requirements and document such training; 8) Obtain signed confidentiality statements from staff; 9) Establish disciplinary actions for staff who do not adhere to HIPPA-related policies; 10) Assure that PHI is not left unattended or visible in public areas; 11) Properly dispose of protected health information that is no longer needed; 12) Honor service recipients rights to access to records as specified in HIPAA.

Provider Manual, Chapter 8 Creation and Maintenance of Provider Records Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

8- 4

8
8.4.b. Privacy Notices: HIPAA requires that service recipients and their legal representatives be provided information regarding their rights as specified in HIPAA. Consequently, service recipients in the DMRS system have received or will receive a Notice of Privacy Practices (document available in Appendix D) that explains privacy rights. The notice will be reissued any time a significant change is made in the content of the notice. As of the effective date of this provider manual, all applicants who complete the intake process will receive a current copy of the privacy notice in the intake packet. The current notice will be accessible on the DMRS website (website address provided in Appendix F). The notice will also be available in all DMRS offices and will be provided upon request to service recipients, legal representative(s) or family/friends involved in the service recipients life. Providers who have direct care relationships with service recipient(s) are required to post the privacy notice onsite. 8.4.c. Business Associate/Provider Requirements for Honoring Individual HIPAA Rights: DMRS provider business associates are responsible for honoring individual rights as specified in HIPAA. DMRS providers must: 1) Allow service recipients to see their records; 2) Provide copies of personal records to the service recipient upon request; 3) Provide information to service recipients about how information is used and shared; 4) Respond to requests from service recipients to restrict the use and/or disclosure of personal information; 5) Respond to requests from service recipients to change information in records that is incorrect; 6) Provide service recipients a list of people or entities who have obtained information from their records; 7) Honor requests from service recipients that certain health information not be shared; and 8) Honor requests to rescind consents to share information. 8.5. Record Sets A record set is a compilation of documents and recorded information pertaining to the provision of a group of services or a particular service. Different record sets containing the information pertinent to the type of service(s) provided are maintained by different types of providers. The following record sets will be discussed in this chapter: 1) The Service Recipient Comprehensive Record; 2) The Service Recipient Residential Record; 3) The Day Services Record;

Provider Manual, Chapter 8 Creation and Maintenance of Provider Records Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

8- 5

8
4) 5) 6) 7) 8) 9) 8.6. The Personal Assistant Record; The Support Coordination Record; The Clinical Service Record; The Ancillary Provider Record; Provider Personnel Records; and Provider Administrative Records.

The Service Recipient Comprehensive Record A Service Recipient Comprehensive Record will be maintained for each DMRS service recipient. Multiple providers may contribute information to the Comprehensive Record. The Comprehensive Record contains all information relevant to planning, implementing and evaluating the provision of services and supports specified in the Individual Support Plan (ISP). The contents of the Comprehensive Record will vary, depending upon the types of services that are required to support the service recipient in the community setting. Portions of the Comprehensive Record may be kept at different locations, including provider administrative offices or the service recipients home, depending on the nature and age of the documentation/information contained in the record. Table 8.6. shows the required contents of a Comprehensive Record, including the portions of the Comprehensive Record that are to be kept in the Service Recipient Residential Record (the record kept in the service recipients home). 8.6.a. Responsibility for Maintaining Service Recipient Comprehensive Records: The primary provider is responsible for maintaining the Comprehensive Record. Responsibility for maintaining the Service Recipient Comprehensive Record is distributed as follows: 1) If the service recipient receives residential services, the residential provider is the primary provider responsible for maintaining the Comprehensive Record. 2) If residential services are not required, but the service recipient receives day services, the day service provider is the primary provider responsible for maintaining the Comprehensive Record. 3) If the service recipient requires neither residential nor day services, but receives personal assistance services, the personal assistance provider is the primary provider responsible for maintaining the Comprehensive Record; 4) If the service recipient receives neither residential, day nor personal assistance services, the support coordination provider is the primary provider responsible for maintaining the Comprehensive Record. 5) If the service recipient has neither a residential, day nor support coordination provider, the DMRS Regional Office will maintain the comprehensive individual record.

Provider Manual, Chapter 8 Creation and Maintenance of Provider Records Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

8- 6

8
The primary provider is responsible for maintaining the original portion of the record that is created for the provision of all of the services that provider is responsible for providing. The primary provider is also responsible for maintaining copies of all documentation created by other sources that is obtained by the provider and essential to the provision of the services the provider is rendering. For components of the comprehensive record that other service providers are responsible for maintaining, the primary provider must maintain information regarding the location of that information and how to access such information within a two (2) hour time period. The primary provider is not required to maintain copies of all documents contained in the comprehensive record. Other service providers are expected to cooperate with requests made for comprehensive records to be made available for audit, survey or other monitoring purposes. The primary providers responsibility in obtaining requested information for auditors/surveyors from other service providers is generally limited to being able to provide correct information to the individual requesting the documentation so that person may initiate contact with the provider responsible for maintaining the portion of the record being requested. 8.6.b. Comprehensive Record Active and Archived Files: Service Recipient Comprehensive Records must be maintained for a period of ten (10) years. The most current year is considered to be the active file. Records relevant to services provided during the past two (2) to ten (10) years may be kept in archived files. There are two exceptions to the one-year rule for maintaining records as active vs. archived files. The first pertains to documents that are more than one (1) year old that continue to be relevant to the services currently provided. Such records are to be kept in the active file. Examples of such documents may include: 1) A physicians history and physical that was performed two (2) years ago, but is the most current history and physical available; 2) A therapy evaluation or discharge summary for a service recipient who needs to be monitored for specific indications of deterioration in condition that could warrant initiation of a new period of therapy services; or 3) Physicians orders that are more than one year old, but continue to be in effect. The second exception pertains to staff communication notes. For some service recipients, staff communication notes may become quite voluminous. To ensure that staff communication notes are usable, they may be archived after a period of six (6) months. Whether records are in active or archived files, they must be accessible within two (2) hours. 8.6.c. Obtaining Information from Other Providers: A primary goal within the DMRS service system is the elimination of duplication in maintaining record sets to the extent possible. Providers are encouraged to work with DMRS in identifying ways to

Provider Manual, Chapter 8 Creation and Maintenance of Provider Records Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

8- 7

8
effectively maintain essential documentation of the services provided in the most concise format. When it is necessary for providers to share information with other providers working with the same service recipient, it is expected that providers will be judicious in determining the information that can simply be reviewed versus documentation that must be maintained in the form of duplicate copies. If duplicate or unnecessary copies are requested, it is acceptable for providers to charge reasonable amounts for their cost in making copies and providing the requested documents. Providers are expected to be considerate of the staff time required to provide copies and understand that staffing and workload issues may prevent provision of record copies within a requested time frame. The requesting provider may have to directly obtain copies from or review records in another providers administrative office if records are needed within a particular time frame. 8.7. The Service Recipient Residential Record When a service recipient receives residential services, the portion of the Comprehensive Record that is kept in the home is called the Residential Record. The residential record is to contain documentation necessary for provision of those services that occur in the residential or home environment, primarily those provided by direct support staff. The residential record is to be utilized by direct support staff to document services provided and to communicate significant events to other staff. In order for the Residential Record to be used in accordance with intended purposes, it must be organized, compact and contain relevant information. Table 8.6 shows required contents of the Service Recipient Residential Record. The Residential Record shall contain: 1) The Health Care Oversight Form; 2) Medication administration records, if applicable; 3) Medication Profile Sheets, if applicable; 4) Elimination, weight, menstrual, seizure and/or sleep records, if applicable; 5) The Physician-Ordered Treatment Log, if applicable; 6) The physicians orders; 7) Advanced Directives/Power of Attorney, if applicable; 8) Critical health and safety information; 9) Emergency contact information; 10) A current photograph of the service recipient; 11) Consents for treatment; 12) The Health Passport; 13) Insurance cards; 14) The current ISP, including the BSP if applicable; 15) Any written staff instructions determined to be needed; 16) The Individual Transition Plan, if applicable;

Provider Manual, Chapter 8 Creation and Maintenance of Provider Records Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

8- 8

8
17) The Emergency Crisis Plan, if applicable; 18) Monthly Reviews; 19) Therapy and behavior data; 20) Staff Communication notes. 8.7.a. Staff Communication Notes: Staff Communication Notes is the portion of the Comprehensive Record that contains direct support staff entries describing what occurred with the service recipient during a staff members scheduled work periods. Staff Communication Notes are useful in the provision of services to the extent that they are utilized by direct support staff to communicate and share information with other direct support staff involved in service provision. Staff Communication Notes can ensure timely awareness of acute factors that may affect the service recipient and impact the supports provided. Providers must ensure ongoing supervision and feedback to direct support staff to ensure that only relevant entries are recorded. Entries such as slept well or had a good night provide little useful information and simply take up space. Staff Communication Notes are to include information relevant to the implementation of staff instructions, the completion of ISP action steps and/or the progress made toward achieving ISP outcomes. Routine events or data that must be documented on a daily basis can be concisely documented utilizing a checklist format. Staff Communication Notes are to contain narrative descriptions of : 1) 2) 3) 4) 5) Significant achievements realized by the service recipient; Significant health-related events or symptomology and staff response; Unusual behaviors and staff response; Unusual activities or contacts and service recipient response; Atypical service recipient responses to implementation of staff instructions or ISP action steps; 6) Other unusual or significant events that vary from the service recipients normal activities or responses; and 7) Clinician presence in the home or at the day service site. 8.7.b. Staff Instructions: Provider requirements applicable to staff instructions are provided in Chapter 3, Section 3.13. 8.7.c. Monthly Reviews: Provider requirements pertaining to monthly reviews are provided in Chapter 3, Section 3.14.

Provider Manual, Chapter 8 Creation and Maintenance of Provider Records Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

8- 9

8
8.7.d. Emergency Contact Information: Emergency contact information is to be included in the Residential Records and other records sets as noted in subsequent sections and on Table 7.8. Emergency contact information shall include: 1) The name, address an telephone number of the contact(s); 2) The name, address and telephone number of the service recipients primary care physician; 3) The names, addresses and telephone numbers of any other medical, mental health or behavior service providers that may need to be contacted in an emergency situation; 4) The name and telephone number of the service recipients legal representative(s), if applicable; 5) The name and telephone numbers of any family members (who are not legal representatives) that are to be notified in event of an emergency; 6) The name of the service recipients residential provider, if applicable, and the name of a contact person and that persons telephone number; 7) The name of the service recipients support coordinator/case manager, the name of the provider who employs the support coordinator/case manager, a telephone number that is accessible twenty-four (24) hours per day and seven (7) days per week for contacting the support coordinator/case manager in case of emergency. 8.8. The Support Coordination Record The support coordination record includes all documents and information pertaining to developing and monitoring implementation of the ISP, including required contacts with the service recipient, other providers and legal representatives/family members. Support Coordination Records are kept in the support coordination providers business office. Minimum requirements pertaining to the contents of the Support Coordination Record are provided in Table 8.6. Documentation requirements for support coordination are discussed in detail in Chapter 4, Section 4.8. The Support Coordination Record shall contain: 1) The Uniform Assessment; 2) Reports from medical and other consultants (e.g. therapy consultation reports, specialty physician consult reports, psychiatric consult reports, etc.); 3) Clinical service assessment Reports; 4) Medicaid financial eligibility documentation (Department of Human Services Forms 2350 and 2362 for a three (3) year period); 5) Medicaid medical eligibility documentation (the PAE packet); 6) The date of admission/enrollment; 7) The annual dental examination; 8) The Annual Medical and Assessment Plan;

Provider Manual, Chapter 8 Creation and Maintenance of Provider Records Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

8- 10

8
9) The annual physical; 10) The Health Care Oversight form; 11) The Physical Status Review; 12) Court orders pertaining to guardianship/conservatorship, if applicable; 13) The Freedom of Choice Form; 14) Critical health and safety information; 15) Emergency contact information; 16) The current ISP, including the BSP if applicable; 17) The Individual Transition Plan, if applicable; 18) The Individual Education Plan, if applicable; 19) Support coordination monthly reviews; 20) Clinical Service Contact notes; 21) Correspondence, as applicable; 22) Discharge summaries, if applicable; 23) Required ISC documentation forms; and 24) Provider monthly reviews and other monthly reports as applicable to the needs of the service recipient. 8.9. Clinical Service Records A Clinical Service Record is maintained by each clinical services provider involved in implementation of the ISP. Clinical service providers include physical, occupational and speech/language therapists, nutritionists, behavior analysts/specialists, orientation and mobility specialists and nurses. The required content of different types of Clinical Service Records is provided in Table 8.6. Individual clinical service records are described below. Clinical service providers are not required to maintain copies of all documentation reviewed during assessments or evaluation of ongoing services. It is expected that the end product, i.e. the assessment report, clinical service plans of care and/or written staff instructions, etc. will be reflective of thorough records review and information gathering. 8.9.a. The Nursing Record: Nursing records shall contain: 1) 2) 3) 4) 5) 6) 7) 8) Nursing assessment reports; The Physical Status Review; Physician orders for nursing services; Authorization(s) for release of information; Signed consents for nursing treatment(s); The current ISP; The Individual Transition Plan, if applicable; Clinical Service Contact Notes;

Provider Manual, Chapter 8 Creation and Maintenance of Provider Records Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

8- 11

8
9) Nursing Monthly Reviews; 10) Correspondence as applicable; and 11) A discharge summary, if applicable. 8.9.b. Nutrition, Physical Therapy, Occupational Therapy, Speech/ Language/Hearing, and Orientation and Mobility Records: Each of these record sets shall contain: 1) Reports of any assessments performed; 2) Physicians orders for the clinical service provided; 3) Authorization(s) for release of information; 4) Signed consents for treatment; 5) The current ISP; 6) The Individual Transition Plan, if applicable; 7) Monthly reviews pertaining to the clinical service provided; 8) Clinical Service Contact Notes; 9) Therapy data; 10) Correspondence as applicable; and 11) A discharge summary, if applicable. 8.9.c. Behavior Service Records: Behavior service records shall contain: 1) Consents for treatment; 2) The current ISP (with attached BSP); 3) The Individual Transition Plan, if applicable; 4) Individual Emergency Crisis Plans, as applicable; 5) Monthly reviews for behavior services; 6) Behavior data; 7) Clinical Service Contact Notes; 8) Human Rights and Behavior Support Committee approvals; 9) Correspondence, as applicable; and 10) A discharge summary, if applicable. 8.9.d. Clinical Service Assessments: A clinical service assessment must include: 1) 2) 3) 4) The reason for referral; Relevant service recipient preferences and outcomes; Pertinent health history and current health status; Documentation of interviews with the service recipient, family member(s), legal representative(s), the support coordinator or case manager and direct support staff

Provider Manual, Chapter 8 Creation and Maintenance of Provider Records Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

8- 12

8
regarding therapy-related issues, concerns, capabilities or other needed information; 5) Documentation of review of relevant service recipient records; 6) Documentation of assessment/evaluation and findings related to applicable clinical parameters (e.g., fine/gross motor skills, perceptual skills, daily living skills, use of adaptive equipment, falls history, balance, strength, mobility skills, communication skills, oral-motor skills, hearing abilities); 7) Identification of risk factors or health safety issues; 8) Evaluation of functional potential; 9) Identification of equipment needs; 10) Documentation of comprehensive clinical analysis of assessment findings which justifies any services recommended based on assessment findings; 11) Recommendations; 12) Proposed actions, goals or outcomes to be included in the ISP, if services are recommended; and 13) Clinical service practitioner signature and credentials with the date the assessment was completed. 8.9.e. Clinical Service Contact Notes: A contact note must be written each time contact is made with the person receiving services for the purpose of providing a service or performing a related activity. Each contact note must contain: 1) 2) 3) 4) 5) The name of the service recipient; The time the service began and ended; The purpose of the contact, including the ISP action step or outcome addressed; The type of services provided; Any training provided to direct support staff or instruction provided to the service recipient or family; 6) Data collected or reviewed by the therapist to evaluate progress in achieving action steps or outcomes, including assessment of the service recipients response to implementation of staff instructions and therapy services; 7) The status of any equipment pending approval or delivery; 8) Plans for follow-up actions, changes in staff instruction and/or changes in the therapy plan of care and ISP; 9) Units of service used during contact period; 10) Clinical service practitioner name, credentials and date of contact.

8.9.f. Clinical Service Monthly Review Requirements: Monthly reviews are required for any month during which clinical services are provided. Monthly reviews provide a summary of the progress toward implementing the ISP action steps and outcomes related to the clinical services rendered during the month. Monthly reviews include onsite

Provider Manual, Chapter 8 Creation and Maintenance of Provider Records Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

8- 13

8
reassessment of the persons status and response to the services provided, as well as evaluation of the effectiveness of the clinical service plan and related staff instructions. Revisions to the clinical service plan of care and/or related staff instructions and amendments/updates to the ISP are to be initiated when the current plans do not effectively address the service recipients needs. Basic provider requirements for monthly reviews are specified in Chapter 3, Section 3.14. 8.9.g. Discharge Summaries: Discharge summaries are required to be completed by clinical service providers when clinical services are discontinued. Discharge summaries must contain: 1) 2) 3) 4) 5) 6) 7) 8) The name of the service recipient being discharged; A summary of the services provided; The status of the service recipient at the time of discharge; Progress in implementing the clinical service plan of care and in completing or meeting ISP action steps and outcomes; Recommendations regarding maintaining status at the time of discharge; Indicators for initiating a new referral for assessment and/or services as applicable/appropriate; The clinical service practitioners name and credentials with the date the discharge summary was completed; and The effective date of discharge.

8.10. The Day Services Record When Residential and Day services are rendered by the same provider, the residential and day record sets may be maintained in a manner that avoids duplication of information. The Day Services Record shall contain: 1) Medication administration records pertaining to time periods day services are provided, if applicable; 2) Medication Profile Sheets, if applicable; 3) Elimination, menstrual and seizure records pertaining to time periods during which day services are provided; 4) Physician-Ordered Treatment Log for treatments provided during day service hours, if applicable; 5) Physicians orders; 6) Advanced Directives/Power of Attorney; 7) Critical health and safety information; 8) Individual emergency contact information; 9) A current photograph of the service recipient;

Provider Manual, Chapter 8 Creation and Maintenance of Provider Records Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

8- 14

8
10) Consents for treatment as applicable; 11) The Health Passport; 12) Insurance cards; 13) The current ISP, including the BSP if applicable; 14) Any necessary written staff instructions; 15) The Individual Transition Plan, if applicable; 16) The Emergency Crisis Plan, if applicable; 17) Monthly reviews; 18) Clinical progress/data notes; 19) Therapy and behavior data; 20) Human Rights Committee and Behavior Support Committee approvals; 21) Clinical service contacts notes (i.e. sign-in and sign-out notes, staff training documentation); and 22) Staff communication notes. 8.11. The Personal Assistant Record Records maintained by personal assistance providers shall contain: 1) Medication administration records pertaining to time periods personal assistance services are provided, if applicable; 2) Medication Profile Sheets, if applicable; 3) Elimination, menstrual, sleep and seizure records; 4) Physician-Ordered Treatment Log for treatments provided during personal assistance service hours, if applicable; 5) Physicians orders; 6) Advanced Directives/Power of Attorney; 7) Critical health and safety information; 8) Individual emergency contact information; 9) A current photograph of the service recipient; 10) Consents for treatment as applicable; 11) The Health Passport; 12) Insurance cards; 13) The current ISP, including the BSP if applicable; 14) Any necessary written staff instructions; 15) The Individual Transition Plan, if applicable; 16) The Emergency Crisis Plan, if applicable; 17) Monthly reviews for personal assistance services; 18) Clinical progress/data notes; 19) Therapy and behavior data; 20) Human Rights Committee and Behavior Support Committee approvals; and

Provider Manual, Chapter 8 Creation and Maintenance of Provider Records Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

8- 15

8
21) Staff communication notes. 8.12. Respite Records Records maintained by respite and behavioral respite providers shall contain: 1) The Health Care Oversight Form; 2) Medication administration records pertaining to time periods respite services are provided, if applicable; 3) Medication Profile Sheets, if applicable; 4) Elimination, menstrual, sleep and seizure records pertaining to time periods during which respite services are provided; 5) Physician-Ordered Treatment Log for treatments provided during respite service hours, if applicable; 6) Physicians orders; 7) Advanced Directives/Power of Attorney; 8) Critical health and safety information; 9) Emergency contact information; 10) A current photograph of the service recipient; 11) Consents for treatment as applicable; 12) The Health Passport; 13) Insurance cards; 14) The current ISP, including the BSP if applicable; 15) Any necessary written staff instructions; 16) The Individual Transition Plan, if applicable; 17) The Emergency Crisis Plan, if applicable; 18) Monthly reviews pertaining to Respite Services; 19) Clinical progress/data notes; 20) Therapy and behavior data; 21) Human Rights Committee approvals; 22) Clinical Service Contact Notes; and 23) Staff communication notes. 8.13. Ancillary Provider Records Ancillary provider records are the records kept by dental, vision or mental health providers when services are funded by DMRS programs. Ancillary records also refer to providers of intermittent services such as equipment providers, home modification contractors or stand-alone transportation providers.

Provider Manual, Chapter 8 Creation and Maintenance of Provider Records Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

8- 16

8
8.13.a. Dental, Vision and Mental Health Provider Record Requirements: Dental, vision and mental health providers must maintain service recipient records in accordance with professional licensure standards for the service being provided. For purposes of reimbursement of services through a DMRS program, documentation must be available describing: 1) The type of services provided; 2) The service recipients response to the service provided; 3) The date and time services were provided, inclusive of the total time required to provide the service; 4) Any follow-up instructions or actions to be taken related to the service provided; and 5) The cost of the service provided, inclusive of an itemized account of all charges. 8.13.b. Other Ancillary Providers: Other providers of intermittent services, equipment or supplies must document: 1) The type of service or equipment provided; 2) The date the service was rendered or the equipment was delivered; 3) Any staff or primary caregiver training or instruction provided regarding use of equipment or supplies; 4) The cost of the service, supplies or equipment provided. 8.14. Provider Personnel Records Providers who employ one (1) or more staff must maintain personnel records. Providers must ensure that such records sufficiently document staff qualifications, training and supervision. 8.14.a. Requirements Pertaining to Individual Employee Records: The following documentation must be maintained in provider personnel records for each individual employed: 1) An employment application; 2) Any resumes provided that document education and experience with transcripts/diplomas that verify the educational information provided (required for professional/clinical staff); 3) Results of the background check performed; 4) Reference checks; 5) Results obtained from checking the Department of Healths Tennessee Elderly and Vulnerable Abuse Registry and the Sexual Offender Registry;

Provider Manual, Chapter 8 Creation and Maintenance of Provider Records Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

8- 17

8
6) 7) 8) 9) A signed confidentiality agreement; Current licensure and/or certification as applicable, including renewal number; Copies of tests for DMRS required training; Signed documentation of completion of the therapeutic services orientation with the regional team for therapy, nutrition and orientation and mobility practitioners; 10) Documentation of any required ongoing continuing education credits received; 11) Performance evaluations; 12) Documentation of any disciplinary actions taken; and 13) Perpetrator history (i.e. criminal history and history pertaining to substantiation as the perpetrator of abuse, neglect or exploitation); and 14) Consent forms signed by the employee to allow the provider to perform background checks or access other employment related information. The following

8.14.b. Requirements Pertaining to Contract Staff Records: documentation must be available for contracted staff:

1) A copy of resume(s) with transcripts/diplomas to verify educational information provided for staff providing or supervising direct care services to service recipients under the terms of the contract; 2) A copy of the contract specifying performance terms and conditions; 3) The providers evaluation performed for the purpose of determining whether the contract staff met performance expectations specified in the contract; and 4) A copy of applicable professional licenses or certifications for licensed/certified staff. 8.15. Provider Administrative Records Providers are required to maintain administrative records for a period of ten (10) years. Administrative records include financial records, written policies and procedures, board or advisory group appointments, committee members and/or documentation of other administrative functions specified in applicable state or federal law, rule or regulation. 8.16. Distribution and Transfer of Records Between Providers To ensure integration of services, communication must occur between providers. Sharing documents and service recipient records is one of the ways that communication occurs between multiple providers who may be involved with providing services and supports to the same service recipient. 8.16.a. General Requirements Pertaining to Distribution of Records: The following requirements are applicable to distribution of records between providers:

Provider Manual, Chapter 8 Creation and Maintenance of Provider Records Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

8- 18

8
1) The legal standard for mailing documents and records is first class mail, return receipt requested; 2) Any documents or service recipient records that must be distributed to another provider are to be mailed to the providers primary business office; and 3) Original documents or records created by a provider are to be maintained in that providers file with copies of the document or record distributed as necessary. 8.16.b. Transfer of Records When a Change in Providers Occurs: When a service recipient changes providers for any reason, it is essential that sufficient records be transferred to allow service provision to continue uninterrupted and to allow the overall health, safety and welfare of the service recipient to be assured. Records may be transferred in the following manner: 1) Records may be provided to the service recipient or the service recipients legal representative to be delivered to the receiving provider; or 2) Consent may be obtained from the service recipient or legal representative to release records directly to the receiving provider. 3) It is acceptable to transfer copies of original records rather than transfer the original. 4) Records need to be transferred on or before the date the new provider assumes service responsibility. If consent is obtained to transfer records directly to the new provider, the transferring provider will be unable to release third party medical, psychiatric, behavioral or other health-related information contained in the record directly to the new provider. The transferring provider will be able to release only that information directly authored or generated. The transferring provider will be required to provide a list of the sources for directly obtaining any third party information contained in the service recipients record. 8.16.c. Transfer of Records When a Change in Primary Providers Occurs: The record sets maintained by the primary provider shall follow the service recipient when a new primary provider is selected. The primary provider is responsible for maintaining the Service Recipient Comprehensive Record. If the service recipient is receiving residential services, the Service Recipient Comprehensive Record will include the Service Recipient Residential Record that is maintained in the home. The transferring primary provider is responsible for: 1) Ensuring that a complete Service Recipient Comprehensive Record for at least one (1) year prior to change in providers is made available to the receiving

Provider Manual, Chapter 8 Creation and Maintenance of Provider Records Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

8- 19

8
2) 3) provider (Service recipient can request additional records as needed to provide adequate historical information.); Maintaining a copy of all records for service recipients who transfer or are otherwise no longer receiving services for a period of ten (10) years; Obtaining permission to transfer the Service Recipient Comprehensive Record to the new provider from the service recipient or the service recipients legal representative; Ensuring that the transfer of the Service Recipient Comprehensive Record occurs on or prior to the effective date of transfer when the receiving provider becomes responsible for the provision of services; and Documenting the transfer of records along with other pertinent information in the transfer summary.

4)

5)

The receiving primary provider is responsible for: 1) Accepting and documenting receipt of the transferred records; 2) Ensuring that required records are appropriately filed; 3) For residential providers, ensuring that required records are available in the Service Recipient Residential Record. 8.16.d. Transfer of Records When a Change in Support Coordination Providers Occurs: The transferring support coordination agency must ensure that the following information is made available for transfer to the receiving support coordination provider: 1) A transfer summary; and 2) A copy of the support coordination record for at least the previous one (1) year time period (Service recipient can request additional records as needed to provide adequate historical information.). 8.16.e. Transfer of Records When a Change in Professional/Clinical Providers Occurs: A transfer summary must be completed by the transferring provider with a copy provided to the receiving provider. A copy of the professional clinical provider record for a period of one (1) year prior to the date of transfer shall be provided to the new provider on or before the new provider assumes responsibility for services. 8.16.f. Transfer Summaries: Transfer summaries are intended to describe the service recipients current condition, situation and/or service needs, as well as any outstanding issues at the time a transition between two providers occurs. Transfer summaries shall include:

Provider Manual, Chapter 8 Creation and Maintenance of Provider Records Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

8- 20

8
1) Due dates that are essential to the service for which the provider change is occurring, such as: ISP due dates; Due dates for level of care reevaluations or financial eligibility determinations; Dates of any medical or other appointments already scheduled; Due dates for annual medical, dental or other appointments that have not been scheduled; 2) Pending or outstanding issues, such as: Pending ISP updates or amendments that need to be submitted or have been submitted to the DMRS Regional Office; Pending referrals; Outstanding health- or mental health-related recommendations; Outstanding medical equipment or equipment repairs; Issues that otherwise require follow-up by the receiving provider; 3) Progress toward achieving ISP action steps or outcomes since the last monthly review; 4) Service recipient status as of last contact and/or anticipated dates of discharge for clinical services as applicable; and 5) Other significant issues affecting the service recipient as of the effective date of transfer to the receiving provider. 8.16.g. Transfer of Records When Provider Agreements are Voluntarily or Involuntarily Terminated: In the event that a provider goes out of business or otherwise voluntarily terminates a provider agreement with DMRS or in the event that DMRS terminates a provider agreement for non-compliance or other cause, sufficient measures must be taken to ensure that records are available to ensure continuity of services. All requirements for transfer of records to receiving providers as described in this chapter will apply. In the event that the transferring provider demonstrates unwillingness to transfer essential records, DMRS Regional Office will implement measures to obtain and transfer essential records as necessary.

Provider Manual, Chapter 8 Creation and Maintenance of Provider Records Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

8- 21

RECORDS REQUIREMENTS Table 8.6

8
SPEECH/LANGUAGE/HEARING RECORD ORIENTATION AND MOBILITY RECORD OCCUPATIONAL THERAPY RECORD

SUPPORT COORDINATION RECORD

PERSONAL ASSISTANCE RECORD

BEHAVIOR SERVICES RECORD

RECORD SECTION AND ITEM ASSESSMENTS/CONSULTS Uniform Assessment Reports From Medical/Clinical Service Consultants Assessment Reports ELIGIBILITY INFORMATION 2350's; if applicable 2362's; maintained for 3 year period ICF/MR Facility Transfer Form; if applicable PAE Packet Date of Admission FINANCIAL INFORMATION Copies of Leases; if applicable DHS Letter for Food Stamps; if applicable Insurance Policies; as applicable Monthly Records of Financial Information (i.e. bank statements); as applicable Representative Payee Report Forms SSA/SSI Letters; as applicable HEALTH Annual Dental Exam Annual Medical and Assessment Plan (CM) Annual Physical Health Care Oversight Immunization Records Psychological Medication Adminsitration Records; as applicable

8-22

Provider Manual, Chapter 8. Creation and Maintenance of Provider Records Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

PHYSICAL THERAPY RECORD

COMPREHENSIVE RECORD

DAY SERVICES RECORD

RESIDENTIAL RECORD

NUTRITION RECORD

NURSING RECORD

RESPITE RECORD

RECORDS REQUIREMENTS Table 8.6

8
SPEECH/LANGUAGE/HEARING RECORD ORIENTATION AND MOBILITY RECORD OCCUPATIONAL THERAPY RECORD

SUPPORT COORDINATION RECORD

PERSONAL ASSISTANCE RECORD

BEHAVIOR SERVICES RECORD

RECORD SECTION AND ITEM Medication Profile Sheet; as applicable Elimination Records; as applicable Weight Records; as applicable Menstral Records; as applicable Seizure Records; as applicable Sleep Records; as applicable Physican Ordered Treatment Log; as applicable Physical Status Review Physican Orders LEGAL Advanced Directives/POA Guardianship/Conservator Court Orders Authorization for Release of Information Freedom of Choice PERSONAL INFORMATION Critical Health and Safety Information Emergency Contact Information Current Photo Consents for Treatment Health Passport Insurance Cards PLANS AND ACCOMPLISHMENTS Current ISP Staff Instruction, if applicable Individual Transition Plan; as applicable

Provider Manual, Chapter 8. Creation and Maintenance of Provider Records Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

PHYSICAL THERAPY RECORD

COMPREHENSIVE RECORD

DAY SERVICES RECORD

RESIDENTIAL RECORD

NUTRITION RECORD

NURSING RECORD

RESPITE RECORD

8-23

RECORDS REQUIREMENTS Table 8.6

8
SPEECH/LANGUAGE/HEARING RECORD ORIENTATION AND MOBILITY RECORD OCCUPATIONAL THERAPY RECORD

SUPPORT COORDINATION RECORD

PERSONAL ASSISTANCE RECORD

BEHAVIOR SERVICES RECORD

RECORD SECTION AND ITEM Individual Education Plan; as applicable Individual Emergeny Crisis Plans; as applicable Monthly Reviews (Per Funded Service) Clinical Service Contact Notes (e.g., Staff Training Documentation, Sign-In and Out Notes) Clinical Service Contact Notes and/or Data Notes Therapy Data Behavior Data Human Rights & Behavior Supports Committee Approval NOTES/LOGS Staff Communication Notes OTHER Clothing/Property Inventory Correspondence; as applicable Discharge Summary SUPPORT COORDINATION Required Documentation Forms Services Coordinator Monthly Reports/Records *

*

* To contain comprehensive review of all funded services for the person

Provider Manual, Chapter 8. Creation and Maintenance of Provider Records Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

PHYSICAL THERAPY RECORD

COMPREHENSIVE RECORD

DAY SERVICES RECORD

RESIDENTIAL RECORD

NUTRITION RECORD

NURSING RECORD

RESPITE RECORD

8-24

9
CHAPTER 9 RESIDENTIAL SERVICES

9.1.

Introduction There are a variety of residential service options available to service recipients who are not able or chose not to live in a home with family members. The residential service option selected must be one that meets the service recipients needs and that is able to ensure the service recipients health and safety. Residential service options include residential habilitation, family model residential support, medical residential services and supported living.

9.2.

Residential Habilitation 9.2.a. Waiver Definition of Residential Habilitation: The waiver definition shall apply to all residential habilitation services funded via a Medicaid waiver. The waiver definition shall also be used for state-funded residential habilitation services. The waiver definition for residential habilitation services approved by the Centers for Medicaid and Medicare Services (CMS) is: Residential Habilitation: Residential Habilitation shall mean a type of residential service having individualized services and supports that enable an enrollee to acquire, retain or improve skills necessary to reside in a community-based setting including direct assistance with activities of daily living (e.g., bathing, dressing, personal hygiene, eating, meal preparation, household chores) essential to the health and safety of the enrollee, budget management, attending appointments and interpersonal and social skills building to enable the enrollee to live in a home in the community. It also may include medication administration as permitted under Tennessees Nurse Practice Act. The Residential Habilitation dwelling may be rented, leased or owned by the Residential Habilitation provider and shall be licensed by the State of Tennessee. The Residential Habilitation provider shall provide personal funds management as specified in the plan of care. Therapeutic goals and objectives shall be required for enrollees receiving Residential Habilitation. The Residential Habilitation provider shall oversee the enrollees health care needs.

Provider Manual, Chapter 9 Residential Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

9-1

9
A Residential Habilitation home shall have no more than four (4) residents with the exception that homes which were already providing services to more than four (4) residents prior to July 1, 2000, may continue to do so. The Residential Habilitation provider shall be responsible for providing an appropriate level of services and supports 24 hours per day during the hours the enrollee is not receiving Day Services or is not at school or work. With the exception of transportation to and from medical services covered through the Medicaid State Plan/TennCare program, transportation shall be a component of Residential Habilitation and shall be included in the reimbursement rate for such. With the exception of Individual Transportation Services necessary for Orientation and Mobility Training or Behavioral Respite Services, an enrollee receiving Residential Habilitation shall not be eligible to receive Individual Transportation Services. Reimbursement for Residential Habilitation shall not be made for room and board or for the cost of maintenance of the dwelling, and reimbursement shall not include payment made to members of the enrollees immediate family or to the enrollees conservator. This service shall not be provided in inpatient hospitals, nursing facilities and Intermediate Care Facilities for the Mentally Retarded (ICF/MRs). 9.2.b. Licensure of Residential Habilitation Providers: Residential habilitation providers must obtain and maintain licensure as a Mental Retardation Residential Habilitation Facility in accordance with DMHDD licensure regulations. Licensure must be obtained prior to occupancy of such facility. Licensure is not required for microboards serving only one (1) service recipient. 9.2.c. Room and Board Charges: No more than eighty per cent (80%) of the maximum Supplemental Security Income (SSI) benefit for the current calendar year may be charged to a service recipient for room and board expenses by a provider who owns a residential habilitation home. 9.2.d. Additional Requirements/Considerations Applicable to Habilitation Providers: Additional requirements/considerations include: Residential

1) A residential habilitation home owner must provide a minimum of sixty (60) calendar days notice prior to terminating a tenancy; 2) Upon expiration of a lease agreement in situations where a new provider has been chosen, the owner of a residential habilitation home must continue to lease

Provider Manual, Chapter 9 Residential Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

9-2

9
to the service recipient until suitable alternative housing arrangements are made; and 3) A residential habilitation home cannot be owned by staff or board members employed or appointed by the provider or their family members, with the exception of microboards (Microboard members who are also family members of the service recipient may own the service recipients home.). 9.3. Family Model Residential Support 9.3.a. Waiver Definition of Family Model Residential Support: The waiver definition shall apply to all family model residential support funded via a Medicaid waiver. The waiver definition shall also be used for state-funded family model residential support. The waiver definition for family model residential support approved by the Centers for Medicaid and Medicare Services (CMS) is: Family Model Residential Support: Family Model Residential Support shall mean a type of residential service having individualized services and supports that enable an enrollee to acquire, retain or improve skills necessary to reside successfully in a family environment in the home of trained caregivers other than the family of origin. The service includes direct assistance as needed with activities of daily living (e.g., bathing, dressing, personal hygiene, eating, meal preparation excluding the cost of food), household chores essential to the health and safety of the enrollee, budget management, attending appointments and interpersonal and social skills building to enable the enrollee to live in a home in the community. It also may include medication administration as permitted under Tennessees Nurse Practice Act. The caregivers shall be recruited, screened and trained prior to providing services, and supervised by the Family Model Residential Support provider agency. The Family Model Residential Support provider shall oversee the enrollees health care needs. With the exception of homes that were already providing services to three (3) residents prior to January 1, 2004, a Family Model Residential Support home shall have no more than two (2) residents who receive services and supports. The Family Model Residential Support provider shall be responsible for providing an appropriate level of services and supports 24 hours per day during the hours the enrollee is not receiving Day Services or is not at school or work. Therapeutic goals and objectives shall be required for enrollees receiving Family Model Residential Support. With the exception of transportation to and from medical services covered through the Medicaid State Plan/TennCare program, transportation shall be a component of Family Model Residential Support and shall be included in the reimbursement rate for such. With

Provider Manual, Chapter 9 Residential Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

9-3

9
the exception of Individual Transportation Services necessary for Orientation and Mobility Training or Behavioral Respite Services, an enrollee receiving Family Model Residential Support shall not be eligible to receive Individual Transportation Services. This service shall not be provided in inpatient hospitals, nursing facilities, and Intermediate Care Facilities for the Mentally Retarded (ICF/MRs). Reimbursement for Family Model Residential Support shall not be made for room and board or for the cost of maintenance of the dwelling, and reimbursement shall not include payment made to the enrollees parent, step-parent, spouse, child or sibling or to any other individual who is a conservator unless so permitted in the Order for Conservatorship. 9.3.b. Licensure of Family Model Residential Support Providers: A family model residential support provider must obtain and maintain licensure as a Mental Retardation Placement Services Facility in accordance with DMHDD licensure regulations. Licensure must be obtained prior to placement of service recipients. Licensure is not required for microboards serving only one (1) service recipient. 9.3.c. Room and Board Charges: No more than seventy per cent (70%) of the maximum Supplemental Security Income (SSI) benefit for the current calendar year may be charged to a service recipient for room and board expenses by a provider of family model residential support. 9.3.d. Additional Requirements/Considerations Applicable to Family Model Residential Support Providers: Additional requirements/considerations include: 1) Mobile homes may be utilized as family model residential support homes only if the home was manufactured after 1974 and meets standards specified by the Tennessee State Fire Marshal for the use of mobile homes to support persons with mental retardation (current standards are included in the DMRS Home Inspection Form in Appendix D); 2) Prior to placement of a service recipient in a family model residential home, the provider must complete a DMRS-compliant home study and the DMRS Family Model Residential Supports Initial Site Survey to ensure that the home meets the service recipients needs and that the family and service recipient are compatible and well matched (tools provided in Appendix D); 3) Following placement of a service recipient, the provider is required to perform a supervisory visit to the home on a monthly basis and complete the DMRS Family Model Residential Supports Monitoring Tool on an annual basis;

Provider Manual, Chapter 9 Residential Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

9-4

9
4) The family model residential supports provider must maintain a personnel file, including documentation of required training, for each member of the family involved in the provision of family model residential support services; 5) The family model residential support provider must ensure that families involved in the provision of this service offer the service recipient opportunities to participate in family and community activities in accordance with outcomes specified in the ISP; 6) The family model residential supports provider must ensure that the service recipient has access to a telephone and all common living areas within the home with due regard to privacy and personal possessions; 7) The family model residential supports provider must assure that the service recipient is offered choice in selection of religious and other activities; 8) The family model residential supports provider must assure that the service recipient is afforded the freedom to associate with those of his/her choosing and have visitors at reasonable hours; and 9) The service recipient may be assigned reasonable responsibilities, commensurate with expressed interests and abilities, in the home environment. 9.4. Medical Residential Services 9.4.a. Waiver Definition of Medical Residential Services: The waiver definition shall apply to all medical residential services funded via a Medicaid waiver. The waiver definition shall also be used for state-funded medical residential services. The waiver definition for medical residential services approved by the Centers for Medicaid and Medicare Services (CMS) is: Medical Residential Services: Medical Residential Services shall mean a type of residential service provided in a residence where all residents require direct skilled nursing services and habilitative services and supports that enable an enrollee to acquire, retain or improve skills necessary to reside in a community-based setting. Medical Residential Services must be ordered by the enrollees physician, physician assistant or nurse practitioner, who shall document the medical necessity of the services and specify the nature and frequency of the nursing services. The enrollee who receives Medical Residential Services shall require direct skilled nursing services on a daily basis and at a level which can not for practical purposes be provided through two or fewer daily skilled nursing visits. The service includes direct assistance as needed with activities of daily living (e.g., bathing, dressing, personal hygiene, eating, meal preparation excluding cost of food), household chores essential to the health and safety of the enrollee, budget management, attending appointments and interpersonal and social skills building to enable the enrollee

Provider Manual, Chapter 9 Residential Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

9-5

9
to live in a home in the community. It also may include medication administration as permitted under Tennessees Nurse Practice Act. If an enrollee receiving Medical Residential Services owns or leases the place of residence, the enrollee (or the enrollees parent, guardian or conservator acting on behalf of the enrollee) shall have a voice in choosing other individuals with direct skilled nursing service needs who reside in the residence and the staff who provide services and supports. The enrollee shall have the right to manage personal funds as specified in the individual support plan. The Medical Residential Services provider shall be responsible for providing an appropriate level of services and supports 24 hours per day when the enrollee is not receiving Day Services or is not at school or work. Therapeutic goals and objectives shall be required for enrollees receiving Medical Residential Services support. Medical Residential Services are not intended to replace services available through the Medicaid State Plan/TennCare program. With the exception of transportation to and from medical services covered through the Medicaid State Plan/TennCare program, transportation shall be a component of Medical Residential Services and shall be included in the reimbursement rate for such. With the exception of Individual Transportation Services necessary for Orientation and Mobility Training or Behavioral Respite Services, an enrollee receiving Medical Residential Services shall not be eligible to receive Individual Transportation Services. Reimbursement for Medical Residential Services shall not include the cost of maintenance of the dwelling, and reimbursement shall not include payment made to members of the enrollees immediate family or to the enrollees conservator. Reimbursement shall not be made for room and board if the home is rented, leased or owned by the provider. If the home is rented, leased or owned by the enrollee, reimbursement shall not be made for room and board with the exception of a reasonable portion that is attributed to a live-in caregiver who is unrelated to the enrollee and who provides services to the enrollee in the enrollees place of residence. If an enrollee owns or leases the place of residence, residential expenses (e.g., phone, cable TV, food, rent) shall be apportioned between the enrollee, other residents in the home and (as applicable) live-in or other caregivers. This service shall not be provided in inpatient hospitals, nursing facilities, and Intermediate Care Facilities for the Mentally Retarded (ICF/MRs).

Provider Manual, Chapter 9 Residential Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

9-6

9
9.4.b. Licensure of Medical Residential Service Providers: Medical residential service providers must obtain and maintain licensure as either a Mental Retardation Residential Habilitation Facility or a Mental Retardation Supported Living Services Facility in accordance with DMHDD licensure regulations. In addition to the requirements specified for medical residential service in this section, requirements pertaining to the applicable licensure category must be met. Licensure must be obtained prior to occupancy of such facility. Licensure is not required for microboards serving only one (1) service recipient. 9.4.c. Room and Board Charges: No more than eighty per cent (80%) of the maximum Supplemental Security Income (SSI) benefit for the current calendar year may be charged to a service recipient for room and board expenses by a provider who owns a medical residential home licensed as a residential habilitation facility. 9.4.d. Additional Requirements/Considerations Applicable to Medical Residential Service Providers: Medical residential service rates allow the provision of health care supports. Requirements that must be met for this service include: 1) The provision of Registered Nurse oversight to assure that individual service recipient health care needs are addressed, including: Review of medication administration documentation and monitoring to assure the availability of ordered medications; Supervision of and/or attendance during health-related appointments and follow-up; Interaction with physicians, pharmacists, therapists and other medical providers as needed to assure coordination of health-related services; Completion of Physical Status Reviews (PSR) in accordance with PSR guidelines (see Appendix D); Documentation of monthly face-to-face visits with the service recipient(s) for the purpose of providing health-related oversight; Supervision of licensed practical nurses; and Provision of health-related training as necessary to direct support staff; 2) The provision of direct nursing services in accordance with physicians orders for activities that can only be performed by a licensed nurse in accordance with the Tennessee Nurse Practice Act (e.g. tube feedings, dressing changes, administration of injectable medications by intramuscular or intravenous routes); and 3) The documentation of nursing services provided to enhance basic residential services.

Provider Manual, Chapter 9 Residential Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

9-7

9
9.5. Supported Living 9.5.a. Waiver Definition of Supported Living: The waiver definition shall apply to all supported living services funded via a Medicaid waiver. The waiver definition shall also be used for state-funded supported living services. The waiver definition for supported living services approved by the Centers for Medicaid and Medicare Services (CMS) is: Supported Living: Supported Living shall mean a type of residential service having individualized services and supports that enable an enrollee to acquire, retain, or improve skills necessary to reside in a home that is under the control and responsibility of the enrollee. The service includes direct assistance as needed with activities of daily living (e.g., bathing, dressing, personal hygiene, eating, meal preparation excluding the cost of food), household chores essential to the health and safety of the enrollee, budget management, attending appointments and interpersonal and social skills building to enable the enrollee to live in a home in the community. It also may include medication administration as permitted under Tennessees Nurse Practice Act. The Supported Living provider shall not own the enrollees place of residence or be a co-signer of a lease on the enrollees place of residence unless the Supported Living provider signs a written agreement with the enrollee that states that the enrollee will not be required to move if the primary reason is because the enrollee desires to change to a different Supported Living provider. A Supported Living provider shall not own, be owned by or be affiliated with any entity that leases or rents a place of residence to an enrollee if such entity requires, as a condition of renting or leasing, the enrollee to move if the Supported Living provider changes. The enrollee (or the enrollees parent, guardian or conservator acting on behalf of the enrollee) shall have a voice in choosing the individuals who reside in the Supported Living residence and the staff who provide services and supports. The enrollee shall have the right to manage personal funds as specified in the Individual Support Plan. The Supported Living home shall have no more than 3 residents including the enrollee. If two or more individuals share the home, each may select the Supported Living provider of their choice. Therapeutic goals and objectives shall be required for enrollees receiving Supported Living. The Supported Living provider shall oversee the enrollees health care needs. Unless the residence is individually licensed or inspected by a public housing agency utilizing the HUD Section 8 safety checklist, the residence must have an operable smoke detector and a second means of egress. The Supported Living provider shall be responsible for providing an appropriate level of services and supports 24 hours per day during the hours the enrollee is not receiving Day Services or is not at school or work.

Provider Manual, Chapter 9 Residential Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

9-8

9
With the exception of transportation to and from medical services covered through the Medicaid State Plan/TennCare program, transportation shall be a component of Supported Living and shall be included in the reimbursement rate for such. With the exception of Individual Transportation Services necessary for Orientation and Mobility Training or Behavioral Respite Services, an enrollee receiving Supported Living shall not be eligible to receive Individual Transportation Services. Reimbursement for Supported Living shall not be made for room and board with the exception of a reasonable portion that is attributed to a live-in caregiver who is unrelated to the enrollee and who provides services to the enrollee in the enrollees home. Reimbursement for Supported Living shall not include the cost of maintenance of the dwelling. Residential expenses (e.g., phone, cable TV, food, rent) shall be apportioned between the enrollee, other residents in the home and (as applicable) live-in or other caregivers. This service shall not be provided in inpatient hospitals, nursing facilities and Intermediate Care Facilities for the Mentally Retarded (ICF/MRs). 9.5.b. Licensure of Supported Living Providers: Supported living providers must obtain and maintain licensure as a Mental Retardation Supported Living Services Facility in accordance with DMHDD licensure regulations. Licensure must be obtained prior to occupancy of such facility. Licensure is not required for microboards serving only one (1) service recipient. 9.5.c. Home Ownership and Control Associated With Supported Living Services: Supported living services are provided in a home owned or leased by the service recipient. The amount and type of supports required for the service recipient to enjoy the benefits and accept the responsibilities associated with home ownership or individual lease arrangements are variable, depending upon each service recipients unique abilities and needs. Supported living provides a residential option which allows greater service recipient involvement and control in the operation of the home. Involvement and control in operation of the home includes: 1) Participation in determining the support services needed; 2) Involvement in the selection of direct support staff, including being given the opportunity to meet, and to the degree possible, approve the employment of direct support staff; 3) Participation in developing the roles and responsibilities of direct support staff, including the opportunity to direct day to day activities;

Provider Manual, Chapter 9 Residential Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

9-9

9
4) Participation in hiring, evaluating and terminating direct support staff; 5) Involvement in the selection of housemates with whom to live; and 6) Involvement in managing personal funds to the extent possible, including paying rent, buying groceries, paying utilities, etc. Supported living focuses on the service recipient, rather than the provider having primary control and responsibility regarding operation of the home and support services. Supported living services are available to service recipients regardless of disability level. Legal representatives, family members or other natural supports available within the community are often instrumental in maximizing the assistance available to the service recipient in understanding and assuming home ownership responsibilities. Supported living services continue to be an option for service recipients and families seeking involvement, control and exercise of self-determination. 9.5.d. Lease Requirements Applicable to Supported Living Services: The following requirements are applicable when lease arrangements are made for service recipients who chose supported living services: 1) The preferred lease option is for the home lease to be signed by the service recipient or legal representative; 2) A provider may co-sign a lease with a service recipient, but may not be the sole lease holder; 3) If a provider does co-sign a lease with a service recipient, the provider must also sign a written agreement with the service recipient stating that the service recipient will not be required to move or pay an increased lease payment due to a change of supported living providers; 4) A provider may not own a supported living home leased to a service recipient and require as a condition of the lease agreement that the service recipient move if a different supported living provider is chosen; 5) A provider may not be affiliated with the owner of a supported living home leased to a service recipient if the entity owning the home requires that the service recipient move as a condition of the lease if a different supported living provider is chosen; 6) The owner of a supported living home may not be an employee or board member employed or appointed by the supported living provider; 7) The lease must provide for a sixty (60) day notice to the service recipient prior to termination of the lease agreement or increase in the rent or lease amount; 8) The rental payment or lease amounts shall not exceed fair market value for similar property in the same general location;

Provider Manual, Chapter 9 Residential Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

9 - 10

9
9) The term of the rental or lease agreement shall not exceed one (1) year unless specified in the ISP and in the best interests of the service recipient for purposes of obtaining a home with accessibility modifications; 10) No more than one months rent may be charged as a security deposit; and 11) All notices related to termination of or changes in the lease agreement must be provided to the service recipient, and/or legal representative or other person designated by the service recipient. 9.5.e. Availability of Mortgage/Lease Documentation: Individual leases and mortgage documentation must be accessible to auditors and surveyors representing CMS, TennCare, DMRS and other state and federal agencies responsible for regulation and oversight of DMRS programs. Lease/mortgage payment information must also be available for review if the provider is involved with assisting the service recipient in managing financial resources. 9.6. Semi-Independent Living Services Semi-independent living is a state-funded residential service option. Semi-independent living provides an option to adult service recipients who do not need direct support staff to live on-site for supervision purposes, but do need intermittent or limited support to remain in a community housing situation. Individuals are eligible for state-funded semiindependent living services only if no more than two-hundred fifty (250) hours per month of staff support are needed. 9.6.a. Licensure Requirements: Semi-independent living providers must obtain and maintain compliance with DMHDD licensure requirements for Mental Retardation SemiIndependent Living Facilities. 9.6.b. Other Requirements/Considerations Applicable to Semi Independent Living: Additional requirements/considerations applicable to semi-independent living providers include: 1) Supported living lease and lease/mortgage documentation requirements described in Sections 9.5.d. and 9.5.e. are applicable to semi-independent living providers; 2) A minimum of one face-to-face contact per week is required with each service recipient receiving semi-independent living services; 3) As of the effective date of this manual, the ISP development process for service recipients receiving semi-independent living services must include risk analysis and the ISP must include any outcomes determined necessary to address identified risk in accordance with the planning process specified in Chapter 3.

Provider Manual, Chapter 9 Residential Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

9 - 11

9
9.7. Out-of-State Residential Services The waiver definitions for each of the residential service options (i.e. residential habilitation services, family model residential supports, medical residential services and supported living services) addresses the provision of these services when the service recipient travels out of state. All of the residential service options may be provided outof-state under the following circumstances: 1) Out-of-state services shall be for the purpose of visiting relatives or for vacations and shall be included in the enrollees plan of care. (Trips to casinos or other gambling establishments shall be excluded.) 2) Out-of-state services shall be limited to a maximum of 14 days per enrollee per year. 3) The waiver service provider agency must be able to assure the health and safety of the enrollee during the period when services will be provided out-of-state and must be willing to assume the additional risk and liability of provision of services out-of-state. 4) During the period when out-of-state services are being provided, the waiver service provider agency must maintain an adequate amount of staffing (including services of a nurse if applicable) to meet the needs of the enrollee and must ensure that staff meet waiver provider qualifications. 5) The waiver service provider agency shall not receive any additional reimbursement for provision of services out-of-state. The costs of travel, lodging, food and other expenses incurred by staff during the provision of out-of-state services shall not be reimbursed through the waiver. The costs of travel, lodging, food and other expenses incurred by the enrollee while receiving out-of-state services shall be the responsibility of the enrollee and shall not be reimbursed through the waiver. 9.8. Staffing Plans Providers of residential habilitation services, family model residential supports, medical residential services and supported living services must develop a staffing plan (schedule) that addresses staffing needs for each service recipient. 9.8.a. Staffing Plan Requirements: The staffing plan must reflect: 1) Compliance with staffing standards specified in licensure regulations; 2) Adequate numbers of trained staff to implement the ISP, including implementation of any staff instructions that are determined necessary, and ensure the health and safety of service recipients;

Provider Manual, Chapter 9 Residential Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

9 - 12

9
3) Efficient use of staff to cover peak and overnight hours; 4) Availability of back-up and emergency staff when scheduled staff cannot report to work; and 5) Presence of at least one staff person when the service recipient is in the home, unless the Individual Support Plan (ISP) allows less than 24-hour supervision. 9.8.b. Monitoring Staffing Plan Compliance: The staffing plan must be available in the home to provide direct support staff information regarding who is to be responsible for service provision for each staffing period or shift. DMRS Agency Teams, DMRS Quality Assurance staff and other state and federal staff responsible for monitoring service provision will compare the ISP, staffing plans and employee time sheets to determine the adequacy of staffing provided. 9.9. Health Oversight Residential service providers share responsibility with DMRS and TennCare for assuring the overall health, safety and welfare of service recipients. Please refer to Chapter 11 for requirements specific to health oversight. When a therapist makes recommendations pertaining to dietary modifications requiring a separate physicians order, the residential provider is responsible for obtaining the order. 9.10. Personal Funds Management Personal funds are individual financial resources, including earned and unearned income (e.g., trust funds), that are used by or on behalf of a service recipient to pay for necessary personal expenses. Service recipients have the right to participate to the extent desired and practical in accordance with their skills and capabilities in the management of personal funds. TennCare policy sets forth requirements pertaining to all providers, including residential service providers, assisting in the management of personal funds. These general requirements are listed in Chapter 6, Section 6.10. TennCare policy also specifies requirements specific to residential services. The same requirements shall apply to providers who provide DMRS state-funded residential services. 9.10.a. Addressing Personal Funds Management in the ISP: The ISP must specify the extent to which the service recipient is capable of and willing to participate in management of personal funds, as well as the extent to which the residential service provider is entrusted with assisting in the management of personal funds. Requirements pertaining to the ISP are specified in Chapter 3.

Provider Manual, Chapter 9 Residential Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

9 - 13

9
9.10.b. Use of Earned Income in Determining Room and Board Payments: For service recipients who receive paychecks from a supported employment provider or day habilitation workshop, the amount of the paycheck will not be used to determine the amount of the room and board payment, unless otherwise required by federal law. 9.10.c. Use of Personal Funds for Restitution of Property Damage: Service recipients personal funds may not be used for restitution purposes when damages are caused by the service recipient, unless approved by a human rights committee and specified in the ISP. If approval is obtained from a human rights committee, the ISP must be amended to include a payment schedule that assures that the service recipient will continue to have sufficient personal allowance funds to support implementation of actions and outcomes specified in the ISP. 9.10.d. Rental Insurance: Service recipients may be offered the choice of purchasing rental insurance; however, the purchase of such insurance may not be presented as a condition of receiving services. 9.11. Home Environmental and Safety Requirements Applicable to Residential Services 9.11.a. Licensure Environmental and Safety Requirements: Residential service providers are responsible for compliance with the Department of Mental Health and Developmental Disabilities (DMHDD) licensure requirements applicable to the type of residential service being provided. DMHDD rule cites applicable to DMRS residential provider types are provided in Table 9.10. on pages 9-17 and 9-18. 9.11.b. Tennessee Housing Development Authority (THDA) Home Inspection Requirements: All service recipient supported living residences, as of the effective date of this manual, will be inspected by DMRS prior to the date of initial service recipient occupancy. Thereafter, an inspection will be performed by DMRS at least every two (2) years. Inspections will be conducted by a certified life safety codes inspector employed by DMRS. Inspections will be conducted utilizing the THDA Comprehensive Home Inspection Form provided in Appendix D. 9.11.c. United States Department of Labor, Occupational Safety and Health Administration (OSHA) Standards: Residential providers are required to comply with OSHA standards for universal precautions, blood-borne pathogens and exposure control. Information regarding methods of maintaining OSHA compliance is provided in Appendix T.

Provider Manual, Chapter 9 Residential Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

9 - 14

9
9.12. Transportation Provided as a Component of a Residential Service The reimbursement rates for every type of residential service are inclusive of transportation needed by service recipients with the exception of transportation to and from medical service appointments covered by the Medicaid/TennCare state plan. Although individual transportation is provided as a stand-alone service in the Medicaid waivers and DMRS state-funded programs, service recipients receiving residential services are not eligible to receive individual transportation services unless such transportation services are necessary for Orientation and Mobility Training. General requirements pertaining to staff who transport and vehicles used to transport service recipients are described in Chapter 16. 9.13 Inappropriate Charges to Service Recipients or Service Recipient Families Providers may not impose charges upon service recipient or family members of service recipients for items used as a part of conducting business as a provider, such as administrative functions/costs (e.g., cell phones required as a condition for taking the service recipient on community outings, although cell phones may be purchased using the service recipients funds if requested by the service recipient or legal representative), paper products (e.g., paper towels and toilet paper used by staff) or office supplies (e.g., copy paper, writing utensils). Providers may not require service recipients to pay for supplies such as gloves that are required by OSHA or other state and federal regulatory authorities to provide basic first aid or observe universal precautions. Providers must ensure that service recipients do not pay for food consumed by staff working in the home. Staff working in the home may not consume food purchased with the service recipients food stamps. 9.14. Sign-in Logs Residential providers are responsible for maintaining a sign-in log for each service recipient home that documents the individuals who visit the residence throughout the day and indicates the purpose for the visit. The sign-in log must indicate the time the visitor entered and left the home. 9.15 Housing Resources 9.15.a. Establishment Funds: Establishment funds are available as a state-funded DMRS service. Establishment funds may be used for initial housing-related expenses when service recipients are first enrolled in a DMRS community program and chose a residential service option or when a service recipient who is enrolled accesses funded residential services for the first time. Establishment funds may also be used to replace

Provider Manual, Chapter 9 Residential Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

9 - 15

9
house-hold items when such items are broken or damaged and cannot be repaired or cannot be repaired at a cost below the cost of replacing the item. Establishment funds are limited to a maximum of $4000 per fiscal year. Receipts or invoices must be provided and payment will be made based on actual expenses incurred. Establishment funds may be used for expenses including, but not limited to the following: 1) 2) 3) 4) 5) The first months rent when leasing or renting a property; Housing security deposits; Utility deposits; Furniture and appliances; Household items such as dishes, silverware, pots and pans, bed linens, towels, home dcor items, fire extinguishers and smoke alarms; and 6) Essential furniture/appliance repairs or replacement items. 9.15.b. MR Housing: Limited state funds are available to assist service recipients in making lease, rent or mortgage payments. Because funding is very limited, DMRS is able to initiate MR Housing payments only for class members. However, DMRS nonclass members who were approved in the past to receive MR Housing will continue to be able to receive such payments as long as state funds are available. The amount of MR housing authorized for a service recipient is base on income and expenses. Authorization of MR Housing requires that an individual room and board budget be completed. The budget is to be submitted to the DMRS Regional Office by the support coordinator/case manager for authorization. Any time an increase in MR Housing is needed, a new budget must be completed and submitted to the Regional Office. Amounts of MR Housing in excess of $450 must be approved by the DMRS Central Office. 9.15.c. Housing Resource Manual: A resource manual has been developed by DMRS to assist in buying or renting a home, accessibility and fair housing laws/resources, titled Individualizing Residential Supports Resource Manual and is accessible on the DMRS website and upon request by contacting any DMRS office.

Provider Manual, Chapter 9 Residential Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

9 - 16

Provider Manual, Chapter 9 Residential Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005
Adult Habilitation Day Facility 4 or More Clients Not Capable of Self Preservation Adult Habilitation Day Facility Adult Habilitation Day Facility 1 or More Mobile Non-Ambulatory Clients Pre-School Facility Diagnosis & Evaluation Facility Institutional Facility Residential Habilitation Facility 4 or More Clients Not Capable of Self Preservation Residential Habilitation Facility 2 or 3 Clients Residential Habilitation Facility 1 or More Mobile Non-Ambulatory Clients Adequacy of Facility & Ancillary Services (0940-5-5) Life Safety 1& 2 Family Dwellings (0940-5-4-.07(2) Life Safety Board & Care ((0940-5-4-.06(1) Life Safety Business (0940-5-4-.04) Life Safety Educational (0940-5-4-.03(2) Life Safety Health Care (0940-5-4-.02(2) Life Safety Industrial (0940-5-4-.07(2) Minimum Program Requriements All Facility (0940-5-6) Minimum Program Requriements 0940-5-20 Minimum Program Requriements 0940-5-21 Minimum Program Requriements 0940-5-22 Minimum Program Requriements 0940-5-24 Minimum Program Requriements 0940-5-25 Minimum Program Requriements 0940-5-27 Minimum Program Requriements 0940-5-28 Minimum Program Requriements 0940-5-32 Mobile Non-Ambulatory 0940-5-4-.09(2)

9 - 17

Residential Habilitation Facility 4 or More Clients Residential Habilitation Facility 1 or More Mobile Non-Ambulatory Clients Boarding Home Facility 2 or 3 Clients Boarding Home Facility 4 or More Clients Placement Services Respite Care Services Facility Semi-Independent Living Facility Supported Living Services Facility

Provider Manual, Chapter 9 Residential Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005
Adequacy of Facility & Ancillary Services (0940-5-5) Life Safety 1& 2 Family Dwellings (0940-5-4-.07(2) Life Safety Board & Care ((0940-5-4-.06(1) Life Safety Business (0940-5-4-.04) Life Safety Educational (0940-5-4-.03(2) Life Safety Health Care (0940-5-4-.02(2) Life Safety Industrial (0940-5-4-.07(2) Minimum Program Requriements All Facility (0940-5-6) Minimum Program Requriements 0940-5-20 Minimum Program Requriements 0940-5-21 Minimum Program Requriements 0940-5-22 Minimum Program Requriements 0940-5-24 Minimum Program Requriements 0940-5-25 Minimum Program Requriements 0940-5-27 Minimum Program Requriements 0940-5-28 Minimum Program Requriements 0940-5-32 Mobile Non-Ambulatory 0940-5-4-.09(2)

9 - 18

10
CHAPTER 10 DAY SERVICES

10.1.

Introduction It is the policy of the Division of Mental Retardation Services (DMRS) that service recipients shall have the opportunity to live the life they choose to the extent possible given their financial resources and abilities. DMRS acknowledges and recognizes that service recipients should have meaningful lives. Exactly what meaningful looks like must be defined in terms of the individual choices made by or on behalf of each service recipient. The manner in which time is spent during the day-time hours is a highly important choice that must be made and addressed in every service recipients individual support plan (ISP). One of DMRS primary goals is for service recipients to have adequate information about and access to any of the day service options that are available within the DMRS service system. DMRS respects the informed choices made by service recipients and legal representatives. Regardless of what day service(s) best meet the service recipients needs, DMRS will be diligent in ensuring that day activities are meaningful to the service recipient, that day hours are not spent in completing irrelevant activities that only fill time and that day services are provided in accordance with measurable outcomes as specified in the ISP. DMRS supports the Employment First! initiative spearheaded by the Tennessee Employment Consortium (TEC). The Employment First! project was launched with the primary goal of increasing the number of people with mental retardation employed in the state of Tennessee. Thus far, the project has been successful in increasing the percentage of DMRS service recipients who are employed and has also resulted in production of the Day Services Resource Handbook, which is available at DMRS offices and will soon be available on the DMRS website (see contact information in Appendix F). In support of Employment First!, DMRS advocates that employment be considered in planning for day services. For those individuals who chose other day services options, DMRS requires that the option of employment be reconsidered, at a minimum, during the annual ISP update and that vocational evaluations be completed every three (3) years unless declined by the service recipient and/or legal representative as applicable. DMRS advocates that service recipients who want a job should have one and that with necessary and

Provider Manual, Chapter 10 Day Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

10 - 1

10
appropriate supports, service recipients who chose employment can successfully work in the community. DMRS also believes that service recipients who want to retire should be able to do so when they reach the age that retirement would be expected for a person in the general population. 10.2. Waiver Definition of Day Services The waiver definition shall apply to all day services funded via a Medicaid waiver. The waiver definition shall also be used for DMRS state-funded day services. The waiver definition for day services approved by the Centers for Medicaid and Medicare Services (CMS) is: Day Services: Day Services shall mean individualized services and supports that enable an enrollee to acquire, retain or improve skills necessary to reside in a community-based setting; to participate in community activities and utilize community resources; to acquire and maintain employment; and to participate in retirement activities. Therapeutic goals and objectives shall be required for enrollees receiving Day Services. Day Services may be provided in settings such as specialized facilities licensed to provide Day Services, community centers or other community sites or job sites. Services may also be provided in the enrollees place of residence if there is a health, behavioral or other medical reason or if the enrollee has chosen retirement. This service shall not be provided in inpatient hospitals, nursing facilities and Intermediate Care Facilities for the Mentally Retarded. With the exception of employment that is staff supported, Day Services shall be provided only on weekdays during the day (i.e., between the hours of 7:30 a.m. and 6:00 p.m.), as specified in the plan of care. Day Services shall be limited to a maximum of 6 hours per day and 5 days per week up to a maximum of 243 days per enrollee per year. Except for transportation to and from medical services otherwise covered through the Medicaid State Plan/TennCare program, transportation that is needed during the time that the enrollee is receiving Day Services shall be a component of Day Services and shall be included in the Day Services reimbursement rate. Transportation to and from the enrollees place of residence to Day Services shall be the responsibility of the Day Services provider. With the exception of transportation necessary for Orientation and Mobility Training, Individual Transportation Services shall not be billed when provided during the same time period as Day Services.

Provider Manual, Chapter 10 Day Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

10 - 2

10
Day Services shall not replace services available under a program funded by the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act. For an enrollee receiving employment supports, reimbursement shall not be made for incentive payments, subsidies, or unrelated vocational training expenses such as the following: 1) Incentive payments made to an employer to encourage or subsidize the employer's participation in a supported employment program; 2) Payments that are passed through to users of supported employment programs; or 3) Payments for vocational training that is not directly related to an enrollee's supported employment program. Day Services are not intended to replace services available through the Medicaid State Plan/TennCare program. 10.3. Planning for Day Services Individual support planning is discussed in detail in Chapter 3. Information specific to day services, including follow-along services, are described in Chapter 3, Section 3.12.k. and l. 10.3.a. Vocational Evaluations: Vocational evaluations may be used as a tool for making service recipients and members of the Planning Team aware of available employment options and for determining the best employment alternatives to meet individual needs. It is required that vocational evaluations performed by either employment-based day service providers or the Department of Human Services (DHS), Division of Rehabilitation Services (DRS) be made available to service recipients on a regular basis. Each year during the ISP update process, the service recipient and other members of the Planning Team will have the opportunity to discuss the appropriateness of current day services and whether changes to the ISP should be made. If the service recipient has expressed interest in pursuing employment-based options, a vocational assessment should be completed and submitted to the support coordinator/case manager at least ninety (90) calendar days prior to the Planning Meeting. This allows the support coordinator an opportunity to review the assessment results with the service recipient and legal representative/family members prior to incorporation of assessment recommendations into the ISP draft. Recommendations included in the vocational evaluation are to be considered by the Planning Team and incorporated into the ISP as appropriate. If employment is not an option that is recommended by the Planning Team, the support coordinator/case manager will indicate that the service recipient does not choose to work and will not require a vocational evaluation.

Provider Manual, Chapter 10 Day Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

10 - 3

10
10.3.b. Frequency of Vocational Evaluations: A vocational assessment may be performed at any time it is needed, but is required at least every three (3) years unless the service recipient or legal representative (as applicable) does not wish to seek employment and declines to sign a consent for the assessment. The support coordinator/case manager is responsible for maintaining documentation of refusal of the assessment and the reasons why the assessment was refused. 10.3.c. Required Vocational Evaluation Format: The DRS Supplemental Evaluation Basic Evaluation Form or other assessment format approved by DMRS will be utilized to perform vocational evaluations. The DRS Vocational Evaluation consists of two parts: The Situational Job Assessment and the Summary of General Job Requirements. 10.3.d. Situational Job Assessments: Situational Job Assessments must be completed at the work site within the community. The following information must be included in the written assessment: 1) The location where the assessment was completed; 2) The date the assessment was completed; 3) The signature of the person completing the assessment and the date of completion of the written report; 4) The amount of time spent at the job site where the assessment took place; 5) Any physical or cognitive barriers affecting the service recipients ability to perform job duties or functions for the duration of the assessment; 6) The level of job coach intervention needed for the individual to perform necessary job tasks; 7) The natural supports available within the work environment that could be utilized to enhance independence; 8) The job tasks the service recipient liked and disliked; 9) A description of any behavioral issues that could affect job performance; and 10) A description of any special training or assistance needed to ensure job site accessibility. 10.3.e. Summary of General Job Requirements: The summary of general job requirements is intended to ensure that the service recipient is placed in a job situation that offers the best possible chance for success. The summary of general job requirements must include the following: 1) A summary of interests, likes, dislikes, skills and other personal information that may be indicative of the type of job that would be suitable for the service recipient;

Provider Manual, Chapter 10 Day Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

10 - 4

10
2) Resources for transportation to and from work and any special training or assistance needed for access to transportation; 3) If the person does not receive residential services, the willingness of natural supports within the service recipients home or community to be involved in supporting the service recipients work-related outcomes; 4) Any barriers to successful job performance that exist within the residential/home environment; 5) The anticipated role of the residential provider or natural supports at home in supporting the service recipients work-related outcomes; 6) The factors affecting the work schedule, such as the times of the day the service recipient is available to work and the number of consecutive hours the service recipient is able to tolerate; 7) Any work disincentives that exist; 8) The service recipients ability to communicate within the work environment and any communication assistance needed; 9) Medication taken that could affect work performance or limit the type of work duties the service recipient is capable of performing; 10) Potential barriers or challenges to performance of work duties, such as behavioral or mental health issues or medical conditions; 11) Identification of specific supports needed to complete job duties successfully; 12) Identification of the level of job coaching needed and information about the service recipient that is essential for the job coach to provide adequate supports; and 13) A summary of recommendations for job placement and supports based on the information obtained. 10.4. Requirements for Provision of Day Services Requirements related to day services will be described in three distinct categories: Employment-based day services, community-based day services and facility-based day services. Day services options may be provided in combination. For example, a person may work three (3) days per week receiving employment-based day services and receive personal assistance or community-based day services during other days. The combination of day services to be provided will be specified in the ISP. 10.4.a. Employment-Based Day Services: Employment-based day services facilitate access and support activities such as competitive employment, self-employment, enclaves and work crews. Requirements for employment-based day services are as follows:

Provider Manual, Chapter 10 Day Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

10 - 5

10
1) The service recipient must receive fair and commensurate wages in accordance with the Fair Labor Standards Act and Tennessee Labor laws (see cite in Appendix C); 2) The services must be provided in an integrated work setting with the exception of persons who are self-employed and work from their homes; 3) The services must be individualized and aligned with the outcomes and action steps specified in the ISP; 4) The services must include ongoing assistance and/or specialized supervision with job skills/duties as needed to enable the service recipient to sustain employment; 5) The services must include communication between the employer and day service provider to ensure the service recipients success in the work environment; 6) The services must include communication with other providers and staff participation on the Planning Team as necessary to ensure service coordination and integration; 7) The services must be provided in a safe work environment and must be provided in accordance with the providers written supervision plan; 8) The services provided must support vocational growth such as career advancement or job duty changes as specified in the ISP; and 9) The services must be provided by staff who have completed job coach training as specified in Chapter 7. 10.4.b. Community-based Day Services: Community-based day services enable the service recipient to participate in meaningful and productive activities in integrated settings with other community members who may or may not have disabilities. Community-based day services may be provided in a service recipients home if there is a health, behavioral or other medical reason or if the enrollee has chosen retirement as indicated in the service definition on page 10-2. Supports provided may facilitate job exploration activities, volunteer work, educational activities and other meaningful, measurable community activities that promote developing relationships and maintaining ongoing relationships with friends and family members. Requirements for communitybased day services include: 1) The services must be individualized and aligned with the outcomes and action steps specified in the ISP; 2) The services must be provided in an integrated community setting with the exception of services provided in the home; 3) The services provided must include ongoing assistance and/or specialized supervision with skills or functional abilities as needed to access or participate in the community activities specified in the ISP; 4) The services provided must be provided in a safe community setting and must be provided in accordance with the providers written supervision plan;

Provider Manual, Chapter 10 Day Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

10 - 6

10
5) A monthly schedule of day activities is to be maintained by the provider for the purpose of being able to locate service recipients and direct support staff during day activities; 6) The services provided must include documented communication with other providers and staff participation on the Planning Team as necessary to ensure service coordination and integration; and 7) The services provided must be geared toward enhancing personal growth. 10.4.c. Facility-based Day Services: Facility-based day services are provided in a licensed day habilitation facility. Activities are generally geared toward providing training in personal care, providing supports to enhance the development of needed skills and/or providing vocational activities that are within the interests and abilities of the service recipient. Requirements for facility-based day services include: 1) The service recipient must receive fair and commensurate wages in accordance with the Fair Labor Standards Act and Tennessee Labor laws (see cite in Appendix C); 2) The services must be individualized and aligned with the outcomes and action steps specified in the ISP; 3) The services must include ongoing assistance and/or supervision as needed to enable the service recipient to continue facility-based day activities; 4) The services must include communication with other providers and staff participation on the Planning Team as necessary to ensure service coordination and integration; 5) The services must be provided in a safe environment as specified in day habilitation licensure regulations (see cite in Appendix C) and must be provided in accordance with the providers written supervision plan; and 6) The services provided must support personal and/or vocational skills such as activities that enhance individual growth or provide opportunity for job changes as specified in the ISP. 10.4.d. Staffing Requirements: A staffing plan must be developed for each day service provided. Staffing plans are to be kept in provider administrative offices along with documentation to support that the staffing plan was followed. Staffing plans must ensure: 1) Compliance with applicable licensure standards; 2) Availability of sufficient staff to meet the day service needs of each service recipient; 3) Availability of sufficient staff to protect the health and safety of the service recipients present at the day service delivery site; and

Provider Manual, Chapter 10 Day Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

10 - 7

10
4) Availability of back-up staffing when scheduled staff are unable to report to work. 10.5. Utilizing Natural Supports in the Provision of Day Services The use of natural, or unpaid, supports in the workplace is encouraged. The use of natural supports can be beneficial to the service recipient. Benefits to the service recipient may include increased inclusion in the work environment, development of positive relationships with co-workers and improved job performance. 10.5.a. Requirements and Limitations: When natural supports are utilized, the following requirements and limitations will apply: 1) The type and amounts of assistance provided by natural supports must be described in the ISP and updated as needed during the monthly review process; 2) Applicable federal and state confidentiality guidelines for sharing information with natural supports will apply, i.e., the service recipient or legal representative will need to consent if protected health information needs to be shared with coworkers who are not employed by the day service provider; 3) Work-related natural supports are to be utilized only to provide on-the-job training and support that would be provided to any person hired in a similar position; 4) Day service providers are prohibited from contracting with the service recipients employer to allow natural supports within the work environment to be substituted for support that must be provided by trained job coaches; 5) State-funded day service providers are permitted to bill at the DMRS published rates for times during which natural supports are utilized if service provision and documentation requirements are met; however providers are prohibited from billing the Medicaid waiver programs for times when services are provided by natural supports; 6) Natural supports are to be included in the providers staffing plan; however, the day service provider retains responsibility for safety and other requirements associated with the service being provided; and 7) A job coach employed by the day service provider must be available on call if needed to come to the work site immediately upon request from the service recipient or the service recipients employer. 10.5.b. Reimbursement of Employment Services When Natural Supports are Utilized: Day service providers offering employment supports have two reimbursement options when natural supports are utilized. The option applicable to a specific service recipient will be specified in the ISP. The options are as follows:

Provider Manual, Chapter 10 Day Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

10 - 8

10
1) Reimbursement at follow-along rate: Follow-along services are reimbursed as a monthly rate. A provider-employed job coach must have face-to-face contact with the service recipient as needed, with a minimum of two (2) face-to-face contacts per month. One contact per month must be at the site where day services are rendered, unless the person receiving services requests that contact not be made at the worksite or the Planning Team determines that it is disruptive or detrimental to the person for contact to occur at the work site. In such circumstances, two (2) face-to-face contacts will still be required, but the sites of the contacts will be addressed in the ISP. 2) Reimbursement at the employment-based rate: Employment-based services are reimbursed at a daily rate. Provider staff rendering employment-based services must maintain contact as needed, with a minimum of three (3) contacts per week. One contact per week must be at the work site. Providers are prohibited from substituting natural supports for paid, trained provideremployed staff when billing at the special needs rate or the group model employment rate or through any of the Medicaid waiver programs. 10.5.c. Reimbursement of Follow-Along Services When the Service Recipient is not Employed: In the event that a job offer is withdrawn or a service recipient is terminated by an employer, the provider may bill for up to two (2) months when efforts to secure employment are ongoing. A minimum of two (2) contacts per month, made for the purpose of attending job interviews with the service recipient, must be documented for reimbursement to occur. 10.6. Documentation Requirements for Provision of Day Services General requirements for service recipient records are provided in Chapter 8. Requirements specific to the provision of day services are described in this section. 10.6.a. Staff Instructions: Provider responsibilities for implementing the ISP, including those related to developing and implementing staff instructions are discussed in Chapter 3, Section 3.13. and Chapter 6, Section 6.11. 10.6.b. Staff Notes: Check list formats may be used to document completion of routine daily activities. Significant accomplishments, unusual events or occurrences, the service recipients response to day service activities and/or any monitoring activities related to the service recipients employment-related performance are to be documented in narrative form in the staff notes. Required contacts must be documented in staff notes.

Provider Manual, Chapter 10 Day Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

10 - 9

10
Documentation should be relevant and related to the outcomes and action steps specified in the ISP. 10.6.c. Monthly Reviews: The day service provider must complete a monthly review for ISP action steps and outcomes related to the provision of day services. The monthly review provides a summary of the progress towards completion of action steps and achievement of outcomes and identifies any barriers that have presented during the month. The monthly review also is to identify issues that require follow-up during the upcoming month(s) and describe follow-up activities completed for issues identified in previous monthly review(s). The monthly review is to be submitted to the support coordinator or case manager by the twentieth (20th) day of the month following the month for which the review is being completed. Monthly reviews are discussed in greater detail in Chapter 3, Section 3.14. 10.7. Vocational Rehabilitation Services Vocational Rehabilitation (VR) is a federal/state funded program that provides services to help people with disabilities enter or return to employment. VR services are provided by the Department of Human Services, Division of Rehabilitation Services (DRS). Any available VR services must be accessed prior to provision of DMRS-funded day services. DMRS-funded day services are available only to service recipients who do not qualify for VR services, who have been denied access to VR services or who have exhausted VR services and continue to require support. Referrals for VR services may be made by contacting a VR Office (contact information provided in Appendix B) by mail, telephone or internet. Additional information, including the VR Application for Services, is available on the DHS website (website information provided in Appendix F). Eligibility for VR services is determined by a VR Counselor employed by DRS. In making an eligibility determination, the VR Counselor relies upon the information contained in the application and upon additional supporting documentation such as medical examinations, psychological examinations, vocational evaluations and other diagnostic information. A working age individual must meet the following criteria to be determined eligible for VR services: 1) The person must have a physical or mental impairment which constitutes or results in a substantial impediment to employment; 2) The person must be able to benefit from VR services in terms of employment outcome; and 3) The person must require VR services to prepare for, secure, retain or regain employment. Persons receiving Supplemental Security Income (SSI) or Social Security Disability Income (SSDI) based on disability or blindness are presumed

Provider Manual, Chapter 10 Day Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

10 - 10

10
eligible if there is intent to go to work, unless there is clear and convincing evidence that the disability is too severe for the person to benefit from VR services in terms of employment outcome.

Provider Manual, Chapter 10 Day Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

10 - 11

11
CHAPTER 11 HEALTH MANAGEMENT & OVERSIGHT

11.1. Introduction Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. World Health Organization, 1946 Maintaining optimal health is one of the most basic supports provided by DIDD and DIDD service providers. Achieving this outcome is dependent upon a number of factors including the following: Helping people to make person centered decisions about a healthy lifestyle and to participate, to the extent possible, in decisions about their health. Ensuring that people receive preventive health-related care and services, including recommended physical and dental exams. Ensuring that people receive assessment, treatment and follow up for acute and chronic health issues as recommended by treating practitioner(s). Medication management including proper administration, observation of medication effects and proper documentation as well as reporting any concerns to the proper professional(s). Maintaining accurate records to assure current information regarding health is available. 11.2. People are supported to have the best possible health DIDD and DIDD providers have a shared responsibility to ensure that people maintain the best possible health. Best possible health is different for each person and depends on the individuals current overall health status and what can be done to provide preventative care, treat existing and acquired conditions or improve current health status. 11.2.a. Conceptual overview of Health Care Oversight: It is important to note the ongoing expectation of DIDD that each person receives the level of health care oversight necessary to ensure that all his/her health care needs are met. Providers of residential, day, personal assistance, independent support coordination and clinical services are required to define in policy how they will manage and document the health care of persons served. Health management and oversight mechanisms applicable to all persons served must be incorporated into the providers policies and procedures.

Provider Manual, Chapter 11 Health Management and Oversight Final: 6/12/2012, Effective Date: 6/15/2012

11- 1

11
Health care oversight is an ongoing systematic monitoring and review to assure the persons health care needs are being addressed. It can be broad or limited. This includes activities such as oversight of the Medication Administration Record and medication variances. Providers are obligated to ensure that qualified staff performs appropriate health care oversight. Providers are responsible for obtaining a Professional Supports Services License from the Department of Health (DOH, reference TCA 1200-08-34) if health care supports includes the completion of tasks that can only be performed by licensed staff. 11.2.b. Health Care Management and Oversight Responsibilities of Residential, Day, Nursing and Personal Assistance Providers: Providers are expected to develop/maintain policies and implement practices that achieve the following outcomes related to health care management and oversight: 1) Appropriate consents are obtained prior to sharing health related information and prior to providing services and treatments that require informed consent; Necessary medical, dental and other appointments are arranged and attended in a timely manner including routine appointments and any recommended follow-up appointments, exams or treatment; Arranging and/or providing transportation for medical, dental and other appointments, timely arrival of persons supported to scheduled appointment, and preparation of the person supported for any procedure scheduled; Staff accompanying persons supported to medical, dental and other appointments are familiar with the person served and are able to provide necessary information such as current medications and all physical and behavioral health issues and concerns (e.g. aggression, anxiety, etc.) to practitioners; The day and residential agencys process ensures that medical providers have information about the persons current medication as well as any pertinent historical information about any allergies or issues related to specific medications. Staff assist the person and/or family in requesting clarifications as needed from practitioners in regard to information provided about health-related conditions or treatments; Adequate information describing the outcome of the appointment and any further recommendations is incorporated into the persons record and appropriate internal and external staff (i.e. support coordinators, case managers) are informed of recommended changes to services and/or the ISP; Orders, treatments and recommendations from medical and clinical practitioners are implemented as recommended; Staff monitor for and identify basic medical signs and symptoms such as swelling, rashes, shortness of breath, bleeding, etc., and report these to a medical practitioner, when appropriate (e.g., nurse, primary care provider (PCP) or emergency services);
11- 2

2)

3)

4)

5)

6)

7)

8) 9)

Provider Manual, Chapter 11 Health Management and Oversight Final: 6/12/2012, Effective Date: 6/15/2012

11
10) Staff knows how to respond to symptoms that may indicate serious health problems requiring immediate attention and are able to take the appropriate actions (e.g., choking); 11) Staff recognizes and communicates symptoms that are uncharacteristic or abnormal for a person so the appropriate medical, clinical, dental or mental health evaluations can be initiated; 12) Medications are administered as ordered; 13) Medication administration is completed and appropriately documented by licensed and unlicensed staff; 14) Medication variances are detected, reported and addressed immediately; 15) Medication changes and other significant changes in health status are communicated to all direct support professionals who provide services to the person, to conservators/legal representatives, to family members, to support coordinators/case managers and to any other professionals who provide direct services and need the information to ensure services are appropriate and adequate; 16) Health considerations such as eating a healthy diet, participating in regular exercise and getting adequate sleep are incorporated into daily routines in accordance with the recommendations of the persons treating health care practitioners (e.g., PCP or nutritionist) and preferences as specified in the support plan; 17) Food and nourishment are provided in accordance with nutritional needs, prescribed diets, mealtime instructions and physicians orders. 11.2.c. Responsibilities of Support Coordinators and Case Managers in supporting health and oversight: Support Coordinator and Case Manager responsibilities include: 1) Information is routinely provided about services and supports available through the waiver, state plan and other community services regarding best health care choices to persons served, their families and/or legal representatives; Information regarding how particular treatments and services such as physical therapy, occupational therapy, behavior services, and nutrition services may contribute to best possible health choices for the person served is routinely provided; Necessary information and support is routinely provided to persons served and their family/legal representatives about addressing end of life issues. Assistance with arranging and scheduling transportation to medical, dental, or other health care related appointments.

2)

3)

4)

Provider Manual, Chapter 11 Health Management and Oversight Final: 6/12/2012, Effective Date: 6/15/2012

11- 3

11
11.3. Primary Care Practitioner and Dental Services Persons served shall have access to primary care services as needed. Regular contact with the Primary Care Provider (PCP) for physical examination, appropriate medical screenings and medical care of acute and chronic conditions is essential to maintenance of best possible health. Persons served shall have access to dental services as needed. Regular contact with the dentist is essential to maintenance of best possible health. 11.3.a. Frequency of Physician Contacts: Each person served must receive a medical examination according to TennCare Rules. Table 11.5 describes TennCare, CMS, and DIDD minimum requirements for medical examination by the physician. Table 11.5 Schedule for Medical Examinations per TennCare Rule Age Minimum Frequency Up to age 21 In accordance with TennCare Early Periodic Screening, Diagnosis and Treatment (ESPDT) standards. Age 21-64 Every one (1) to three (3) years as determined and documented by the PCP. Age 65 and Annually older
Note: TennCare rules indicate physical exams must be annual unless otherwise noted by exception by the attending primary care practitioner.

11.3.b. Provider Responsibility for Scheduling and Keeping Physician Appointments: In residential services, the provider is responsible for making, and supporting the person in keeping the appointment and ensuring the outcome of the appointment is documented in the persons record. In day services with no residential component, the provider is responsible for working with the person, family or legal representative to make appointments, supporting the person in keeping the appointment and ensuring the outcome of the appointment is properly documented in the persons record. If the person does not obtain the medical examination as required, the provider must document, in case notes, evidence of all supports given and/or offered to the person and their family.

Provider Manual, Chapter 11 Health Management and Oversight Final: 6/12/2012, Effective Date: 6/15/2012

11- 4

11
If a person does not receive residential or day services, the persons Support Coordinator/Case Manager will assist the primary caregiver as needed to ensure appointments are made, kept and proper documentation is obtained. The Support Coordinator/Case Manager must take every available opportunity to ensure the person attends medical examinations as needed or required (e.g. periodic medical examinations). If the person does not obtain the medical examination as required, the support coordinator/case manager must document, in case notes, evidence of all supports given and/or offered to the person and their family as well as update the persons risk assessment as to the refusal to obtain an annual examination.

11.3.c. Documentation of Primary Care Provider (PCP) and Other Physician Visits: It is not required that primary care providers use any particular form to document the history, physical examinations and/or assessments. Documentation is required to demonstrate that an appropriate health review has been performed. Documentation of all physician visits must be maintained. While not required, providers may wish to develop a standard form for use in assisting with the communication of all needed information. Documentation of periodic health reviews is required to demonstrate that these have been performed. 11.4. Management of Medication Administration A statutory exemption (TCA 4-5-202 and 68-1-904) was established as a means to allow unlicensed staff to administer certain medications to people who receive DIDD services. As a result of this exemption, DOH promulgated rules which established a mechanism of training unlicensed staff to administer medications. The training curriculum, Medication Administration for Unlicensed Personnel, was developed by DIDD and is based on DOH rules. 11.4.a. Operating a Medication Administration Training Program for Unlicensed Personnel Any provider agency employee who is not otherwise authorized by law to administer medications in a program for intellectual disabilities shall be allowed to perform such duties only after passing a competency test. An employee who administers medications in a program in compliance with the provision of this paragraph shall be exempt from the licensing requirement of the Nurse Practice Act and the Department of Health (DOH) Rules 1200-20-12-.03. Authority: T.C.A. 68-1-904.
Provider Manual, Chapter 11 Health Management and Oversight Final: 6/12/2012, Effective Date: 6/15/2012 11- 5

11
Before administering medications, an unlicensed employee must satisfactorily complete a medication administration training program as set forth in Department of Health Rule 1200-20-12-.02(2). 11.4.b. Utilizing Unlicensed Staff to Administer Medications: Providers who employ unlicensed staff who administer medications must be able to manage medication administration in accordance with state rules. Providers are required to develop, maintain and implement written policies and procedures that meet DOH requirements pertaining to the administration of medication by unlicensed staff. Provider policies and procedures shall be reviewed and accepted by DIDD Office of Health Services or designee prior to any unlicensed staff administering medications. 11.4.c. The Medication Administration Record (MAR): A separate MAR must be maintained for each person receiving medications. MAR required elements are specified in DOH rules (1200-20-12-.06) and are also included in the training curriculum Medication Administration for Unlicensed Personnel. 11.5. Provider Responsibility for Administration of Medications Providers employing staff who administer or assist with administration of medications are responsible for the administration and management of medications during the hours services are provided. 11.5.a. Provider Responsibilities for psychotropic medications: Psychotropic medications are appropriate as part of the treatment plan for psychiatric illness. The responsibilities of providers in relation to people with prescribed psychotropic medications include, but are not limited to: 1) Documenting the response of the person supported on the psychotropic medication in terms of side effects, frequency of targeted behaviors, recipients quality of life, and whether or not the person is taking his/her psychotropic medication as prescribed; 2) Ensuring that Tardive Dyskinesia screenings are completed by the prescribing physician or appropriately trained staff at least every six (6) months for people using psychotropic or other medications known to cause Tardive Dyskinesia; 3) Ensuring that there is a plan for as needed or PRN orders for psychotropic medications as ordered by the physician. The plan shall include a list of less restrictive measures to be taken or attempted to stabilize the situation should a crisis occur. Psychotropic medication may only be administered by a licensed nurse after a registered nurse or prescribing practitioner has determined that all other less restrictive measures have been taken.

Provider Manual, Chapter 11 Health Management and Oversight Final: 6/12/2012, Effective Date: 6/15/2012

11- 6

11
4) Providing current information to clinicians regarding the medications taken by the person served, including any psychotropic medications; and 5) Ensuring training has been provided on recognizing Neuroleptic Malignant Syndrome, Serotonin Syndrome and other potentially life threatening side effects. 11.6. Managing Medication Variances Providers who employ unlicensed and licensed staff to administer medications must manage medication variances. A medication variance occurs when a medication is given in a way that is not consistent with how it was ordered by the prescribing practitioner. Medication variances result when: medications are given to the wrong person, medications are omitted, medications are given at the wrong time, the wrong dose is given, the wrong medication is given, the medication is given by the wrong route (e.g., via injection when by mouth was ordered), medications are not prepared according to orders (e.g. given whole when ordered crushed or given in pill form when liquid form is ordered). A description of medication variances and required responses to variances are provided in the Medication Administration for Unlicensed Personnel training. Providers are required to implement written policies that ensure: reporting requirements are met, medication variances are identified and tracked, medication variance trends are identified. 11.6.a. Provider Response to Medication Variance: Providers must take prompt actions to address any medication variance that occurs, per the category of the variance. The first priority is to determine how the medication variance has affected, or could affect, the person and ensure measures are taken to stabilize or prevent deterioration of health status. If the potential for harm is present, the persons prescribing primary care practitioner, pharmacist or a hospital emergency room should be contacted for consultation. Actions expected to occur following stabilization of the persons health status include, but are not limited to: 1) Contacting the health care practitioner who prescribed the medication. 2) Documenting the variance in the record. 3) Documenting instructions received from the prescribing practitioner consulted and follow up actions taken by staff member.

Provider Manual, Chapter 11 Health Management and Oversight Final: 6/12/2012, Effective Date: 6/15/2012

11- 7

11
Medication variance categories include Categories A - I. Categories D and above require primary care practitioner contact. See Medication Variance Form MR0484 for further information. 11.6.b. Documenting and Reporting the Medication Variance: The provider is responsible for documenting medication variances in the persons record. The documentation should report what medication was given, what medication should have been given, and any intervention that resulted. The Medication Administration Record (MAR) should indicate the nature of the variance. For example, if the dose was administered incorrectly or omitted; if the wrong medication was administered; if medication was given by the wrong route and/or if medication was not prepared according to orders (e.g. given whole when ordered crushed or given in pill form when liquid is ordered). When any variance occurs, a DIDD approved medication variance form should also be completed. Not all medication variances are reportable incidents. Reportable incidents are defined in Chapter 18 of this manual. 11.7. Response to Medical Emergencies All persons will have some form of identification that includes emergency contact information. Direct support staff should be trained to recognize symptoms indicative of medical emergency such as excessive bleeding, choking, loss of consciousness, expression of significant pain, obvious bone fracture, obvious break in skin integrity, etc. Staff should also be able to recognize any symptoms specific to the person that indicate he or she is feeling sick or becoming ill, based on known medical conditions or past experiences. All staff should be able to provide emergency personnel with accurate and detailed information regarding the incident or circumstances which preceded the persons current medical condition, such as diagnosed medical conditions, allergies and current medications. Staff should be knowledgeable about advance medical directives for the person. Note that Do Not Resuscitate orders do not apply to choking. The names of the physicians treating the person should be presented to emergency personnel as well. Written policies and procedures and training that communicate to direct care staff actions expected to be taken in a medical emergency should include at a minimum: Instructions that 911 calls must not be delayed; Information regarding initiation of emergency first aid procedures; Instructions on how to help someone who is or appears to be choking; Requirements for provision of information to emergency medical personnel; Requirements for notification of designated provider supervisory staff; and Making information accessible in a timely manner.

Provider Manual, Chapter 11 Health Management and Oversight Final: 6/12/2012, Effective Date: 6/15/2012

11- 8

11
11.8. Provision of Basic First Aid Staff is to administer basic first aid. requirements. See Chapter 7 for specific training

11.8.a. First Aid Supplies/Kits: Stocked first aid kits must be accessible in residential settings and in any other site where services are routinely provided such as a home, day service site and vehicles used for transportation. First aid supplies will be kept in a secure container which includes items that are compliant with standards set forth by the Occupational Health and Safety Administration (reference 29 CFR 1910.266 App A). The following list sets forth the minimally acceptable number and type of first aid supplies for first aid kits: 1) Gauze pads (at least 4 x 4 inches) 2) Two large gauze pads (at least 8 x 10 inches) 3) Box adhesive bandages (such as Band-Aids or equivalent) 4) One package gauze roller bandage at least 2 inches wide 5) Two triangular bandages or equivalent 6) Wound cleaning agent such as sealed moistened towelettes 7) Scissors 8) At least one blanket 9) Tweezers 10) Adhesive tape 11) Latex gloves 12) Resuscitation equipment such as resuscitation bag, airway, or pocket mask 13) Two elastic wraps 14) Splint 15) Directions for requesting emergency assistance

11.9.

Ensuring Continuity of Care During Hospitalization and Upon Discharge 11.9.a. Primary Provider Responsibilities: When in-patient hospitalization is necessary, communication, planning, collaboration and coordination between DIDD, provider staff and hospital staff is essential to continuity of care. Primary provider responsibilities include: 1) Ensuring a contact list is provided to hospital staff describing individuals to be called regarding medical issues and the circumstances under which such calls are to be made;

Provider Manual, Chapter 11 Health Management and Oversight Final: 6/12/2012, Effective Date: 6/15/2012

11- 9

11
2) Ensuring that required items are taken to the hospital with the person, including personal items, medical information and copies of other relevant information including but not limited to a list of current medications and dosages; 3) Ensuring appropriate individuals are contacted, including family members, legal representatives, the support coordinator/case manager, medical providers and other DIDD providers. 11.9.b. Support Coordination/Case Management Responsibilities: Be aware of changes to health status or needs of person in regards to longterm supports which may result from the hospitalization. If such changes occur, update the ISP within 14 calendar days from date of discharge to ensure the persons needs continue to be met. 1) Provide the hospital with contact numbers for the support coordinator/case manager, as well as information regarding how to make contact after hours. 2) Provide communication links between the person, family, legal representative, service provider and hospital staff. 3) Make hospital discharge planning staff aware of the role and assistance that the support coordinator/case manager is able to offer in identifying and obtaining the supports and services available to the person upon discharge. 11.9.c. Discharge Planning: Discharge planning should begin as soon as a person is admitted to an inpatient hospital. The support coordinator/case manager will collaborate with the family and/or the residential provider to ensure the person has adequate supports while receiving in-patient hospital care. The support coordinator/case manager will also coordinate any amendments to the ISP to include any anticipated additional services that may be needed post-discharge. Discharge planning activities performed by the ISC should include: 1) Where the person is to go following discharge; 2) Identification of individuals and/or medical professionals to be contacted and informed when discharge is imminent; 3) Arrangements to resume or change previous professional services as appropriate and/or arrangements for providers of any new services and supports needed post-discharge; 4) Arrangements for any environmental modifications or new equipment needed post discharge; 5) Arrangements for transportation to alternative treatment facilities if necessary;
Provider Manual, Chapter 11 Health Management and Oversight Final: 6/12/2012, Effective Date: 6/15/2012 11- 10

11
6) Providing instruction and/or training to new staff as needed to support the person served post-discharge; 7) Ensuring an adequate supply of medication needed in accordance with physicians orders post discharge; and 8) Making arrangements for follow-up appointments.

Provider Manual, Chapter 11 Health Management and Oversight Final: 6/12/2012, Effective Date: 6/15/2012

11- 11

13
CHAPTER 13 THERAPY SERVICES

13.1.

Introduction Therapy services can be a crucial component in assisting DMRS service recipients to develop or maintain the skills and abilities needed to achieve outcomes identified in the Individual Support Plan (ISP). This chapter provides information about therapy services that are provided and funded through Medicaid HCBS waivers or state-funded DMRS programs. Therapy services provided through a Medicaid waiver and other DMRSfunded programs are not intended to replace the services that are covered by a service recipients TennCare managed care organization (MCO) or by Medicare or private health insurance. The TennCare MCO is required to cover therapy services as medically necessary in accordance with the TennCare MCO contract. The TennCare MCO contract is available on the TennCare website (see Appendix F). The TennCare MCO generally provides therapy services needed when a service recipient has an acute illness or injury or when therapy services are needed following a significant medical event, such as surgery. If a service recipient is enrolled in a Medicaid waiver or other DMRS-funded programs and experiences an acute issue requiring therapy services, funding for such services that is available through Medicare, the TennCare MCO or private insurance must be accessed and utilized before Medicaid waiver or other DMRS-funded therapy services will be provided or resumed.

13.2.

Waiver Definition for Physical Therapy The waiver definition shall apply to all physical therapy services provided in a Medicaid waiver. The waiver definition shall also be used to define physical therapy services provided in other DMRS-funded programs. The waiver definition for physical therapy services approved by the Centers for Medicaid and Medicare Services (CMS) is: Physical Therapy: Physical therapy shall mean diagnostic, therapeutic and corrective services which are within the scope of state licensure. Physical Therapy services provided to improve or maintain current functional abilities as well as prevent or minimize deterioration of chronic conditions leading to a further loss of function are also included within this definition. Services must be provided by a licensed physical therapist or by a licensed physical therapist assistant working under the supervision of a

Provider Manual, Chapter 13 Therapy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

13- 1

13
licensed physical therapist. Physical Therapy must be ordered by a physician, physician assistant or nurse practitioner and must be provided face-to-face with the enrollee. Physical Therapy therapeutic and corrective services shall not be ordered concurrently with Physical Therapy assessments (i.e., assess and treat orders are not accepted). Physical Therapy shall be provided in accordance with a treatment plan developed by a licensed physical therapist based on a comprehensive assessment of the enrollees needs and shall include specific functional and measurable therapeutic goals and objectives. The goals and objectives shall be related to provision of Physical Therapy to prevent or minimize deterioration involving a chronic condition which would result in further loss of function. Continuing approval of Physical Therapy services shall require documentation of reassessment of the enrollees condition and continuing progress of the enrollee toward meeting the goals and objectives. Physical Therapy shall not be billed when provided during the same time period as Occupational Therapy; Speech, Language and Hearing Services; Nutrition Services, Orientation and Mobility Training; or Behavior Services, unless there is documentation in the enrollees record of medical justification for the two services to be provided concurrently. Physical Therapy shall not be billed with Day Services if the Day Services are reimbursed on a per hour basis. Physical Therapy is not intended to replace services that would normally be provided by direct care staff. Physical Therapy services are not intended to replace services available through the Medicaid State Plan/TennCare program or services available under the Rehabilitation Act of 1973 or Individuals with Disabilities Education Act. To the extent that such services are covered in the Medicaid State Plan/TennCare Program, all applicable Medicaid State Plan/TennCare Program services shall be exhausted prior to using the waiver service. Physical Therapy assessments shall be limited to a maximum of 3.0 hours per enrollee per day, and other Physical Therapy services shall be limited to a maximum of 1.5 hours per enrollee per day. Physical Therapy assessments shall not be billed on the same day with other Physical Therapy services. 13.3. Waiver Definition for Occupational Therapy The waiver definition shall apply to all occupational therapy services provided in a Medicaid waiver. The waiver definition shall also be used to define occupational therapy services provided in other DMRS-funded programs. The waiver definition for occupational therapy services approved by the CMS is:

Provider Manual, Chapter 13 Therapy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

13- 2

13
Occupational Therapy: Occupational Therapy shall mean diagnostic, therapeutic and corrective services which are within the scope of state licensure. Occupational Therapy services provided to improve or maintain current functional abilities as well as prevent or minimize deterioration of chronic conditions leading to a further loss of function are also included within this definition. Services must be provided by a licensed occupational therapist or by a licensed occupational therapist assistant working under the supervision of a licensed occupational therapist. Occupational Therapy must be ordered by a physician, physician assistant or nurse practitioner and must be provided face-to-face with the enrollee. Occupational Therapy therapeutic and corrective services shall not be ordered concurrently with Occupational Therapy assessments (i.e., assess and treat orders are not accepted). Occupational Therapy shall be provided in accordance with a treatment plan developed by a licensed occupational therapist based on a comprehensive assessment of the enrollees needs and shall include specific functional and measurable therapeutic goals and objectives. The goals and objectives shall be related to provision of Occupational Therapy to prevent or minimize deterioration involving a chronic condition which would result in further loss of function. Continuing approval of Occupational Therapy services shall require documentation of reassessment of the enrollees condition and continuing progress of the enrollee toward meeting the goals and objectives. Occupational Therapy shall not be billed when provided during the same time period as Physical Therapy; Speech, Hearing and Language Services; Nutrition Services, Orientation and Mobility Training, or Behavior Services, unless there is documentation in the enrollees record of medical justification for the two services to be provided concurrently. Occupational Therapy shall not be billed with Day Services if the Day Services are reimbursed on a per hour basis. Occupational Therapy is not intended to replace services that would normally be provided by direct care staff. Occupational Therapy services are not intended to replace services available through the Medicaid State Plan/TennCare program or services available under the Rehabilitation Act of 1973 or Individuals with Disabilities Education Act. To the extent that such services are covered in the Medicaid State Plan/TennCare Program, all applicable Medicaid State Plan/TennCare Program services shall be exhausted prior to using the waiver service. Occupational Therapy assessments shall be limited to a maximum of 3.0 hours per enrollee per day, and other Occupational Therapy services shall be limited to a maximum of 1.5 hours per enrollee per day. Occupational Therapy assessments shall not be billed on the same day with other Occupational Therapy services.

Provider Manual, Chapter 13 Therapy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

13- 3

13
13.4. Waiver Definition for Speech, Language and Hearing Services The waiver definition shall apply to all speech, language and hearing services provided in a Medicaid waiver. The waiver definition shall also be used to define speech, language and hearing services provided in other DMRS-funded programs. The waiver definition for speech, language and hearing services approved by the CMS is: Speech, Language and Hearing Services: Speech, Language and Hearing Services shall mean diagnostic, therapeutic and corrective services which are within the scope of state licensure which enable an enrollee to improve or maintain current functional abilities and to prevent or minimize deterioration of chronic conditions leading to a further loss of function. Services must be provided by a licensed speech language pathologist or by a licensed audiologist. Speech, Language and Hearing Services must be ordered by a physician, physician assistant or nurse practitioner and must be provided face to face with the enrollee. Speech, Language and Hearing therapeutic and corrective services shall not be ordered concurrently with Speech, Language and Hearing assessments (i.e., assess and treat orders are not accepted). Speech, Language and Hearing Services shall be provided in accordance with a treatment plan developed by a licensed speech language pathologist or a licensed audiologist based on a comprehensive assessment of the enrollees needs and shall include specific functional and measurable therapeutic goals and objectives. The goals and objectives shall be related to provision of Speech, Language and Hearing Services to prevent or minimize deterioration involving a chronic condition which would result in further loss of function. Continuing approval of Speech, Language and Hearing Services shall require documentation of reassessment of the enrollees condition and continuing progress of the enrollee toward meeting the goals and objectives. Speech, Language and Hearing Services shall not be billed when provided during the same time period as Physical Therapy, Occupational Therapy, Nutrition Services, Orientation and Mobility Training or Behavior Services, unless there is documentation in the enrollees record of medical justification for the two services to be provided concurrently. Speech, Language and Hearing Services shall not be billed with Day Services if the Day Services are reimbursed on a per hour basis. Speech, Language and Hearing Services are not intended to replace services that would normally be provided by direct care staff or to replace services available through the Medicaid State Plan/TennCare program. To the extent that such services are covered in the Medicaid State Plan/TennCare Program, all applicable Medicaid State Plan/TennCare Program services shall be exhausted prior to using the waiver service. Speech, Language and Hearing Services assessments shall be limited to a maximum of 3.0 hours per enrollee per day, and other Speech, Language and Hearing Services shall be

Provider Manual, Chapter 13 Therapy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

13- 4

13
limited to a maximum of 1.5 hours per enrollee per day. Speech, Language and Hearing Services assessments shall not be billed on the same day with other Speech, Language and Hearing Services. 13.5. Licensure Requirements As indicated in the waiver definitions above, therapy services must be provided by or under the supervision of a licensed physical therapist or occupational therapist, or by a licensed speech language pathologist or audiologist. Therapists with a temporary license are not allowed to provide therapy services in the DMRS system. Licensed professionals providing therapy services must either be employed or contracted by a licensed home care organization (either a traditional home health agency or a professional support services provider) or be an individual practitioner who has obtained licensure to provide professional support services. Licensure is obtained from the Tennessee Department of Health (see contact information in Appendix B). Reimbursement will not be provided for periods during which licensure has lapsed. 13.5.a. Services Provided by Therapy Assistants and Aides: Reimbursement will not be provided for therapy assistants who are not adequately supervised by a licensed therapist in accordance with professional practice acts and professional standards (see Section 13.5.c.). Reimbursement will not be provided for services rendered by physical therapy or occupational therapy aides. 13.5.b. Services Provided by Clinical Fellows or Students: Reimbursement will not be provided for services rendered by individuals completing clinical fellowships in speech language pathology or audiology or for students in the therapy field. 13.5.c. Supervision of Physical and Occupational Therapy Assistants: The waiver will reimburse providers for the services of a physical or occupational therapy assistant when such services are provided under the direction/supervision of a licensed physical or occupational therapist. Time required to supervise a therapy assistant has been addressed when setting the rates for reimbursement of therapy assistant services. Consequently, reimbursement for time spent supervising a therapy assistant will not be provided. When services are provided concurrently by a therapist and a therapy assistant, reimbursement will be provided for the services of only one of the professionals, either the therapist or the therapy assistant. To direct/supervise a therapy assistant, the licensed therapist must document: 1) Instructing and supporting the therapy assistant; 2) Monitoring the therapy assistants provision of services;

Provider Manual, Chapter 13 Therapy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

13- 5

13
3) On-site observation of the therapy assistants treatment and evaluating the appropriateness of the treatment a minimum of every sixty (60) calendar days or more frequently as needed; 4) Providing follow-up with the therapy assistant regarding recommendations resulting from the supervisory visit; 5) Complying with any other supervisory requirements specified in the Rules of Tennessee Board of Occupational and Physical Therapy Examiners Committee of Physical Therapy Division of Health Related Boards, Chapter 1150-1, General Rules Governing the Practice of Physical Therapy and General Rules Governing the Practice of Occupational Therapy; and 13.6. Other Requirements for Therapy Services Therapy services will be approved and/or reimbursed only if licensure requirements (see Section 13.5.) are met and services are provided in accordance with the waiver service definitions provided in previous sections. This section provides additional information regarding requirements for therapy services. 13.6.a. Physician Order Requirement: Therapy services will not be approved without a physicians order and reimbursement will not be provided for therapy services rendered without an order from a physician, physicians assistant or nurse practitioner. Physicians orders must include the amount, frequency and duration of the service to be provided. Assess and treat orders will not be accepted. An order must be obtained for the therapy assessment. When recommendations based upon the therapy assessment are available, an order must be obtained for therapy services to be provided based upon the medical practitioners review and determination of whether the recommendations are appropriate and medically necessary. 13.6.b. Face-to-Face Requirement: Approval will be granted for units of time spent providing direct services to an individual. Documenting provision of such services is considered a part of the service. Rates for therapy services are inclusive of the time required for documentation and other administrative activities. Consequently, additional reimbursement is not provided for units of time spent in documentation, whether the documentation is done at the service delivery site or in the therapists office or home. 13.6.c. Plan of Care Requirements: The therapy plan described in the waiver service definition must be aligned with the action steps and outcomes specified in an approved ISP. The therapy plan must be developed in accordance with the planning process described in Chapter 3.

Provider Manual, Chapter 13 Therapy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

13- 6

13
13.6.d. Provision of Concurrent Services (Co-treatment): Reimbursement will not be made for certain services provided during the same time period unless there is adequate justification documented in the therapy record to support the need for co-treatment. Cotreatment may involve different therapy services, such as occupational therapy, physical therapy and/or speech/language and hearing services. Co-treatment may also apply to the provision of therapy services during the same time as other clinical services, such as behavioral services, nutrition services, orientation and mobility training or nursing services. There must be documentation of the medical necessity to justify the provision of the services concurrently. For example, a physical therapist may be needed to position an individual properly in a side-lyer while a speech language pathologist provides trials of food in this position and assesses the individuals tolerance to the feeding based on physical signs and oxygen saturation levels during the trials. While orders must be obtained for each of the clinical services to be concurrently provided, a specific order to co-treat or provide the services at the same time is not required. Co-treatment does not specifically have to be specified in the ISP; however, each of the services to be provided concurrently must be included. Co-treatment is a intervention or mechanism for addressing or achieving an outcome and is not a goal or outcome in and of itself. 13.6.e. Utilization of Therapy Services: Therapy services are to be utilized to perform functions which contribute to the action steps and outcomes specified in the ISP that cannot be provided by persons other than licensed therapy professionals. Therapy services will not be approved or reimbursed if the activities that need to be completed with the service recipient could be safely performed by direct support staff. Therapy services may be utilized to: 1) Assess service recipient functional abilities and limitations in light of the achievement of action steps and outcomes in the ISP and make recommendations as to how the implementation of a therapy plan could expedite meeting action steps and outcomes or help in overcoming functional barriers; 2) Assess the need for adaptive equipment/assistive technology in light of the action steps and outcomes in the ISP; 3) Develop a therapy plan of care with input from the Circle of Support, including the service recipients legal representative; 4) Seek input in developing the therapy plan of care from direct support staff and other service providers as appropriate; 5) Assist in converting therapy recommendations to staff instructions that are integrated with the service recipients daily activities; 6) Provide competency-based training to facilitate direct support staff implementation of any staff instructions provided;

Provider Manual, Chapter 13 Therapy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

13- 7

13
7) Provide training to ensure proper use of adaptive equipment/assistive technology when training is needed beyond that which is provided by the manufacturer or supplier of the equipment; 8) Provide direct hands-on therapy services to develop, improve or maintain skills related to ISP action steps that cannot be accomplished/implemented by direct support staff. 13.6.f. Non-Reimbursable Activities: Reimbursement will not be provided for: 10) Time spent in the community with a service recipient when no skilled services are provided and/or no therapeutic goals are identified (e.g., watching a service recipient participate in activities such as bowling, watching a sporting event with a service recipient, going shopping with a service recipient or riding in a van with the service recipient). 11) Time spent waiting for a service recipient to arrive at the location where therapy services are to be provided; 12) Time spent performing administrative functions such as documentation, staff supervision, telephone conversations, etc.; 13) Time spent traveling to and from sites to locate a service recipient who is scheduled to receive therapy services; 14) Ongoing range of motion provided by a therapist that does not result in measurable functional change in an activity of daily living within a reasonable time period (i.e. two to four months); 15) Endurance activities that are not related to improvement of a functional skill or identified ISP outcome; 16) Range of motion activities or endurance-related activities that could be provided by direct support staff; 17) Ambulation of a service recipient who has an established functional gait pattern; 18) Time spent determining an appropriate communication system without specific documentation showing measurement/evaluation of the outcome of trials and practice sessions; 19) Sensory-based or other activities that are not linked to ISP action steps; 20) Activities related to implementation of an exercise or weight loss program that could be supervised by direct support staff; 21) Ongoing services to facilitate participation in fitness-related leisure activities such as gym work-outs, martial arts, bowling, playing games, walking in the park, shopping mall, library, museum, etc. that could be supervised by direct support staff; 22) Unjustified or excessive time spent monitoring implementation of staff instructions without analyzing measurable data;

Provider Manual, Chapter 13 Therapy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

13- 8

13
23) Services or intermittent assessments not supported by the original assessment and included in the ISP; and 24) Services provided in a Intermediate Care Facility for the Mentally Retarded (ICF/MR), Skilled Nursing Facility (SNF), local K12 educational facility or other federally funded program. 13.6.g. Continuation of Therapy Services: Therapy services are generally approved for a time-limited period that may be based upon a physicians order or upon a therapy practitioners estimation of the time required to achieve the therapeutic outcomes specified in the therapy plan of care and ISP. If additional time is needed beyond the period of approval originally obtained, a new service authorization request must be submitted. Continued approval of and reimbursement for therapy services will require documentation that the service recipients condition has been reassessed and that progress toward meeting individual outcomes is ongoing. 13.7. Limits on Units of Service A limit has been established on the number of units of each therapy service that may be provided and reimbursed during a day. The limits are based upon utilization history and upon the amount of direct therapy service that a service recipient would typically be able to tolerate in a single session. Additional time is allowed for assessment to ensure that assessments are completed with expediency so that the service recipients therapy needs may be addressed as soon as possible. 13.7.a. Reimbursement of Direct Face-to-Face Therapy Services: Reimbursement may be authorized for provision of each direct therapy service specified in the ISP, including the training of direct support staff by licensed therapists, for up to one and onehalf (1.5) hours per enrollee per day. 13.7.b. Reimbursement of Therapy Assessments: Reimbursement of face-to-face therapy assessments will be provided for up to three (3) hours per day for the purpose of performing therapy assessments. 13.8. Establishing the Need for a Therapy Assessment The need for a therapy assessment may arise when: 1) Other assessments, such as the uniform assessment, risk assessment or Physical Status Review (PSR) indicate the need for further evaluation; 2) A health/safety issue is identified that requires a particular type of therapy assessment to achieve appropriate resolution; or

Provider Manual, Chapter 13 Therapy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

13- 9

13
3) A service recipient cannot accomplish a particular action step or outcome and therapy assessment and recommendations are warranted to determine recommendations for potential changes to the ISP which could result in achievement of actions steps or outcomes. 13.8.a. Indicators for Occupational Therapy Assessment: An occupational therapy assessment may be justified when a service recipient has issues, limitations or decline in functional abilities related to: 1) Home management and leisure activities; 2) Mealtime difficulties (e.g., difficulty eating, choking, signs of aspiration, poor positioning or the need for adaptive equipment); 3) Difficulty getting on or off the toilet or in and out of the bathtub or shower; 4) Poor oral hygiene; 5) Limited use of the hands; 6) Contractures or decreased range of motion of the shoulders, arms or hands; 7) Sensory processing issues (e.g., self-injurious behavior, self-stimulating behavior, difficulty transitioning from one location to another, touch avoidance or sensitivity to sounds, lights or smells); 8) Accessibility issues in the home, workplace or community; or 9) Vocational needs. 13.8.b. Indicators for Physical Therapy Assessment: A physical therapy assessment may be justified when a service recipient has issues, limitations or decline in functional abilities related to: 1) Difficulty transferring from one surface to another, such as from a wheelchair to the bed; 2) Inability to be mobile without physical assistance; 3) Difficulty moving from a sitting to a standing position; 4) Improperly fitting equipment; 5) Inability to move adequately to alternate positions; 6) Skin breakdown resulting from limited mobility; 7) Unsteady gait or changes in walking pattern; 8) Falls or near falls; 9) Chronic physical impairments, contractures or muscular tightening; or 10) Limited movement due to pain. Physical therapy assessment may also be indicated when an environmental accessibility evaluation is needed or when there is frequent occurrence of staff injuries resulting from providing assistance with transfers or mobility.

Provider Manual, Chapter 13 Therapy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

13- 10

13
13.8.c. Indicators for Speech Language Assessment: A speech language assessment may be justified when a service recipient has issues such as: 1) Difficulty chewing or swallowing, eating too fast, loss of food/fluid from the mouth or pocketing food in the mouth; 2) Signs of aspiration including gagging, wheezing, coughing, choking, persistent drooling, wet vocal quality, changes in breathing during or after meals, refusal of fluid/liquids, frequent upper respiratory infections and/or aspiration pneumonia; 3) Difficulty or frustration with trying to make others understand what is being communicated, including difficulty making wants and needs known, inability to make choices and/or inability to voice opinions; 4) Difficulty communicating with new people or in new environments; 5) Discrepancy between receptive and expressive language skills (i.e., ability to understand exceeds ability to express); or 6) Social skills deficits (e.g., inappropriate use of affection, inappropriate use of words, inability to take turns or inappropriate behaviors related to inability to make self understood). 13.8.d. Indicators for Hearing Assessment: A hearing assessment may be justified when a service recipient has issues such as: 1) Being unresponsive to auditory cues such as speech, slamming doors, car horns, etc.; 2) Turning the head to favor a particular ear when spoken to; 3) Requesting that things be repeated very frequently; 4) Watching for facial cues when spoken to; 5) Being unable to follow verbal directions; 6) Turning the television up too loud; 7) Pulling or rubbing ears when spoken to; 8) Complaining of or showing signs of dizziness; 9) Complaining of ringing in the ears; 10) Complaining of or exhibiting sudden hearing loss or deafness; 11) Hypersensitivity to certain noises or keeping the hands over the ears when certain noises are encountered; 12) Having a hearing aid that is not used, previous use of a hearing aid that is not currently in the service recipients possession or complaining that an available hearing aid does not help; 13) Having malformed ear lobes or ear canals; 14) Having history of ear infections or fluid behind the eardrum; 15) Having history of cerumen (ear wax) buildup;

Provider Manual, Chapter 13 Therapy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

13- 11

13
16) Having drainage from the ear(s); 17) Having a history of previously identified hearing loss; or 18) Normal aging processes that result in decreased hearing function. 13.9. Assessing Durable Medical Equipment and Assistive Technology Needs Service recipients may require durable medical or assistive technology equipment such as wheelchair seating systems, positioning aids, hearing aids, communication devices, specialized dishes or utensils, etc. to ensure health/safety, improve independence or overcome barriers to outcome achievement (see Chapter 14, Section 14.2 for the waiver definition and requirements related to durable medical equipment and assistive technology equipment). Therapy providers are responsible for identifying the need for such equipment/assistive technology during a therapy assessment. Following the assessment, the therapy provider will have a role in ensuring that recommended equipment is provided within a reasonable time frame. The time frame required to provide such equipment may vary depending upon the complexity of the equipment needed, whether the equipment needed is standard equipment or must be made to order, the funding source requirements for justification of the equipment needed or other factors. Therapy provider responsibilities related to assessing for and obtaining equipment include: 1) Performing and documenting assessments; 2) Submitting the written therapy assessment to the support coordinator /case manager; 3) Identifying appropriate equipment, possibly through use of trial equipment as available; 4) Obtaining physicians orders for the equipment needed; 5) Providing letters of justification, physicians order and additional information/documentation needed to obtain approval or reimbursement authorization for the equipment; 6) Obtaining a signed release from the service recipient when pictures or videos must be provided to justify the equipment request; 7) Assisting the service recipient and support coordinator to identify a durable medical equipment or assistive technology provider; 8) Maintaining contact with the support coordinator regarding the status of the equipment request; and 9) Developing staff instructions and/or providing staff training upon delivery of new equipment, when training/instruction beyond that provided by the manufacturer/equipment provider is required.

Provider Manual, Chapter 13 Therapy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

13- 12

13
13.9.a. Customized Equipment Needs: In some cases, a therapy provider many identify the potential need for customized equipment or assistive technology, but may not have the skills required to fully determine what will best meet the service recipients needs. The need for certain types of customized equipment such as custom hand splints, custom positioning equipment, custom seating equipment, custom communication systems or custom modifications to standard equipment may require referral to a therapist with expertise in assessing needs and fabricating customized equipment. When such situations occur, coordination must be ensured by the support coordinator and therapists involved to avoid duplication of services and to either avoid or justify concurrent billing as appropriate. Special service codes have been developed specific to approval of services and reimbursement of providers approved to assess specialized equipment/assistive technology needs and provide related training. 13.9.b. Addressing Equipment Needs in the ISP: As with other therapy services, the need for equipment assessments and equipment must be considered by the Circle of Support, and addressed in the ISP as determined appropriate. 13.10. Referrals for Therapy Assessments 13.10.a. Information Provided upon Referral: A referral request received by a therapy services provider should include sufficient information to allow the therapist to determine why the referral is being made. Additional information should be requested from the referring entity if the following information is not included: 1) Relevant information pertaining to the therapy service requested from the uniform assessment, the risk assessment, the PSR or other assessments that may have prompted the therapy assessment request; 2) Relevant information pertaining to an identified health/safety risk that may have prompted the need for the particular type of therapy assessment requested; and 3) The ISP action steps and outcomes relevant to the particular type of therapy assessment requested. 13.10.b. Completion of a Referral Form: A referral form must be completed by either the referring entity or therapy provider which includes the information indicated in Section 13.10.a. as well as the date of the referral, the name of the referring entity and identifying and demographic information specific to the service recipient. The referral form may be faxed between the therapy provider and the referring entity to ensure completion.

Provider Manual, Chapter 13 Therapy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

13- 13

13
13.10.c. Acceptance of an Assessment Referral: Upon receipt of a completed referral form, the therapy provider is expected to review the available information and determine if able to complete the requested assessment and provide any therapy services that may be recommended as a result of the assessment. If not, the therapy provider must notify the referring entity of such as soon as possible. If so, the therapy provider will accept the referral by completing the DMRS form titled Request for Provision of Therapeutic Services (see Appendix D) and will obtain physicians orders for the therapy assessment, if not already available. The completed Request for Authorization of Funding for Therapies, Nutrition and Orientation and Mobility Assessment and Services form and physicians orders are to be submitted to the support coordinator/case manager. The support coordinator/case manager will seek approval of therapy services by amending/updating the ISP in accordance with the planning process specified in Chapter 3 and submitting it to the DMRS Regional Office. 13.10.d. Requesting Approval for Therapy Assessments: Obtaining approval of an ISP containing a request for therapy assessment is the responsibility of the support coordinator/case manager. Regional Office staff will review and approve the ISP, including the request for therapy assessment, if forms are properly completed, if required supporting documentation is provided, if the ISP is appropriate to the service recipients needs and if services are adequately justified and found to be medically necessary. The following information must be submitted with or included in the ISP/service authorization request for therapy assessment services: 1) Documentation of the indicators/reasons for therapy assessment (see Section 13.8. of this chapter); 2) Physicians orders; 3) Estimated number of units of services needed to complete the assessment; and 4) Documentation of how the units of service requested for therapy assessment will be utilized. 13.11. Completing a Therapy Assessment An assessment must be completed prior to the provision of therapy services, as one of the purposes of the assessment is to justify the need for a particular therapy service. Reimbursements will be provided only for assessments completed by licensed therapists. Therapy assistants will not be reimbursed for completing assessments. The assessment should indicate information sought from the service recipient and any other pertinent sources of information, including the family/legal representative as applicable, the support coordinator, direct support professionals and other providers of services, including other clinicians. Upon notification that therapy assessment units have been approved/authorized, the therapy provider is required to complete the assessment within

Provider Manual, Chapter 13 Therapy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

13- 14

13
thirty (30) calendar days of the approval date. Therapy assessments should be inclusive of all service recipient environments (e.g. the home, the worksite, locations where routine outings occur) that are relevant based on the reasons/indicators for the therapy assessment. 13.12. Development of a Therapy Plan of Care 13.12.a. Minimum Requirements for Therapy Plans of Care: When services are recommended following a therapy assessment, a therapy plan of care must be developed by the therapist which includes the following information: 1) Action steps that are person-centered and measurable; 2) The estimated amount (number of units), frequency (number of therapy visits needed within a specific time period) and duration (estimated number of days/weeks/months services will be needed) of therapy services needed to achieve functional outcomes; 3) The number of service units that will be needed to complete the annual reassessment, if it is anticipated that therapy services will be needed beyond the current ISP period; and 4) Any additional plan of care requirements specified in the Department of Health rules, Standards for Home Care Organizations Providing Professional Support Services. 13.12.b. Addressing Therapy Plan of Care in the ISP: The therapy plan of care, including applicable time frames for completion of therapy action steps, must be integrated with other services required by the service recipient. This is accomplished in part by ensuring that the therapy plan is reflective of and consistent with ISP outcomes. Therapy services not indicated in an approved ISP will not be reimbursed. If a therapy assessment results in a recommendation that does not relate to an existing ISP outcome, one of the following actions may occur: 1) Additional outcomes may be included in the ISP in accordance with the planning process specified in Chapter 3; 2) The service recipient or service recipients legal representative may choose not to accept the recommendation; or 3) The recommendation may be earmarked to be considered for inclusion in the ISP at a later date. Therapy services may be included in an initial ISP, an ISP amendment or an ISP update (see Chapter 3 for detailed information about the planning process). The support coordinator/case manager will distribute the therapy plan of care to the members of the

Provider Manual, Chapter 13 Therapy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

13- 15

13
Planning Team for review. Therapists are expected to attend Planning Meetings if the support coordinator/case manager indicates that the service recipient or the service recipients legal representative has requested their attendance to discuss therapy-related issues. The therapists role during a Planning Meeting is to: 1) 2) 3) 4) Answer questions about the therapy assessment and/or plan of care; Provide information about alternatives to the recommended course of action: Revise the therapy plan of care as discussed during the meeting: and Document the reason why particular recommendations were not accepted during the planning process.

13.12.c. Annual Therapy Reassessments: For therapy services to continue into a new ISP period, a therapy reassessment will be required within one-hundred-twenty (120) calendar days prior to the ISP effective date. The therapy plan of care must be updated as necessary to reflect recommendations that are consistent with therapy assessment results. For service recipients who have had an initial assessment completed within six (6) months of the ISP effective date and who have had no significant health or functional changes, an abbreviated assessment can be completed. The abbreviated assessment must include an updated therapy plan of care. Therapy reassessments and updates to the therapy plan of care must be completed by the licensed therapist. Reimbursement will not be provided for therapy assistants to complete reassessments and updates to the therapy plan of care. The written therapy assessment and updated therapy plan of care must be submitted to the service recipients support coordinator/case manager no later than ninety (90) calendar days prior to the ISP effective date. The therapy assessment and proposed therapy plan of care will be reviewed during the ISP planning process by Planning Team members (see Chapter 3 for detailed information regarding the planning process and annual ISP updates). 13.12.d. Obtaining Physicians Orders for Services: Therapists are responsible for ensuring that physicians orders for therapy services and/or changes in therapy orders are obtained from the physician, physicians assistant or nurse practitioner. Therapy services will not be approved in absence of written physicians orders that include the amount, frequency and duration of therapy services to be provided. 13.12.e. Obtaining Physicians Orders for Dietary Modifications: When a therapist makes recommendations pertaining to dietary modifications requiring a separate physicians order, the primary provider is responsible for obtaining the order. The primary provider is the residential provider if the person receives residential services, the day provider if the person receives day services and does not receive residential services, the personal assistance provider if the person receives personal assistance services and

Provider Manual, Chapter 13 Therapy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

13- 16

13
does not receive day or residential services. If neither residential, day nor personal assistance services are provided, the support coordinator/case manager is responsible for obtaining the physicians diet order. 13.13. Approval of Therapy Services Identified in the ISP 13.13.a. Justification for Therapy Services: As with therapy assessments, other therapy services must be included in the initial or updated ISP or in an ISP amendment and submitted to the DMRS Regional Office for approval. For approval to occur, physicians orders for the therapy service must be provided and the ISP must document: 1) Justification of the need for therapy services requested based upon a therapy assessment, including documentation of the relationship between therapy services and ISP action steps and outcomes and anticipated utilization of the service units requested; 2) Identification of the amount, frequency and duration of therapy services needed, including any hours needed for annual reassessment if anticipated that therapy services will continue into the next ISP period; and 3) Identification of the number of the total units of service requested. 13.13.b. Justification of Maintenance Therapy: Justification for maintenance therapy must include documentation based upon a therapy assessment supporting that proposed interventions will: 1) Sustain current abilities or prevent deterioration in specific functional skills or physical conditions; 2) Allow continued functioning at the present level of independence; and/or 3) Slow deterioration or improve/maintain the comfort of the service recipient during the process of deterioration. 13.14. Provision of Therapy Services The primary purposes for providing therapy assessment and treatment services include facilitating achievement of ISP action steps and outcomes, increasing or maintaining skills to allow independent functioning, preventing deterioration of skills or physical condition and maintaining optimal health and safety. Provision of therapy services includes: 1) Completion of therapy assessments to determine the need for therapy services; 2) Development and revision of the therapy plan of care (see Section 13.12);

Provider Manual, Chapter 13 Therapy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

13- 17

13
3) Participation in planning meetings to ensure that the therapy plan of care is reflective of the ISP and that emerging risk factors related to therapy services are addressed (see Section 13.12.b.); 4) Development of staff instructions, in collaboration with residential, day and personal assistance providers, for therapy-related action steps included in the ISP (see Chapter 3, Section 3.12.g. for requirements for staff instructions); 5) Provision of training to direct support staff regarding staff instructions and/or use of therapy-related equipment; 6) Monitoring on an ongoing basis to ensure that staff instruction and other therapyrelated interventions are appropriately implemented and effective in meeting service recipient needs; 7) Supervision of therapy assistants (see Section 13.5.c.) 8) Provision of direct, hands-on therapy services that may only be provided by a licensed therapy practitioner; 9) Identification of durable medical/adaptive equipment or assistive technology needed, collaboration with the support coordinator/case manager to obtain the assistive technology devices and/or equipment/supplies and provision of training to provider staff and other caregivers to enable proper use of such; 10) Communicating/collaborating with the service recipient and the service recipients family and/or legal representatives as applicable, managed care organizations or private insurance companies and/or other providers to ensure that therapy-related ISP action steps are achieved and therapy services are integrated; and 11) Documenting the provision of therapy services, including activities and /or data pertaining to the implementation of and progress toward completion/achievement of therapy-related ISP action steps and outcomes. 13.14.a. Locations Where Therapy Services Are Provided: Therapy services are to take place in the site most related to the action step or outcome to be completed or achieved. Reimbursement will not be provided for therapy services provided in locations unrelated to the action step or outcome for which the therapy services were specified. Therapists are required to sign in and out to document the time period during which services were provided. For service recipients receiving therapy services in a residential or day setting, such notations are to be made in the staff notes section of the residential or day record. For individuals living in a family home who do not receive residential or day services, therapy contact notes must be recorded at the service site to document time in and out. Contact notes containing time in and time out must include the signature of the service recipient (if able to sign verifying the correct times) or a caregiver or family member present within the home who is able to verify the time period during which therapy services were provided. A separate entry is required for the time services began and ended. Contact notes must be signed by the licensed therapist

Provider Manual, Chapter 13 Therapy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

13- 18

13
providing or supervising services. If time in and out is not appropriately documented, recoupment may occur due to inability to verify service units provided. 13.14.b. Development of Staff Instructions: The licensed therapist is responsible for developing any staff instructions determined necessary to the implementation of therapyrelated ISP action steps. Staff instructions are written strategies for therapy-related tasks or actions that must be implemented by direct support staff employed by the day, residential or personal assistance provider. Staff instructions must be developed in collaboration with the service recipient, the service recipients family and/or legal representative and the providers who employ direct support staff. Input may be sought from therapy assistants as appropriate; however, reimbursement will not be provided for therapy assistants to participate in development of staff instructions. Staff instructions must be developed and staff training must be provided to allow implementation of the tasks/actions specified within thirty (30) calendar days of the date when therapy services were initiated. Collaboration between two or more therapy disciplines may be necessary to ensure an integrated set of staff instructions for a particular therapy-related action step. When this occurs, one of the therapy clinicians must be identified as having primary responsibility for training staff and monitoring implementation of staff instructions to avoid duplication of services. 13.14.c. Implementation of Staff Instructions: The therapist must provide assistance and consultation to direct support staff to ensure that: 1) Training is provided regarding implementation of therapy related staff instructions; 2) Therapy related Staff instructions are understood sufficiently to ensure implementation; 3) Therapy related staff instructions are integrated into the service recipients daily routine utilizing a daily schedule, monthly calendar or other appropriate tools as needed; 4) Staff are able to communicate therapy related staff instructions and their basic purpose; 5) Staff are encouraged and provided opportunity to communicate success in implementing therapy related staff instructions or information about implementation barriers to the therapy provider; 6) Staff are able to problem-solve and/or obtain assistance with problem-solving should issues arise pertaining to the implementation of therapy related staff instructions; and 7) Staff are able to seek consultation from the therapy provider as needed.

Provider Manual, Chapter 13 Therapy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

13- 19

13
13.14.d. Training Direct Support Staff to Implement Therapy-related Staff Instructions: Therapists are responsible for providing training regarding staff instructions when new instructions are developed, when existing instructions are changed or amended and when new equipment is delivered and training is needed beyond that routinely provided by the manufacturer or equipment provider. In some cases, the provider and therapist may agree that a supervisor or house manager can provide staff training to new/replacement staff. Designation of a trainer may not be appropriate if the persons health status is unstable, if frequent changes in staff instructions are required or if staff instructions are unusually complex. In such situations, the therapist may be the most appropriate provider to manage ongoing staff training for therapy-related staff instructions. The reason(s) that a therapist must provide ongoing staff training must be thoroughly documented in either therapy contact notes or therapy monthly reviews. The therapist must continue to reassess for changes in the situation that would allow designation of a trainer employed by the provider of the direct support staff. These ongoing reassessments are to be documented in therapy monthly reviews. The following requirements apply to therapy providers involved in staff instruction training whether training is provided by the therapy provider or by trainers who have been instructed by the therapy provider: 1) Training must be competency basedstaff must be observed implementing staff instructions correctly or using equipment correctly; 2) Training must include information that allows direct support staff to understand the reason why the staff instruction is to be implemented and how it will help the service recipient achieve ISP action steps or outcomes or maintain health and safety; 3) Training must be appropriately documented, including the training content, the names of staff being trained, the dates training sessions occurred and each staff persons performance and competency level; and 4) Monitoring must occur to ensure that training has resulted in staff instructions being carried out correctly and that implementation issues are identified and remedied. 13.14.e. Direct Therapy Services: Direct therapy services are those services which are provided hands-on by the therapist or therapy assistant to the service recipient. Such services are warranted when the nature of the service specified in the ISP is such that it can only be carried by licensed therapy staff in accordance with licensure rules or recognized professional practice standards. Direct therapy services may be required to complete specific actions for a time-limited period, after which direct care staff can be trained to continue implementation. Direct therapy services may include:

Provider Manual, Chapter 13 Therapy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

13- 20

13
1) Completion of equipment trials by an occupational therapy, physical therapy, speech language pathology or audiology provider; 2) Completion of mealtime technique trials by an occupational therapy or speech language pathology provider; 3) Completion of communication system trials by a speech language pathologist or audiologist; 4) Completion of interviews with the service recipient as well as any direct support staff, appropriate family members or legal representatives present with the service recipient for the purpose of completing assessments, developing/revising the therapy plan of care or developing revising staff instructions pertaining to occupational therapy, physical therapy, speech language pathology or audiology services; 5) Provision of direct support staff competency-based training by an occupational therapist, physical therapist, speech language pathologist or audiologist when new staff instructions are developed or new equipment is delivered; 6) Provision of interventions by an occupational therapy provider intended to improve fine or gross motor skills needed to increase independence in completing self-care or home management tasks; 7) Completion of tolerance tests for positioning equipment by an occupational therapist or physical therapist; 8) Provision of interventions by a physical therapy provider intended to improve independence related to transfer or mobility skills; 9) Provision of interventions intended to facilitate communication by a speech language pathologist or audiologist; 10) Attendance with a service recipient at a PCP, orthopedic physicians or specialty physicians appointment if documentation supports the need; and 11) Provision of assistance with positioning or swallowing techniques by a speech language pathologist during a modified barium swallow study or other diagnostic tests. 13.14.f. Monthly Reviews: The therapist is responsible for reassessing therapy services every thirty (30) calendar days or more frequently as necessary for each person receiving therapy services. This is called a monthly review. The monthly review must be completed by the licensed therapist. Reimbursement will not be provided for therapy assistants to complete monthly reviews. Additional information pertaining to monthly review requirements is provided in Chapter 3, Section 3.14. 13.14.g. Discharge from Therapy Services: The therapist should consider whether discharge from therapy services is appropriate during the monthly review process. If discharge is felt to be appropriate, the therapist must advise the person, the family or

Provider Manual, Chapter 13 Therapy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

13- 21

13
legal representative as appropriate and the support coordinator/case manager. The therapist is to provide discharge information as necessary to the Planning Team. Discharge from therapy services is generally appropriate when: 1) Therapy-related ISP action steps have been completed; 2) The service recipient is no longer benefiting from the service; 3) Therapy interventions have been integrated into the service recipients daily routine and are being carried out independently by the service recipient, by direct support staff and/or through other sources of support; 4) Monitoring by the therapist is no longer necessary; and/or 5) Discontinuation of therapy services is requested by the service recipient or legal representative. 13.15. Documenting the Provision of Therapy Services Therapy providers are required to meet general records requirements pertaining to service recipient records specified in Chapter 8. Monthly review general requirements that therapy providers must meet are provided in Chapter 3, Section 3.18. Therapy providers are required to meet requirements for clinical service assessments (Chapter 8, Section 8.9.d.), clinical service contact notes (Chapter 8, Section 8.9.e.), clinical service monthly reviews (Chapter 8, Section 8.9.f.) and clinical service discharge summaries (Chapter 8, Section 8.9.g.). 13.16. Maintaining and Distributing Therapy Records 13.16.a. Contents of Therapy Records: Therapy providers must maintain clinical service records with contents as specified in Chapter 8, Table 8.6. Original documents (assessments, contact notes, monthly reviews and discharge summaries) created by the therapy provider are to be maintained in the therapy record with copies distributed as indicated in Section 13.16.b. 13.16.b. Distribution of Therapy Records: Copies of therapy assessments, monthly reviews and discharge summaries are to be forwarded to: 1) The support coordinator or case manager for inclusion in the support coordination/case management record; 2) The service recipients legal representative; and 3) The primary provider, for inclusion in the Comprehensive Individual Record. The therapist is to review assessment findings with the service recipient and provide a copy upon request.

Provider Manual, Chapter 13 Therapy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

13- 22

13
13.17. Service Reimbursement Rates 13.17.a. Travel Differential Rates: Different levels of therapy rates have been established to accommodate travel time. Higher rates are paid for therapy services when necessary to arrange for therapy providers to travel to remote or rural areas where providers are not available or where the numbers of providers are insufficient to meet the demand for therapy services. The support coordinator/case manager must obtain preauthorization for differential rates to be paid through the ISP approval/service authorization process. 13.17.b. Determining the Appropriate Rate Level for Therapy Services: The rate level provided is based upon the average time required to travel within a defined mile radius. Mileage will be determined utilizing the Mapquest website (www.mapquest.com) to determine the mileage between the town where the therapy providers residence or office (whichever is closest to the service site) is located and the town where therapy services will be provided. If therapy services are provided to a service recipient in different locations, mileage is to be calculated based on the location of the site where therapy services are most frequently provided. Therapy rate levels are based on the following mileage: 1) Level 1: 2) Level 2: 3) Level 3: 0-45 mile radius (one way) 46-75 mile radius (one way) 76+ mile radius (one way)

13.17.c. Requirements Pertaining to Changing Therapy Rate Levels: When a service recipients usual therapist is unable to provide services due to vacation, medical leave or other reasons, an alternate therapist must be identified to provide services during such absence. In some cases, the alternate therapist may travel from a residence or office that is closer to or further from the service delivery site. When such situations occur, the therapy rate level will remain the same unless the period of absence exceeds fourteen (14) calendar days. When the period of absence exceeds fourteen (14) calendar days, submission of an amended Authorization of Funding for Therapy, Nutrition and Orientation and Mobility Services form (see Appendix D) is required in order to adjust the therapy rate to the appropriate level. The form is to be completed by the therapy provider and submitted to the ISC, who is responsible for requesting service authorization from the DMRS Regional Office. If possible, the authorization request form should be submitted prior to the beginning of the period of absence if the provider is aware that an alternate therapist will need to provide services for an extended period of time. Providers will not receive reimbursement at a higher rate level unless advance authorization is obtained from the DMRS Regional Office. Retroactive requests for authorization of a increase in the rate level will not be approved. If determined that a higher rate was paid

Provider Manual, Chapter 13 Therapy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

13- 23

13
due to the providers failure to submit the required form in a timely manner to adjust the rate downward, recoupment will be initiated. 13.18. Integration of Therapy Services Into the Service Recipients Daily Schedule Therapy providers are to work with the service recipient, family caregivers and residential/day provider staff to schedule therapy services. Therapy services should not prevent or delay other services or planned activities. The therapy provider should accommodate to the service recipients schedule as opposed to the service recipient adjusting his/her schedule to be available at the convenience of the therapist. If for some reason either the service recipient or the therapist needs to reschedule a therapy appointment, notification should be provided to the other party as soon as possible to avoid the frustration caused by missed appointments and the associated costs, such as those generated by travel to the site where services were to be provided.

Provider Manual, Chapter 13 Therapy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

13- 24

14
CHAPTER 14 THERAPY-RELATED SERVICES

14.1.

Introduction Therapy-related services are those services that may be recommended as a result of a therapy assessment of service recipient functional capabilities or that may require therapy assessment/services to ensure that a proper treatment plan is developed or that appropriate equipment or supplies are procured. Orientation and mobility training is included in this chapter as the service itself is akin to therapy services, in that the focus of the service is on teaching the service recipient adaptive skills that enable increased independence within the home and other environments.

14.2.

Specialized Medical Equipment and Supplies and Assistive Technology 14.2.a. Waiver Definition for Specialized Medical Equipment and Supplies and Assistive Technology: The waiver definition shall apply to all specialized equipment and assistive technology services provided in a Medicaid waiver. The waiver definition shall also be used to define such services provided in other DMRS-funded programs. The waiver definition for specialized equipment and assistive technology services approved by the Centers for Medicaid and Medicare Services (CMS) is: Specialized Medical Equipment and Supplies and Assistive Technology: Specialized Medical Equipment and Supplies and Assistive Technology shall mean assistive devices, adaptive aids, controls or appliances which enable an enrollee to increase the ability to perform activities of daily living or to perceive, control or communicate with the environment and supplies for the proper functioning of such items. Specialized Medical Equipment, Supplies and Assistive technology shall be recommended by a qualified health care professional (e.g., occupational therapist, physical therapist, speech language pathologist, physician or nurse practitioner) based on an assessment of the enrollees needs and capabilities and shall be furnished as specified in the plan of care. Specialized Medical Equipment and Supplies and Assistive Technology may also include a face-toface consultative assessment by a physical therapist, occupational therapist or speech therapist to assure that specialized medical equipment and assistive technology which requires custom fitting meets the needs of the enrollee and may include training of the enrollee by a physical therapist, occupational therapist or speech therapist to effectively

Provider Manual, Chapter 14 Therapy Related Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

14- 1

14
utilize such customized equipment. Such assessment or training shall be limited to a maximum of three (3) hours per enrollee per day. Items not of direct medical or remedial benefit to the enrollee shall be excluded. Items that would be covered by the Medicaid State Plan/TennCare program shall be excluded from coverage. Swimming pools, hot tubs, health club memberships and recreational equipment are excluded. Prescription and over-the-counter medications, food and food supplements and diapers and other incontinence supplies are excluded. When medically necessary and not covered by warranty, repair of equipment may be covered when it is substantially less expensive to repair the equipment rather than to replace it. Specialized Medical Equipment, Supplies and Assistive Technology is not intended to replace services available through the Medicaid State Plan/TennCare program or services available under the Rehabilitation Act of 1973 or Individuals with Disabilities Education Act. The purchase price for waiver-reimbursed Specialized Medical Equipment, Supplies and Assistive Technology shall be considered to include the cost of the item as well as basic training on operation and maintenance of the item. Specialized Medical Equipment, Supplies and Assistive Technology shall be limited to a maximum of $10,000 per enrollee per 2 year period. 14.2.b. Examples of Specialized Medical Equipment/ and Supplies and Assistive Technology: Examples include, but are not limited to: 1) 2) 3) 4) 5) Communication devices; Hearing devices; Specialized lifts (excluding Hoyer lifts); Positioning equipment; and Wheelchairs and seating devices.

14.2.c. Additional Requirements Related to Provision of Specialized Medical Equipment, Supplies and Assistive Technology: Additional requirements pertaining to this service category not specified in the service definition include: 1) To ensure that Medicare, private insurance or TennCare Managed Care Organization (MCO) benefits are exhausted prior to accessing Division of Mental Retardation Services (DMRS) services, the service recipient must request the needed equipment or supplies from Medicare, the insurance provider and/or the MCO, as applicable. The Medicaid waiver is the payment source of last resort. If services are denied by other potential reimbursement sources, appeal rights must

Provider Manual, Chapter 14 Therapy Related Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

14- 2

14
be exhausted before the service can be approved to be reimbursed through the waiver (appeals procedures are discussed in Chapter 2, Section 2.17.); 2) A copy of the physicians order for this service must be provided with the Individual Support Plan (ISP) or amended/updated ISP requesting approval of specialized equipment, supplies or assistive technology; 3) If a specific vendor or particular type/brand of equipment is requested, the ISP submitted for approval must provide justification; and 4) If the cost of an individual item requested exceeds $499.99, three (3) written bids from three (3) different vendors must be provided with the ISP submitted to the Regional Office for approval. 14.2.d. Assessment for Specialized Medical Equipment/Supplies and Assistive Technology: An assessment performed by an appropriate licensed therapist is required to document the medical necessity of the items in this service category. Detailed information regarding therapy assessments and assessments of equipment needs is provided in Chapter 13, Section 13.9 and 13.10. 1) If a service recipient already receives therapy services, the current therapy provider should be contacted to perform the assessment. If not, a referral must be made to an occupational or physical therapy provider in accordance with Chapter 13. 2) The person must be present with any adaptive equipment used available during the therapy assessment. 3) Once recommended equipment, supplies or technology is available, the therapist who performed the assessment is required to document verification that the items meet the service recipients needs. 14.3. Environmental Accessibility Modifications 14.3.a. Waiver Definition of Environmental Accessibility Modifications: The waiver definition shall apply to all environmental accessibility modifications provided in a Medicaid waiver. The waiver definition shall also be used to define such services provided in other DMRS-funded programs. The waiver definition for environmental accessibility modifications approved by the Centers for Medicaid and Medicare Services (CMS) is: Environmental Accessibility Modifications: Environmental Accessibility Modifications shall mean only those interior or exterior physical modifications to the enrollees place of residence which are required to ensure the health, welfare and safety of the enrollee or which are necessary to enable the enrollee to function with greater independence.

Provider Manual, Chapter 14 Therapy Related Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

14- 3

14
Environmental Accessibility Modifications which are considered improvements to the home (e.g., roof or flooring repair, installing carpet, installation of central air conditioning; construction of an additional room) are excluded from coverage. Any modification which is not of direct medical or remedial benefit to the enrollee is excluded from coverage. Modification of an existing room which increases the total square footage of the home is also excluded unless the modification is necessary to improve the accessibility of an enrollee having limited mobility, in which case the modification shall be limited to the minimal amount of square footage necessary to accomplish the increased accessibility. Environmental Accessibility Modifications shall be limited to a maximum of $15,000 per enrollee per 2 year period. 14.3.b. Examples of Environmental Accessibility Modifications: Examples include, but are not limited to: 1) Wheelchair ramps: 2) Widening of doorways; 3) Modifications of bathroom and kitchen facilities to enable the enrollee to function with greater independence; and 4) Installation of specialized electrical or plumbing systems to accommodate necessary medical equipment and supplies. 14.3.c. Indicators of the Need for Environmental Accessibility Modifications: Service recipient mobility or sensory issues that affect access, independence and/or safety within the home may result in recommendation for and approval of environmental accessibility modifications. Examples of situations that may indicate the need for modifications include: 1) Mobility requires physical assistance or adaptive equipment such as a cane, walker, wheelchair, tub bench, shower chair or mechanical lift. Environmental modifications must be made for such equipment to be accessible and/or safe for use. 2) Sensory limitations such as poor vision, poor hearing or difficulty processing sensory information (e.g., inability to sense hot or cold temperatures) require modifications to ensure safety and/or allow compensation for the physical limitation. 14.3.d. Assessments for Environmental Accessibility Modifications: An assessment performed by an appropriate licensed therapist is required to document the medical

Provider Manual, Chapter 14 Therapy Related Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

14- 4

14
necessity of the items in this service category. Chapter 13, Sections 13.9 and 13.10 provide description of requirements pertaining to assessment of the need for environmental accessibility modifications. 1) If a service recipient already receives therapy services, the current therapy provider should be contacted to perform the assessment. If not, a referral must be made to an occupational or physical therapy provider in accordance with Chapter 13. 2) The service recipient must be present with any adaptive equipment used available during the therapy assessment. If the service recipient is unable to access the home for the initial assessment (i.e. due to stairs), the service recipient may be assisted into the home during the assessment to simulate accessibility that would be possible with procurement of a ramp. 3) Once recommended equipment, supplies or technology is available, the therapist who performed the assessment is required to document verification that the items meet the service recipients needs. 14.4. Vehicle Accessibility Modifications 14.4.a. Vehicle Accessibility Modifications: The waiver definition shall apply to all vehicle accessibility modifications provided in a Medicaid waiver. The waiver definition shall also be used to define such services provided in other DMRS-funded programs. The waiver definition for vehicle accessibility modifications approved by the Centers for Medicaid and Medicare Services (CMS) is: Vehicle Accessibility Modifications: Vehicle Accessibility Modifications shall mean interior or exterior physical modifications (1) to a vehicle owned by the enrollee or (2) to a vehicle which is owned by the guardian or conservator of the enrollee and which is routinely available for transport of the enrollee. Such modifications must be intended to ensure the transport of the enrollee in a safe manner. Replacement of tires or brakes, oil changes and other vehicle maintenance procedures shall be excluded. Vehicle Accessibility Modifications shall not replace Medicaid State Plan/TennCare Program services, and to the extent that such services are covered in the Medicaid State Plan/TennCare Program, all applicable Medicaid State Plan/TennCare Program services shall be exhausted prior to using the waiver service. Vehicle Accessibility Modifications shall be limited to a maximum of $20,000 per enrollee per five (5) year period. 14.4.b. Examples of Vehicle Accessibility Modifications: Examples include, but are not limited to:

Provider Manual, Chapter 14 Therapy Related Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

14- 5

14
1) Lifts that allow access to the vehicle; and 2) Interior modifications such as grab bars, head/leg rests, devices to secure wheelchairs in a stationary position, roof modifications and safety belts. 14.5. Orientation and Mobility Training 14.5.a. Waiver Definition for Orientation and Mobility Training The waiver definition shall apply to all orientation and mobility training provided in a Medicaid waiver. The waiver definition shall also be used to define such services provided in other DMRS-funded programs. The waiver definition for orientation and mobility training approved by the Centers for Medicaid and Medicare Services (CMS) is: Orientation and Mobility Training: Orientation and Mobility Training shall mean assessment of the ability of an enrollee who is legally blind to move independently, safely and purposefully in the home and community environment; orientation and mobility counseling; and training and education of the enrollee and of caregivers responsible for assisting in the mobility of the enrollee. Orientation and mobility training shall be based on a formal assessment of the enrollee and may include concept development (i.e. body image); motor development (i.e. motor skills needed for balance, posture and gait); sensory development (i.e. functioning of the various sensory systems); residual vision stimulation and training; techniques for travel (indoors and outdoors) including human guide technique, trailing, cane techniques, following directions, search techniques, utilizing landmarks, route planning, techniques for crossing streets and use of public transportation; and instructional use of Low Vision devices. Orientation and Mobility Training shall be provided by a Certified Orientation and Mobility Specialist (COMS) who is nationally certified through the Academy for Certification of Vision Rehabilitation and Education Professionals (ACVREP). Orientation and Mobility Training shall be provided face to face with the enrollee or, for purposes of training and education, with the caregivers responsible for assisting in the mobility of the enrollee. Therapeutic goals and objectives shall be required for enrollees receiving Orientation and Mobility Training. Continuing approval of Orientation and Mobility Training shall require documentation of reassessment of the enrollees condition and continuing progress of the enrollee toward meeting the goals and objectives. An enrollee receiving Orientation and Mobility Training shall be eligible to receive Individual Transportation Services. Orientation and Mobility Training shall not be billed when provided during the same time period as Physical Therapy, Occupational Therapy,

Provider Manual, Chapter 14 Therapy Related Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

14- 6

14
Nutrition Services, Behavior Services, or Speech, Language, and Hearing Services, unless there is documentation in the enrollees record of medical justification for the two services to be provided concurrently. Orientation and Mobility Training shall not replace services available under a program funded by the Rehabilitation Act of 1973 or Individuals with Disabilities Education Act. Orientation and Mobility Training shall be limited to a maximum of 60 hours of services per enrollee per year. 14.5.b. Certification Requirements: As indicated in the service definition, orientation and mobility services must be provided by a Certified Orientation and Mobility Specialist (COMS) who is nationally certified through the Academy for Certification of Vision Rehabilitation and Education Professionals (ACVREP). Reimbursement will not be provided for periods during which certification has lapsed. 14.5.c. Other Requirements for Orientation and Mobility Training Services: The requirements for therapy services as specified in Chapter 13, Section 13.6. (inclusive of a. through g.) shall also apply to orientation and mobility training services. 14.5.d. Establishing a Need for Orientation and Mobility Training Assessment: The need for orientation and mobility training services assessment may arise under the same circumstances listed in Chapter 13, Section 13.8. (items #1 through #3). 14.5.e. Indicators of the Need for a Orientation and Mobility Assessment: Specific indicators for orientation and mobility training assessments may include: The need for orientation and mobility training may be related to: 1) History of visual impairment, including visual acuity at or below 20/200 or field test reporting loss of visual field; or 2) History of glaucoma, cataracts or severe myopia/hyperopia (nearsighted/farsightedness). Accompanying symptoms may include: 1) Agitation or abrupt changes in demeanor when significant changes in lighting occur (e.g., outside to inside, opening/closing of blinds/curtains); 2) Stumbling, bumping into things or hesitation in either familiar or unfamiliar areas; 3) Hesitation when moving from place to place; 4) Lack of initiation of independent movement; and/or

Provider Manual, Chapter 14 Therapy Related Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

14- 7

14
5) Behavior problems when being proper sighted guide techniques. escorted by staff unfamiliar with

14.5.f. Referrals for Orientation and Mobility Training Assessments: Requirements for referrals discussed for therapy services in Chapter 13, Section 13.10. (inclusive of a. through d.) shall also apply to referrals for orientation and mobility assessments. 14.5.g. Completing a Orientation and Mobility Training Assessment: Requirements for completion of therapy assessments discussed in Chapter 13, Section 13.11. shall also apply to orientation and mobility training services. Orientation and mobility providers may perform assessments to determine the need for mobility aids and/or low vision aids. Requirements applicable to specialized medical equipment and supplies and assistive technology needs provided in Chapter 13, Section 13.9. shall apply when assessments are performed by orientation and mobility specialists. 14.5.h. Development of a Orientation and Mobility Plan of Care: Requirements for development of therapy plans of care specified in Chapter 13, Section 13.12. (inclusive of a. through e.) shall apply to orientation and mobility training plans of care. 14.5.i. Approval of Orientation and Mobility Training Services Identified in the ISP: Requirements for approval of therapy services specified in Chapter 13, Section 13.13. (inclusive of a. through b.) shall apply to orientation and mobility training service approval. 14.5.j. Provision of Orientation and Mobility Training Services: The primary purposes for providing orientation and mobility training services is to assist service recipients in achieving ISP outcomes, in increasing or maintaining independence and in maintaining overall health, safety and welfare. Requirements applicable to the provision of therapy services provided in Chapter 13, Sections 13.14.a. through 13.14.g. shall apply to the provision of orientation and mobility training services. Direct orientation and mobility training services are those services which must be provided face-to-face with hands-on assistance provided by the orientation and mobility specialist to the service recipient. Such services are warranted when the nature of the service specified in the ISP is such that it can only be carried by a certified orientation and mobility specialist in accordance with professional practice standards. Direct orientation and mobility training providers may be required to complete specific actions for a time-limited period, after which it may be feasible to train direct support staff to continue implementation. 14.5.k. Documenting the Provision of Orientation and Mobility Training Services: Orientation and mobility training providers are required to meet general records requirements pertaining to service recipient records specified in Chapter 8. Monthly

Provider Manual, Chapter 14 Therapy Related Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

14- 8

14
review general requirements that orientation and mobility providers must meet are provided in Chapter 3, Section 3.18. Orientation and mobility training providers are required to meet requirements for clinical service assessments (Chapter 8, Section 8.9.d.), clinical service contact notes (Chapter 8, Section 8.9.e.), clinical service monthly reviews (Chapter 8, Section 8.9.f.) and clinical service discharge summaries (Chapter 8, Section 8.9.g.). 14.5.l. Maintaining and Distributing Orientation and Mobility Training Records: orientation and mobility training providers must maintain clinical service records with contents as specified in Chapter 8, Table 8.6. Original documents (assessments, contact notes, monthly reviews and discharge summaries) created by the orientation and mobility training provider are to be maintained in the orientation and mobility training record with copies distributed as indicated in Chapter 13, Section 13.16.a. Requirements for distribution of records applicable to orientation and mobility training providers are discussed in Chapter 13, Section 13.16.b. 14.5.m. Service Reimbursement Rates: Information regarding travel differential rates and determining the appropriate rate level provided in Chapter 13, Section 13.17 (inclusive of a. through c.) are applicable to orientation and mobility training providers. 14.5.n. Integration of Orientation and Mobility Training Services Into the Service Recipients Daily Schedule: Integration requirements specified in Chapter 13, Section 13.18. are applicable to orientation and mobility training providers.

Provider Manual, Chapter 14 Therapy Related Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

14- 9

15
CHAPTER 15 NURSING, NUTRITION, VISION AND DENTAL SERVICES
15.1. Introduction This chapter describes the remaining professional/clinical services available within the Division of Mental Retardation Services (DMRS) system, but not covered in previous chapters. 15.2. Nursing Services 15.2.a. Waiver Definition for Nursing Services The waiver definition shall apply to all nursing services provided in a Medicaid waiver. The waiver definition shall also be used to define nursing services provided in other DMRS-funded programs. The waiver definition for nursing services approved by the Centers for Medicaid and Medicare Services (CMS) is: Nursing Services: Nursing Services shall mean skilled nursing services that fall within the scope of Tennessees Nurse Practice Act and that are directly provided to the enrollee in accordance with a plan of care. Nursing Services shall be ordered by the enrollees physician, physician assistant or nurse practitioner, who shall document the medical necessity of the services and specify the nature and frequency of the nursing services. Nursing Services shall be provided face to face with the enrollee by a licensed registered nurse or licensed practical nurse under the supervision of a registered nurse. Nursing assessment and/or nursing oversight shall not be a separate billable service under this definition. Therapeutic goals and objectives shall be required for enrollees receiving Nursing Services. This service shall be provided in home and community settings, as specified in the Plan of Care, excluding inpatient hospitals, nursing facilities and Intermediate Care Facilities for the Mentally Retarded (ICF/MRs). An enrollee who is receiving Medical Residential Services shall not be eligible to receive Nursing Services during the hours Medical Residential Services are being provided.

Provider Manual, Chapter 15 Nursing, Nutrition, Vision and Dental Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

15 - 1

15
Nursing Services shall not be billed when provided during the same time period as other therapies unless there is documentation in the enrollees record of medical justification for the two services to be provided concurrently. Nursing Services are not intended to replace services available through the Medicaid State Plan/TennCare program or services available under the Rehabilitation Act of 1973 or Individuals with Disabilities Education Act. To the extent that such services are covered in the Medicaid State Plan/TennCare Program, all applicable Medicaid State Plan/TennCare Program services shall be exhausted prior to using the waiver service. 15.2.b. Nursing Assessments: Requirements applicable to clinical service assessments are described in Chapter 8, Section 8.9.a. Nursing assessment is not a separate billable service. 15.2.c. Planning Nursing Services: Nurses are required to develop a nursing plan of care which must be consistent with action steps and outcomes specified in the Individual Support Plan (ISP). The nursing plan of care must be guided by the specific nursing activities ordered by the physician, including the amount, frequency and anticipated duration of services required. The nursing plan of care must be consistent with and reflective of the action steps and outcomes specified in the ISP. The nursing plan of care will be reviewed by the planning team and included in the ISP in accordance with the planning process described in Chapter 3. 15.2.d. Obtaining Approval for Nursing Services: The support coordinator/case manager will submit the ISP requesting nursing services to the appropriate Division of Mental Retardation Services (DMRS) Regional Office. To obtain approval for nursing services, the following requirements must be met: 1) The ISP must be submitted with a physicians order; 2) The ISP must provide documentation of a chronic medical condition requiring the provision of nursing services; 3) The ISP must provide documentation to justify that the nursing service is medically necessary to ensure the health and safety of the service recipient or to avoid a more costly and restrictive service; and 4) The ISP must provide documentation that nursing services are not available through the Medicare, the TennCare MCO program or private health insurance; 15.2.e. Provision of Nursing Services: The types of services performed by nurses are governed by the Tennessee Nurse Practice Act (see cite in Appendix C). The Nurse Practice Act allows nurses to perform a number of direct and non-direct functions, although not all of the functions allowed are separate billable services within the DMRS

Provider Manual, Chapter 15 Nursing, Nutrition, Vision and Dental Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

15 - 2

15
system. Services that are billable at the hourly unit rate are limited to direct face-to-face activities such as changing wound dressings, administering injectable medications and other medications that cannot be administered by direct support staff in accordance with state law or teaching direct support staff to perform a nursing-related function that the nurse intends to delegate to direct support staff. 15.2.f. Documentation of Nursing Services: Chapter 8 provides general requirements pertaining to provider documentation and records maintenance. Chapter 8, Section 8.9. describes records requirements applicable to clinical service providers. Additionally, a billing calendar must be submitted each month showing the actual amount of time spent providing nursing services on the date(s) services are billed. The amount of nursing units billed must be consistent with the in/out times noted in contact notes. Nursing activities completed during visits and any contacts or follow-up activities completed between nursing visits must be documented in contact notes. 15.2.g. Reimbursement Considerations: Nursing oversight by a registered nurse is reimbursed only as a part of the service rate for Medical Residential Services and Other Residential Services at a reimbursement level of 4 or higher. The nursing services described in this section of the manual are direct face-to-face skilled services. Such nursing services are reimbursed based on the number of units billed. A unit is defined as one hour. Consequently, nursing rates are paid as hourly rates. Reimbursement will not be provided for: 1) Services provided without a physicians order; 2) Services provided prior to authorization/approval; 3) Services provided that do not require the expertise of a skilled nurse and could be safely performed by direct support staff; 4) Assessment activities not considered a component of the direct nursing service being provided (e.g., If changing a wound dressing, assessment of the wound is a part of the physician ordered nursing activity; however, doing a comprehensive head to toe assessment would not be related.); 5) Services provided to a service recipient in a nursing facility or intermediate care facility for the mentally retarded or within a program operated by a local school system; 6) Time spent waiting for a service recipient to arrive at a particular location; 7) Time spent traveling between service sites to locate the service recipient; 8) Units of service billed, but not supported by required documentation; 9) Visits made for purposes other than the provision of direct, hands-on nursing services (e.g., to perform staff supervisory activities); or 10) Time spent performing administrative activities such as documentation, attending meetings, etc.

Provider Manual, Chapter 15 Nursing, Nutrition, Vision and Dental Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

15 - 3

15
15.3. Nutrition Services 15.3.a. Waiver Definition for Nutrition Services The waiver definition shall apply to all nutrition services provided in a Medicaid waiver. The waiver definition shall also be used to define nutrition services provided in other DMRS-funded programs. The waiver definition for nutrition services approved by the Centers for Medicaid and Medicare Services (CMS) is: Nutrition Services: Nutrition Services shall mean assessment of nutritional needs, nutritional counseling and education of the enrollee and of caregivers responsible for food purchase, food preparation or assisting the enrollee to eat. Nutrition Services must be provided in accordance with therapeutic goals and objectives specified in a plan of care developed by a dietitian or nutritionist. A dietitian or nutritionist who provides Nutrition Services must provide services within the scope of licensure and must be licensed as required by the State of Tennessee. Nutrition Services are intended to promote healthy eating practices and to enable the enrollee and direct support professionals to follow special diets ordered by a physician, physician assistant or nurse practitioner. Nutrition Services must be provided face to face with the enrollee or, for purposes of education, with the caregivers responsible for food purchase, food preparation or assisting the enrollee to eat. Nutrition Services shall not be billed when provided during the same time period as Physical Therapy, Occupational Therapy, Speech, Language and Hearing Services, Orientation and Mobility Training or Behavior Services, unless there is documentation in the enrollees record of medical justification for the two services to be provided concurrently. Nutrition Services are not intended to replace services available through the Medicaid State Plan/TennCare program. Nutrition Services shall be limited to a maximum of 1.5 hours per enrollee per day. 15.3.b. Licensure Requirements: As indicated in the service definition, nutrition services must be provided by a licensed dietitian or nutritionist. Licensure is obtained from the Tennessee Department of Health (see contact information in Appendix B). Reimbursement will not be provided for periods during which licensure has lapsed. 15.3.c. Other Requirements for Nutrition Services: The requirements for therapy services as specified in Chapter 13, Section 13.6. (inclusive of a. through g.) shall also apply to nutrition services.

Provider Manual, Chapter 15 Nursing, Nutrition, Vision and Dental Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

15 - 4

15
15.3.d. Establishing a Need for Nutrition Assessment: The need for nutrition assessment may arise under the same circumstances listed in Chapter 13, Section 13.8. (items #1 through #3). 15.3.e. Indicators of the Need for a Nutrition Assessment: Specific indicators for nutrition assessments may include: 1) Unintentional weight loss; 2) Unintentional weight gain or overweight condition; 3) Constipation or chronic use of enemas; 4) Poor food and/or fluid intake; 5) Skin breakdown; 6) Gastro-esophageal reflux disease (GERD); 7) Diagnoses such as diabetes, hypertension, osteoporosis, anemia, etc.; 8) Rumination; 9) Dehydration; 10) Frequent choking or aspiration pneumonia; 11) Tube feedings are required; 12) Conditions that increase metabolic needs are present, such as infection; 13) Intestinal disorders have been diagnosed, such as malabsorption, gluten intolerance, irritable bowel syndrome or Crohns disease; 14) Chronic disease states exist such as chronic obstructive pulmonary disease (COPD), cancer, renal failure/insufficiency, Alzheimers disease that frequently impact intake and nutritional status; 15) Abnormal laboratory values exist, such as high cholesterol, low iron levels or abnormal protein/albumin levels; 16) Poor eating habits or poor dietary compliance are noted; and/or 17) Staff require training to implement a physician-ordered diet or plan and prepare nutritious meals. 15.3.f. Referrals for Nutrition Assessments: Requirements for referrals discussed for therapy services in Chapter 13, Section 13.10. (inclusive of a. through d.) shall also apply to referrals for nutrition assessments. 15.3.g. Completing a Nutrition Assessment: Requirements for completion of therapy assessments discussed in Chapter 13, Section 13.11. shall also apply to nutrition services. 15.3.h. Development of a Nutrition Plan of Care: Requirements for development of therapy plans of care specified in Chapter 13, Section 13.12. (inclusive of a. through e.) shall apply to nutrition plans of care.

Provider Manual, Chapter 15 Nursing, Nutrition, Vision and Dental Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

15 - 5

15
15.3.i. Approval of Nutrition Services Identified in the ISP: Requirements for approval of therapy services specified in Chapter 13, Section 13.13. (inclusive of a. through b.) shall apply to nutrition service approval. 15.3.j. Provision of Nutrition Services: The primary purposes for providing nutrition services is to assist service recipients in achieving ISP outcomes, in increasing or maintaining independence and in maintaining overall health, safety and welfare. Requirements applicable to the provision of therapy services provided in Chapter 13, Sections 13.14.a. through 13.14.g. shall apply to the provision of nutrition services. The types of services performed by nutritionists/dieticians are governed by the Rules of the Tennessee Board of Dietician/Nutritionist Examiners (see cite in Appendix C). Examples of direct face-to-face nutrition services include: 1) Developing nutritional strategies with the service recipient, a family caregiver and/or direct support staff; 2) Identifying foods/developing menus that will meet dietary needs in accordance with physician ordered diets and personal preferences; 3) Teaching healthy techniques for food preparation; and 4) Teaching healthy techniques for shopping and eating out. 15.3.k. Documenting the Provision of Nutrition Services: Nutrition providers are required to meet general records requirements pertaining to service recipient records specified in Chapter 8. Monthly review general requirements that nutrition providers must meet are provided in Chapter 3, Section 3.18. Nutrition providers are required to meet requirements for clinical service assessments (Chapter 8, Section 8.9.d.), clinical service contact notes (Chapter 8, Section 8.9.e.), clinical service monthly reviews (Chapter 8, Section 8.9.f.) and clinical service discharge summaries (Chapter 8, Section 8.9.g.). 15.3.l. Maintaining and Distributing Nutrition Records: Nutrition providers must maintain clinical service records with contents as specified in Chapter 8, Table 8.6. Original documents (assessments, contact notes, monthly reviews and discharge summaries) created by the nutrition provider are to be maintained in the nutrition record as indicated in Chapter 13, Section 13.16.a. Requirements for distribution of records applicable to nutrition providers are discussed in Chapter 13, Section 13.16.b. 15.3.m. Service Reimbursement Rates: Information regarding travel differential rates and determining the appropriate rate level provided in Chapter 13, Section 13.17 (inclusive of a. through c.) are applicable to nutrition providers.

Provider Manual, Chapter 15 Nursing, Nutrition, Vision and Dental Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

15 - 6

15
15.3.n. Integration of Nutrition Services Into the Service Recipients Daily Schedule: Integration requirements specified in Chapter 13, Section 13.18. are applicable to nutrition providers. 15.4. Vision Services 15.4.a. Waiver Definition for Vision Services: Vision services are available only to service recipients enrolled in the Arlington Waiver. The waiver definition for vision services approved by the Centers for Medicaid and Medicare Services (CMS) is: Vision Services: Vision Services shall mean routine eye examinations and refraction; standard or special frames for eyeglasses; standard, bifocal, multi-focal, or special lenses for eyeglasses; contact lenses; and dispensing fees for ophthalmologists, optometrists, and opticians. Vision Services are not intended to replace services available through the Medicaid State Plan/TennCare program. All Vision Services for children enrolled in the waiver are provided through the TennCare EPSDT program. 15.4.b. Obtaining Approval for Vision Services: A unit of vision services must be defined in the service recipients ISP. Vision services are paid in accordance with the current TennCare vision services rate schedule. The ISP, ISP amendment or ISP update establishing the need for vision services must be submitted to the Regional Office by the service recipients support coordinator/case manager. Any alternative funding resources, such as the TennCare Managed Care Organization or private insurance must have been exhausted before waiver vision services may be accessed. The TennCare program does not cover routine eye examinations and refraction, eyeglass frames or contact lens for adults over the age of 21. The ISP must be authorized in writing by the Regional Office prior to implementation. 15.5. Adult Dental Services 15.5.a. Waiver Definition for Adult Dental Services: The definitions for dental services differ in different waiver programs. The Statewide waiver definition for Adult Dental Services shall apply to the Tennessee Self Determination Waiver Program and to DMRS state-funded dental services.. The Statewide waiver definition for Adult Dental Services is: Adult Dental Services: Adult Dental Services shall mean accepted dental procedures which are provided to adult enrollees (i.e., age 21 years or older) as specified in the plan of care and for which there is no coverage for adults through the Medicaid State

Provider Manual, Chapter 15 Nursing, Nutrition, Vision and Dental Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

15 - 7

15
Plan/TennCare program. Adult Dental Services may include fillings, root canals, extractions, the provision of dentures and other dental treatments to relieve pain and infection. Anesthesia services provided in the dentists office and billed by the dentist shall be included within the definition of Adult Dental Services. Adult Dental Services shall not include hospital outpatient or inpatient facility services or related anesthesiology, radiology, pathology or other medical services in such setting. Adult Dental Services shall exclude orthodontic services. Adult Dental Services shall be limited to adults age 21 years or older who are enrolled in the waiver. Adult Dental Services are not intended to replace services available through the Medicaid State Plan/TennCare program. All Dental Services for children enrolled in the waiver are provided through the TennCare EPSDT program. 15.5.b. Waiver Definition for Dental Services: The waiver definition for Dental Services shall only apply to service recipients enrolled in the Arlington Waiver. The Arlington Waiver definition for dental services is: Dental Services: Dental Services shall mean accepted dental procedures which are provided to adult enrollees (i.e., age 21 years or older) as specified in the plan of care and for which there is no coverage for adults through the Medicaid State Plan/TennCare program. Dental Services may include preventive dental services, fillings, root canals, extractions, periodontics, the provision of dentures and other dental treatments to relieve pain and infection. Anesthesia services provided in the dentists office and billed by the dentist shall be included within the definition of Dental Services. Dental Services shall not include hospital outpatient or inpatient facility services or related anesthesiology, radiology, pathology or other medical services in such setting. Dental Services shall exclude orthodontic services. Dental Services shall be limited to adults age 21 years or older who are enrolled in the waiver. Dental Services are not intended to replace services available through the Medicaid State Plan/TennCare program. All Dental Services for children enrolled in the waiver are provided through the TennCare EPSDT program. 15.5.c. Obtaining Approval of Adult Dental or Dental Services: A unit of dental services must be defined in the ISP. Dental units are paid in accordance with the current TennCare dental rate schedule. Services will be approved only if alternative funding sources, such as a TennCare MCO or private insurance have been exhausted. Dental services must be recommended by a licensed dentist. A Dental Treatment Plan with itemized costs is required. If sedation is required, there must be written justification by a qualified professional. Routine dental care (e.g. preventive examinations, cleanings, etc.) is not covered through statewide waiver Adult Dental Services. Preventive dental care is

Provider Manual, Chapter 15 Nursing, Nutrition, Vision and Dental Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

15 - 8

15
covered under Dental Services in the Arlington Waiver. Dental procedures requiring hospitalization or out-patient surgery are not covered. The ISP, ISP amendment or ISP update documenting the need for the dental service being requested must be submitted to the Regional Office for approval. Approval must be obtained in writing from the Regional Office prior to provision of the dental service.

Provider Manual, Chapter 15 Nursing, Nutrition, Vision and Dental Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

15 - 9

16
CHAPTER 16 Other Services

16.1.

Introduction This chapter provides waiver definitions and additional requirements applicable to respite services, personal assistance services, personal emergency response systems and individual transportation services.

16.2.

Respite Services 16.2.a. Waiver Definition of Respite Services: The waiver definition shall apply to all respite services provided in a Medicaid waiver. The waiver definition shall also be used to define respite services provided in other DMRS-funded programs. The waiver definition for respite services approved by the Centers for Medicaid and Medicare Services (CMS) is: Respite: Respite shall mean services provided to an enrollee when unpaid caregivers are absent or incapacitated due to death, hospitalization, illness, or injury, or when unpaid caregivers need relief from routine caregiving responsibilities. Respite may be provided in the enrollees place of residence, in a Family Model Residential Support home, in a Medicaid-certified ICF/MR, in a home operated by a licensed residential provider, or in the home of an approved respite provider. The Respite provider may also accompany the enrollee on short outings for exercise, recreation, shopping or other purposes while providing respite care. An enrollee receiving residential services (i.e., Supported Living, Residential Habilitation, Medical Residential Services, or Family Model Residential Support) shall not be eligible to receive Respite as a service. The cost of room and board shall be excluded from Respite reimbursement if Respite is provided in a private residence. Respite shall be limited to a maximum of 30 days per enrollee per year. An enrollee receiving Respite shall be eligible to receive Individual Transportation Services.

Provider Manual, Chapter 16 Other Waiver Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

16- 1

16
16.2.b. Additional Requirements Applicable to Respite Services: requirements include: Additional

1) The provider agency must have a respite license in the region in which the service is provided; 2) If this service occurs in a licensed residential setting, the respite person can not exceed that homes licensed capacity. If this service is provided under an agencys supported living license, the home where the person is supported cannot exceed three (3) individuals; 3) If this service is provided under an agencys Family Model Residential Supports license, the home cannot exceed service to two (2) individuals; 4) The service provider must continue implementing ISP outcomes and must continue to ensure transportation to other necessary services; 5) The service provider must ensure management of health care needs including medical appointments and medication management; 6) General documentation requirements and documentation requirements applicable to residential providers described in Chapter 8 are also applicable to respite providers; 7) No more than eighty per cent (80%) of the maximum Supplemental Security Income (SSI) benefit for the current calendar year may be charged to a service recipient for room and board expenses by a respite provider; 8) Respite provided 8 or less hours a day will be billed hourly and the service will be documented by the hour; and 9) For respite provided over 8 hours a day the appropriate daily respite rate will be billed and service documented. 16.3. Personal Assistance Services 16.3.a. Waiver Definition for Personal Assistance Services: The waiver definition shall apply to all personal assistance services provided in a Medicaid waiver. The waiver definition shall also be used to define personal assistance services provided in other DMRS-funded programs. The waiver definition for personal assistance services approved by the Centers for Medicaid and Medicare Services (CMS) is: Personal Assistance: Personal Assistance shall mean the provision of direct assistance with activities of daily living (e.g., bathing, dressing, personal hygiene, eating, meal preparation excluding cost of food), household chores essential to the health and safety of the enrollee, budget management, attending appointments and interpersonal and social skills building to enable the enrollee to live in a home in the community. It also may include medication administration as permitted under Tennessees Nurse Practice Act.

Provider Manual, Chapter 16 Other Waiver Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

16- 2

16
Personal Assistance shall be provided in accordance with therapeutic goals and objectives as specified in the plan of care. Personal Assistance may be provided in the home or community; however, it shall not be provided in school settings and shall not be provided to replace personal assistance services required to be covered by schools or services available through the Medicaid State Plan/TennCare program. Personal Assistance may be provided during the day or night, as specified in the plan of care. With the exception of Personal Assistance reimbursed on a per diem basis, Personal Assistance staff shall not be permitted to have sleep time when on duty. An enrollee who is receiving a residential service (i.e., Supported Living, Residential Habilitation, Medical Residential Services, or Family Model Residential Support) shall not be eligible to receive Personal Assistance. Personal Assistance shall not be provided during the same time period when the enrollee is receiving Day Services. This service shall not be provided in inpatient hospitals, nursing facilities, and Intermediate Care Facilities for the Mentally Retarded (ICF/MRs). Family members who provide Personal Assistance must meet the same standards as providers who are unrelated to the enrollee. The Personal Assistance provider shall not be the spouse and shall not be the enrollees parent if the enrollee is a minor. Reimbursement shall not be made to any other individual who is a conservator unless so permitted in the Order for Conservatorship. An enrollee receiving Personal Assistance shall be eligible to receive Individual Transportation Services. Personal Assistance may be provided out-of-state under the following circumstances: 16.3.b. Out-of-State Personal Assistance Services: The waiver definition for personal assistance addresses the provision of services when the service recipient travels out of state. Personal assistance services may be provided out-of-state under the following circumstances: 1) Out-of-state services shall be for the purpose of visiting relatives or for vacations and shall be included in the enrollees plan of care (Trips to casinos or other gambling establishments shall be excluded.); 2) Out-of-state services shall be limited to a maximum of 14 days per enrollee per year; 3) The waiver service provider agency must be able to assure the health and safety of the enrollee during the period when services will be provided out-of-state and must be willing to assume the additional risk and liability of provision of services out-of-state;

Provider Manual, Chapter 16 Other Waiver Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

16- 3

16
4) During the period when out-of-state services are being provided, the waiver service provider agency must maintain an adequate amount of staffing (including services of a nurse if applicable) to meet the needs of the enrollee and must ensure that staff meet waiver provider qualifications; and 5) The waiver service provider agency shall not receive any additional reimbursement for provision of services out-of-state. The costs of travel, lodging, food, and other expenses incurred by staff during the provision of out-of-state services shall not be reimbursed through the waiver. The costs of travel, lodging, food, and other expenses incurred by the enrollee while receiving out-of-state services shall be the responsibility of the enrollee and shall not be reimbursed through the waiver. 16.3.c. Licensure Requirements: Personal assistance providers must obtain licensure as a home care organization from the Department of Health (DOH) or licensure as a personal support services agency from the Department of Mental Health and Developmental Disabilities (DMHDD), unless providing services to only one service recipient. 16.3.d Environmental Safety Requirements: Prior to initiation of personal assistance services that will be rendered in a private home, DMRS or a DMRS contractor will conduct an inspection of the home to ensure that the service recipients health, safety and welfare can be maintained while receiving services within the designated environment. Assurance of service recipient health, safety and welfare is a federal requirement for Home- and Community- Based Services (HCBS) waivers. The inspection will be conducted utilizing the Personal Assistance Environmental Checklist (see Appendix D). The results of the inspection will be shared with the service recipient and family. Support coordinators/case managers and personal assistance providers will work with the family to assist in the resolution of issues identified and the identification of resources to assist in making repairs or purchasing necessary items required to ensure that the home meets safety standards. The DMRS Housing Resource Directory may be helpful in identifying resources. This resource manual can be accessed on the DMRS website. 16.3.e. Additional Requirements Applicable to Personal Assistance Services: Additional requirements include: 1) Personal Assistance is to be used as an alternative to residential services to assist the natural family, including the service recipient, to continue to live together within the family home and community; 2) Home Care Organizations licensed by the Department of Health may provide personal assistance services, but must ensure that staff meet DMRS training requirements for personal assistance staff;

Provider Manual, Chapter 16 Other Waiver Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

16- 4

16
3) Personal assistance providers may receive reimbursement for individual transportation when the service recipient is transported by personal assistance staff for the purpose of meeting ISP outcomes; 4) An individual may receive both personal assistance services and day services, but not concurrently during the same time period; 5) Children receiving residential services are not eligible to receive personal assistance for days when school is not in session, but may receive a day service rate for such days; 6) The personal assistance provider must meet general records requirements as described in Chapter 8 and must document hourly services provided; 7) The personal assistance provider must complete monthly reviews as indicated in Chapter 3. 16.4. Personal Emergency Response Systems Waiver Definition for Personal Emergency Response Systems: The waiver definition shall apply to all personal emergency response systems provided in a Medicaid waiver. The waiver definition shall also be used to define personal emergency response systems provided in other DMRS-funded programs. The waiver definition for personal emergency response systems approved by the Centers for Medicaid and Medicare Services (CMS) is: Personal Emergency Response System: A Personal Emergency Response System shall mean a stationary or portable electronic device used in the enrollees place of residence which enables the enrollee to secure help in an emergency. The system shall be connected to a response center staffed by trained professionals who respond upon activation of the electronic device. The system shall be limited to those who are alone for parts of the day and who have demonstrated mental and physical capability to utilize such a system effectively. 16.5. Individual Transportation Services 16.5.a. Waiver Definition for Individual Transportation Services: The waiver definition shall apply to all individual transportation services provided in a Medicaid waiver. The waiver definition shall also be used to define individual transportation services provided in other DMRS-funded programs. The waiver definition for individual transportation services approved by the Centers for Medicaid and Medicare Services (CMS) is:

Provider Manual, Chapter 16 Other Waiver Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

16- 5

16
Individual Transportation Services: Individual Transportation Services shall mean non-emergency transport of an enrollee to and from approved activities specified in the plan of care. Whenever possible, family, neighbors, friends or community agencies that can provide this service without charge should be utilized. An enrollee receiving Orientation and Mobility Training shall be eligible to receive Individual Transportation Services to the extent necessary for participation in Orientation and Mobility Training. Enrollees who receive Respite, Behavioral Respite Services or Personal Assistance shall be eligible to receive Individual Transportation Services only to the extent necessary during the time period when Respite, Behavioral Respite Services or Personal Assistance is being provided. Individual Transportation Services shall not be used for: 1) 2) 3) 4) Transportation to and from Day Services; Transportation to and from supported or competitive employment; Transportation of school aged children to and from school; Transportation to and from medical services covered by the Medicaid State Plan/TennCare program; 5) Transportation of an enrollee receiving a residential service, except as specified above for Orientation and Mobility Training and Behavioral Respite Services. Individual Transportation Services are not intended to replace services available through the Medicaid State Plan/TennCare program. 16.5.b. Additional Requirements Applicable to Individual Transportation Services: Additional requirements include: 1) All vehicles used to transport individuals must have operable seat belts; 2) Staff must ensure that service recipients are transported using seat belts in the proper manner; 3) Any mobility support needs applicable to transportation must be met in accordance with the ISP or staff instructions (e.g., if the service recipient uses a wheelchair, staff must be trained to properly use vehicle lifts and secure the wheelchair in the vehicle); 4) Providers must implement a written policy to ensure documentation that vehicles used to transport service recipients are safe and that use of such vehicles meets all transportation service requirements, whether the vehicle is owned by the provider or by provider staff;

Provider Manual, Chapter 16 Other Waiver Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

16- 6

16
5) Providers must maintain a copy of the vehicle liability insurance certificate for vehicles used to transport service recipients, whether the vehicles are owned by the provider or by provider staff; 6) Each vehicle used to transport service recipients must have first aid supplies as required in Chapter 11, Section 11.10.; 7) Providers may not charge service recipients or service recipients families for the cost of routine maintenance or the cost of cleaning the interior or exterior of vehicles owned by the provider or the providers staff; and 8) Providers may not charge service recipients or service recipients families for the cost of providing a cellular phone intended for the use of staff involved in transporting service recipients, unless specifically requested by the service recipient or legal representative.

Provider Manual, Chapter 16 Other Waiver Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

16- 7

17
CHAPTER 17 CONSERVATORSHIP AND ADVOCACY SERVICES

17.1.

Introduction This chapter is intended to provide information regarding two distinct services, conservatorship and advocacy. Service recipients enrolled in the DMRS service delivery system may have either a conservator, an advocate or both. Individuals with mental retardation may have court-appointed legal representatives who have authority to make important decisions that affect their lives. A guardian is an individual who may be court-appointed to serve in this capacity for people under eighteen (18) years of age. For those age eighteen (18) or older, a court-ordered legal representative is called a conservator. Guardians, conservators and other legal options that may provide decision-making assistance to DMRS service recipients are discussed in Chapter 2, Section 2.21. The Tennessee law governing the appointment of conservators is found in the Tennessee Code Annotated (TCA), Title 34. Many times, a family member or friend of the service recipient will be appointed to serve as the persons conservator. However, some service recipients within the Division of Mental Retardation Services (DMRS) System have no family members or other natural supports willing to serve as conservator. Consequently, DMRS offers a state-funded program whereby a paid conservator may be appointed. Many service recipients have the capacity to make decisions and want to exercise selfdetermination, but because of other people's perceptions about their disabilities, may have difficulty getting others to recognize their strengths and capabilities. In such instances, an advocate may assist service recipients in exercising rights to control their own destinies and make important life decisions. Advocates assist service recipients to ensure that their choices are honored by family members, providers and other entities. Advocates, unlike conservators or guardians, are not vested with legal authority to make decisions for a service recipient. However, advocates may in some circumstances be utilized by a conservator to assist with decision-making.

Provider Manual, Chapter 17. Conservatorship and Advocacy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

17- 1

17
DMRS, through a grant program, provides state-funded paid advocacy services. Funding for this program is limited; however, so paid advocacy services are not available to all service recipients within the system. Individuals who do not have access to DMRSfunded advocacy services still have a number of options for advocacy through organizations external to DMRS. A list of the various advocacy organizations that operate within the state of Tennessee is provided in Appendix B. DMRS service providers should have a basic knowledge of conservatorship principles and concepts in order to assist service recipients in accessing conservatorship services if needed. Service recipients and their families may have limited knowledge of options related to the appointment of a conservator. This chapter is intended to provide basic information about the duties and responsibilities of a conservator to aid other service providers in establishing working relationships with the court-appointed legal representatives of service recipients. The information provided in this chapter is also valuable in terms of defining accountability standards for DMRS-funded conservators. Information is provided about advocacy services both to define accountability standards for paid advocates and to define provider responsibilities in working with advocates. Additionally, information provided is intended to assist providers in interacting with paid and unpaid advocates who may assist and/or speak for service recipients. 17.2. The Conservatorship Process A conservator may be appointed by a court when an adult is determined to be a disabled person as defined in Title 34. According to both state and constitutional law, an individual eighteen (18) years of age or older is considered to be an adult competent to carry out and manage life decisions and affairs. Individuals with mental competency issues may meet the definition of a disabled person in Title 34, whether disabled for physical or mental reasons, or both. A disabled person is defined as someone eighteen (18) years of age or older who has been determined by the court to be in need of partial or full supervision, protection and assistance due to a mental illness, physical illness/injury, developmental disability or other mental/physical incapacity. The Court is required by law to impose the least restrictive alternative upon the disabled person that will afford adequate protection to the person and his/her property.

Provider Manual, Chapter 17. Conservatorship and Advocacy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

17- 2

17
17.2.a. Options Applicable to the Appointment of Conservators: Options include: 1) A limited conservatorship may be ordered by the court when it is in the best interest of the disabled person for the conservatorship to be restricted as to authority and/or circumstances (e.g., the court may restrict the authority of the conservator to making financial decisions because the person for whom a conservator has been appointed has been determined capable of making health care decisions); 2) A co-conservatorship may be ordered if it is in the best interest of the disabled person for more than one person to serve as conservator at the same time; 3) A successor conservatorship allows a person to assume conservatorship responsibilities from someone else who is or has been serving as a conservator; or 4) A standby fiduciary may be appointed if the current conservator should be unable or unwilling to serve or if it is otherwise necessary to assign an interim, substitute or temporary person to act as a conservator. 17.2.b. Initiating Appointment of a Conservator: Since deprivation or modification of basic constitutional rights is involved, a conservatorship may only be started or altered after a formal, legal proceeding before a court of competent jurisdiction. The procedure for naming a conservator begins in Tennessee with the filing of a petition in the county of residence of the person for whom the Courts protection is sought. The petition may be filed by any individual having knowledge of the circumstances necessitating the appointment of a conservator. 17.2.d. Selecting an Individual to Serve as Conservator: Any competent adult may serve as a conservator. A non-profit association or business entity (e.g., ComCare, Inc., the current DMRS contractor for paid conservatorship services) can perform this function if qualified to do so. However, Tennessee law does give priority to persons thought of as next of kin when considering who to appoint. A thorough effort to find a potential conservator should be undertaken before filing the petition. Efforts should be described in a written narrative, including the steps taken to establish the identity of potential candidates or a description of the efforts used to determine that no such party exists that is willing and able to serve. A corporate conservator, such as those available from ComCare, Inc., should be considered only if family members are unwilling or unable to serve and there are no other natural supports available within the community who are willing and able to serve. The names and last known addresses and telephone numbers of any relatives located and considered, but unwilling/unable to serve should be provided to the Court for notice purposes.

Provider Manual, Chapter 17. Conservatorship and Advocacy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

17- 3

17
If a family member or other prospective conservator is located who is willing and able to serve, that individual must sign an affidavit confirming availability to be appointed as conservator. The signed affidavit or consent to serve is to be filed with the Court with the petition for conservatorship. The Court has sole discretion in naming a conservator; however, Title 34 lists possible entities to be considered, including: 1) 2) 3) 4) 5) A person(s) designated in writing by the alleged disabled person; The spouse of a disabled person; Any child of a disabled person; The closest relative(s) of the disabled person; and Other persons, such as friends, unrelated caregivers or corporate conservators.

17.2.e. Determination That a Person is Disabled for Purposes of Appointing a Conservator: In order to be declared disabled by a Tennessee Court, a sworn medical examination report is required (TCA 34-3-105). This document must be completed by a physician or psychologist who has examined and is familiar with the person being considered by the court. A statement from a physicians assistant or nurse practitioner is not sufficient. The sworn medical examination report must be dated within ninety (90) days of the date the petition for conservatorship was filed. The sworn medical examination report (blank copy provided in Appendix D) must include the following: 1) 2) 3) 4) The medical history of the person for whom the Courts protection is sought; A description of the nature and type of the persons disability; An opinion as to whether a conservator is needed, and if so, why; Recommendations as to the type of conservator needed and the scope of the conservators authority; and 5) Any other information the court deems necessary or advisable.

17.2.f. Contents of the Conservatorship Petition: The conservatorship petition must include: 1) The name, date of birth, social security number, residence and mailing address of the person for whom the Courts protection is sought; 2) The sworn medical examination report; 3) The name, age, residence and mailing address of the petitioner;

Provider Manual, Chapter 17. Conservatorship and Advocacy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

17- 4

17
4) The name, age, social security number, mailing address and relationship of the proposed conservator to the person for whom the Courts protection is sought; 5) The affidavit from the proposed petitioner indicating awareness of the petition and willingness to serve; 6) The name, mailing address and relationship of the closest living relative(s) (a statement that there is no living spouse, child, parent or sibling is sufficientit is not necessary to list more remote relatives); 7) The name and mailing address of the person or institution, if any, having care and custody of the person or with whom he/she lives; 8) A summary of the facts supporting the petition; 9) A description of the rights to be removed from the person and transferred to the conservator; and 10) A financial management plan. 17.2.g. Changes in Conservatorship: A conservatorship, once established, can be altered only by filing a new petition with the court. It may be necessary to file a petition to revoke or revise a conservatorship order for several reasons, including a change in residency, a change in a persons disability status, indication that an appointed conservator is not appropriately discharging duties or has failed to act in a persons best interest, incapacitation or death of an appointed conservator or conservator resignation. 17.2.h. Scope of Authority: Tennessee is a state that allows limited conservatorships. Limited conservatorship means that a person for whom a conservator has been appointed will retain civil rights that are not specifically removed by the court. A conservator must act in accordance with the order(s) of conservatorship, which defines the scope of the conservators authority. It is required by law that conservatorship orders must clearly indicate if the conservator has limited authority. For example, it is rare for a court to give a conservator control over a persons social interactions. Unless the conservatorship orders specifically remove the right to interact with other individuals, the conservator does not have the authority to limit social interaction or activities. However, not all situations that arise related to a conservators authority are clear. If there is dispute regarding the conservators authority to make a particular decision that cannot be resolved by the involved parties, it may be necessary to seek intervention and/or instruction from the court.

Provider Manual, Chapter 17. Conservatorship and Advocacy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

17- 5

17
17.3. Duties and Responsibilities of a Conservator This section is intended to provide description of the DMRS-funded conservatorship program. A listing of conservator organizations external to DMRS is provided in Appendix B. 17.3.a. Decision Making: Decision making is the primary and fundamental responsibility of a conservator, whether the conservator is a family member, a corporate conservator or other entity. Typically, the power of a conservator to make decisions for a person may include, but is not limited to decisions regarding: 1) Where a person lives and the type of living arrangements needed; 2) What medical treatments and/or health care interventions are in the persons best interest; 3) Which health care providers are utilized to provide medical and other health related treatments/interventions; 4) Whether to give or withhold consent for admission to/discharge from hospitals or other inpatient treatment facilities; 5) Whether to give or withhold consent for habilitative therapies, habilitative training or other habilitative programs; 6) Whether to release confidential and/or protected health information 7) How personal income is expended; and 8) How personal property is managed or maintained. The conservator must exercise care and diligence when making decisions on behalf of a DMRS service recipient that the court has determined to be a disabled person.. The conservator should be cognizant of the fact that while he/she is ultimately responsible for decisions made, such decisions are open to scrutiny. The conservator is expected to: 1) Carry out duties as specified in the courts order of appointment and refrain from making decisions outside the scope of authority defined by the court; 2) Act in accordance with state law in discharging conservator duties and responsibilities; 3) Have or make reasonable effort to establish a relationship with the service recipient (and those with close personal relationships with the service recipient) which makes it possible to ascertain, to the extent possible, the service recipients preferences and needs;

Provider Manual, Chapter 17. Conservatorship and Advocacy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

17- 6

17
4) Acquire information about the service recipients health and personal circumstances to provide a sound basis from which to make decisions on behalf of the service recipient; 5) Make decisions and otherwise act in a manner that benefits and protects the service recipient and the service recipients property (as applicable), including protection of the service recipients individual rights and independence/selfreliance to the extent possible; 6) Make decisions in accordance with the service recipients preferences and needs, unless such decision would not be in the service recipients best interest; 7) Maintain undivided loyalty to the service recipient, placing his/her well-being ahead of the conservators own personal and/or financial interests; and 8) Act in an unselfish, diligent and conscientious manner, showing respect, appreciation and solicitude for the rights, privacy and welfare of the service recipient. 17.3.b. Conservator/Service Recipient Relationships: A relationship involving trust and loyalty between the conservator and a service recipient is most likely to result in the highest quality of life for the service recipient. The conservator is expected to: 1) Protect the personal and financial interests of the service recipient; 2) Foster the service recipients growth and independence to the extent possible; 3) Defend/protect the service recipients rights when third parties attempt to infringe upon or violate such rights; and 4) Provide pertinent information to the service recipient when appropriate, unless provision of such information would not be in the service recipients best interest. 17.3.c. Determining a Place of Residence: A conservator is to make all reasonable efforts to ensure that the service recipient lives in the least restrictive environment that meets his/her needs. The conservator is expected to: 1) Seek information regarding available residential alternatives; 2) Ascertain the preferences of the service recipient to the extent possible in regard to living arrangements and make decisions accordingly unless honoring such preferences would not be in the service recipients best interest; 3) Refrain from removing the service recipient from his/her home or separating the service recipient from family members, friends or other natural supports unless in the service recipients best interest; 4) Seek professional evaluation(s) as needed to determine the least restrictive environment;

Provider Manual, Chapter 17. Conservatorship and Advocacy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

17- 7

17
5) Monitor placement on an ongoing basis to ensure that the service recipients needs are being met; and 6) Seek changes or modifications in regard to the residential environment as necessary to meet the service recipients needs. 17.3.d. Consent to Care, Treatment and Services: A conservator who is empowered to make health-related decisions on behalf of a service recipient may be responsible for granting consent allowing the provision of care, treatment, services and supports. The conservator is expected to: 1) Make health care and other service/support decisions in accordance with the service recipients needs, taking into consideration the service recipients preferences, professional opinions/recommendations, available test results/evaluations, input from caregivers and input from involved family members; 2) Advocate for the service recipient to receive the most appropriate and least restrictive form of care, treatment or intervention; 3) Seek professional evaluation as needed to determine available options and least restrictive alternatives; 4) Work cooperatively and collaboratively with health care and other providers of services and supports needed by the service recipient; 5) Develop a knowledge of or access resources needed to determine state law pertaining to withholding or withdrawing life-sustaining treatment; 6) Participate in service and health-related planning; 7) Maintain sufficient knowledge and awareness of the service recipients services, supports and care to be able to act in his/her best interest; and 8) Advocate for changes in service delivery as needed to ensure that the service recipients needs are met. 17.3.e. Management of Financial Resources and Property: When a conservator is empowered to manage a persons finances and property, the conservator must discharge required duties competently and without self-interest. Conflict of interest must be avoided. Conservators are expected to exercise responsibility in the management of personal funds and property as would be expected of a reasonably prudent lay person acting in the persons best interest in accordance with the courts order and state law.

Provider Manual, Chapter 17. Conservatorship and Advocacy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

17- 8

17
17.4. Advocacy Services This section is intended to provide a description of the DMRS-funded advocacy program. A listing of advocacy organizations external to DMRS and contact information is provided in Appendix B. 17.4.a. Duties and Responsibilities of Advocates: The duties and responsibilities of DMRS-funded advocates include: 1) Understanding the service recipients wants and needs; 2) Providing information to the service recipient regarding individual rights, power and authority; 3) Assisting the service recipient in communicating wants and needs; 4) Assisting the service recipient in seeking remediation when needs are not met and/or decisions are not honored; 5) Documenting advocacy contacts and activities; 6) Working with families and/or conservators of service recipients, as well as, DMRS staff and others involved in facilitating transition from Intermediate Care Facilities for the Mentally Retarded (ICFs/MR) 7) Attending transition and support planning meetings as requested by the service recipient; 8) Reporting issues of concern to DMRS and other appropriate persons or entities; 9) Maintaining personal contact on behalf of each assigned service recipient a minimum of monthly to ensure that health and safety needs (including risk) are being addressed, that community integration is occurring in accordance with the preferences of the service recipient, that access to available benefits is ensured, that personal funds are accessible, that the service recipient is involved in financial decisions as appropriate and that personal finances are being appropriately managed; and 10) Providing self-advocacy information, resources and/or training to service recipients. 17.4.b. Ensuring Personal, Social and Economic Well-being: This particular advocacy responsibility involves determining if: 1) Health and safety risks are being addressed; 2) Community integration opportunities/activities are occurring in accordance with the services recipients preferences;

Provider Manual, Chapter 17. Conservatorship and Advocacy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

17- 9

17
3) Benefits for which the service recipient is eligible are being appropriately accessed; 4) Access to personal funds as needed is maintained; 5) Service recipient involvement in financial decision-making is fostered; and 6) Service recipient financial resources and income is managed in accordance with DMRS policy. 17.5. Provider Responsibilities Related to Court-Appointed Legal Representatives and Advocates: Providers are expected to work cooperatively with service recipients courtappointed legal representatives and advocates. 17.5.a. Provider Responsibilities In Working With Conservators and Other CourtAppointed Legal Representatives: Providers are expected to ensure that appropriate staff: 1) Provide basic information to service recipients about options for assistance with decision-making; 2) Assist in accessing resources available to help service recipients in establishing a conservatorship or other option for surrogate decision-making; 3) Understand the roles and responsibilities of court-appointed legal representatives; 4) Obtain copies of court documents pertaining to the appointment of courtappointed legal representatives; 5) Determine if letters of conservatorship limit scope of authority for decision making; 6) Provide information and service recipient records to court-appointed legal representatives in a timely manner when required/requested; 7) Collaborate/consult with the court-appointed legal representative as needed to ensure service provision in accordance with the ISP; 8) Resolve issues of concern with service provision presented by court-appointed legal representatives in a timely manner; and 9) Advise the court-appointed legal representative if unable to provide services in a manner that is consistent with a decision made. 17.5.b. Provider Responsibilities In Working With Advocates: expected to ensure that appropriate staff: 1) Provide basic information about advocacy services; 2) Assist in accessing advocacy resources as requested or needed; Providers are

Provider Manual, Chapter 17. Conservatorship and Advocacy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

17- 10

17
3) Understand the roles and responsibilities of advocates; 4) Provide information and service recipient records to advocates in a timely manner as appropriate; 5) Collaborate/consult with the advocate as needed to ensure service provision in accordance with the ISP; and 6) Resolve issues with service provision identified by advocates in a timely manner.

Provider Manual, Chapter 17. Conservatorship and Advocacy Services Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

17- 11

18
CHAPTER 18 PROTECTION FROM HARM

18.1

Introduction Assuring the protection and safety of persons supported is a primary mission of the Department of Intellectual and Developmental Disabilities (DIDD) and all DIDD providers. This chapter identifies specific provider requirements intended to achieve the protection and safety of persons supported. Protection from harm is more than developing and implementing policies, plans and responses to incidents that have already occurred. Protection from harm is a legal and moral commitment to support, respect and value the dignity and worth of a person. It is an opportunity for all of us who have responsibility as partners in the service delivery system to strive toward achieving the goal of knowing that the people we support and serve feel safe enough to be able to enjoy their lives. DIDD and provider agencies exist solely for the purpose of enhancing the quality of life of persons supported. Leadership at all levels of the system must foster an internal culture that supports individual respect. Respect for others is the first step in ensuring their safety and well-being. A combination of fostering respect for people, planning to ensure safety and protection and responding to incidents appropriately, including careful analysis of the incidents that do occur will go far in achieving the mission of protection from harm.

18.2

Complaint Resolution System Complaint resolution is an integral component of a system that protects and prevents harm. Providers are expected to establish a complaint resolution system to which a person supported, a family/guardian and/or a legal representative has knowledge of and easy access when seeking assistance and answers for concerns and questions about the care being provided. When the complaint cannot be rectified by the Provider agency, DIDD provides assistance to help resolve outstanding issues. Providers must record complaints, take action to appropriately resolve the complaints presented and document complaint resolutions achieved. All providers should establish a Complaint Resolution System which includes but is not limited to: 1) Designation of a staff member as the complaint contact person; 2) Maintenance of a complaint contact log; and 3) Documentation/trending of complaint activity.

Provider Manual, Chapter 18 Protection from Harm Department of Intellectual and Developmental Disabilities, State of Tennessee Final: 5-31-2012, Effective Date: June 1, 2012

18-1

18
Upon admission and periodically, providers should notify each person supported, family/guardian and/or legal representative of their Complaint Resolution System, its purpose and the steps involved to access it. Providers should attempt to resolve all complaints in a timely manner within 30 days of the date that the complaint was filed. In the event that persons supported, families/guardians and/or legal representatives do not agree with a providers proposed solution to a complaint, they may contact the DIDD Regional Complaint Resolution Coordinator for assistance. The DIDD Regional Complaint Resolution Coordinator will subsequently contact the provider(s) and/or other party(ies) involved to discuss potential resolutions to the complaint. These could include formal mediation or intervention meetings. All efforts are made to reach a satisfactory result for the complainant. The providers Complaint Resolution System will be reviewed for appropriateness during the providers DIDD Quality Assurance survey. 18.3 Incident Management System In collaboration with providers, families/guardians, legal representatives and other stakeholders, DIDD has defined events and incidents that must be reported. All providers must develop and implement a system that provides for appropriate and timely reporting of reportable incidents, as well as appropriate and timely response to these incidents. Incident reporting provides both the provider agency and DIDD information to make adjustments and improvements in the services and care of persons supported. A. Reportable Incidents:

Defined incidents must be submitted to DIDD on the DIDD Reportable Incident Form (RIF). The following categories of incidents must be documented and submitted: 1) Deaths of persons supported regardless of the cause or the location where the death occurred; Allegations of abuse based on TCA 33-2-402 (1), neglect based on TCA 33-2-402 (9) and exploitation based on TCA 33-2-402 (8) (referred to as misappropriation of property in TCA) in accordance with definitions below: a) Abuse: the knowing infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. DIDD considers the three specific subcategories of abuse: 1. Emotional/Psychological Abuse: Actions including, but not limited to:
18-2

2)

Provider Manual, Chapter 18 Protection from Harm Department of Intellectual and Developmental Disabilities, State of Tennessee Final: 5-31-2012, Effective Date: June 1, 2012

18
humiliation, harassment, threats of punishment or deprivation, intimidation towards person supported , or the use of oral, written, or gestured language either directed to the person supported or within eyesight or audible range of the person supported that is demeaning or derogatory to persons with intellectual disabilities.

Emotional/psychological abuse may cause the person supported physical harm, pain, or mental anguish (To determine mental anguish the following question should be considered, Would a member of the general public who does not have an intellectual disability react negatively to the alleged incident of emotional/psychological abuse?). 2. Physical Abuse: Actions including, but not limited to: any physical motion or action (e.g., hitting, slapping, punching, kicking, pinching,) by which physical harm, pain or mental anguish may occur to a person supported; the use of corporal punishment; the use of any restrictive, intrusive procedure to control challenging behavior or for purposes of punishment; or takedowns or prone restraint of any duration.

3.

Sexual Abuse: Any type of sexual activity between a person supported and a staff person or anyone affiliated through DIDD as a contracted entity or volunteer is prohibited. Prohibited sexual activity includes, but is not limited to actions whereby a person supported: is forced, tricked, threatened, or otherwise coerced into sexual activity; is exposed to sexually explicit material or language unless otherwise specified in a plan; has any contact with sexual intent.

Sexual abuse occurs whether or not a person supported is able to give consent to such activities. (TCA 39-13-527 (a)(3)(A): Sexual battery by an authority figure is unlawful sexual contact with a victim by the defendant or the defendant by a victim accompanied by the following circumstances: the defendant was at the time of the offense in a
Provider Manual, Chapter 18 Protection from Harm Department of Intellectual and Developmental Disabilities, State of Tennessee Final: 5-31-2012, Effective Date: June 1, 2012 18-3

18
position of trust, or had supervisory or disciplinary power over the victim by virtue of the defendants legal, professional or occupational status and used the position of trust or power to accomplish the sexual contact. (b) Sexual battery by an authority figure is a Class C felony. b) Neglect: Failure to provide goods or services necessary to avoid physical harm, mental anguish or mental illness, which results in injury or probable risk of serious harm. Neglect towards a person supported includes being on duty while impaired or under the influence of illegal substances or prescription drugs without a valid current prescription for the drug. If a staff person has a valid current prescription for a drug and is impaired while on duty from the prescription drug, this too shall be considered neglect. c) Exploitation: Actions including but not limited to the deliberate misplacement, misappropriation or wrongful, temporary or permanent use of belongings or money with or without the persons consent. DIDD also considers it exploitation to illegally or improperly use a person or persons resources for anothers profit or advantage. DIDD will investigate allegations of exploitation involving an amount of $50 or more per incident, allegations of exploitation involving individual amounts totaling $50 or more within a sixty (60) calendar day period or exploitation involving significant risk or serious adverse consequences to a person supported. (See the Reportable Staff Misconduct definition for further clarification.) The provider is required to reimburse the person supported regardless of the amount of money involved.

Provider Manual, Chapter 18 Protection from Harm Department of Intellectual and Developmental Disabilities, State of Tennessee Final: 5-31-2012, Effective Date: June 1, 2012

18-4

18
3) Serious Injury: Physical harm to a person supported: whether the injury is self-inflicted or inflicted by another person, whether the injury is accidental or not, and whether the cause of the injury is known or unknown, and requiring assessment and treatment (beyond basic first aid that could be administered by a lay person): in a hospital, in a hospital emergency room, in an urgent care center, or from a physician, nurse practitioner or physicians assistant. Serious injury includes, but is not limited to, one or more of the following: Fracture, dislocation, traumatic brain injury (concussion), laceration requiring sutures (or Dermabond when used in place of sutures/staples), torn ligaments, second and third degree burns, loss of consciousness. Other types of injuries such as bruises, abrasions, sprains and muscle strains can rise to the level of serious injury if they are diagnosed as serious or severe, or require treatment beyond first aid that could be administered by a lay person. 4) Suspicious Injury: Injury (whether minor or serious) to a person supported possibly involving or resulting from abuse or neglect. This would also include an injury that does not coincide with the explanation given for the injury. Not knowing how an injury occurred is not reason enough to say the injury is suspicious. There must be further reason to believe the injury may have resulted from abuse or neglect. Reportable Behavioral Incident: Any behavioral incident (physical aggression, self-injurious behavior, swallowing inedible substance, etc) resulting in one or more of the following: Serious injury to a person supported or others; Use of mechanical or manual restraint; Takedowns or prone restraint of any duration for any reason are reportable and prohibited; Administration of psychotropic medication as a response to the incident; Property destruction over $100;
18-5

5)

Provider Manual, Chapter 18 Protection from Harm Department of Intellectual and Developmental Disabilities, State of Tennessee Final: 5-31-2012, Effective Date: June 1, 2012

 6)

18
Assessment or treatment by emergency medical technicians/paramedics or in a hospital emergency room; In person involvement of law enforcement (police) or a Mental Health Mobile Crisis Team; or Psychiatric hospital admission.

Reportable Medical Incident: Any medical incident (illness, accident, etc.) resulting in one or more of the following: medical illness that results in emergency medical interventions; i.e; cardiopulmonary resuscitation (CPR) x-ray to rule out a fracture or the Heimlich Maneuver/abdominal thrust; assessment or treatment by emergency medical technicians or paramedics, or by personnel in a hospital emergency room; medical hospital admission. Persons supported missing for longer than fifteen (15) minutes, unless the Individual Support Plan (ISP) specifies that unsupervised periods of time longer than 15 minutes does not present a risk of harm to the person supported or others; Acts of sexual aggression by a person receiving services toward another person supported, a staff person, or another community member; Criminal Conduct or Probable Criminal Conduct involving a person supported including, but not limited to, arrest or incarceration of a person supported; Reportable Staff Misconduct: Actions or inactions contrary to sound judgment and/or training, related to the provision of services and/or the safeguarding of the persons health, safety, general welfare and/or individual rights. Staff misconduct does not rise to the level of abuse, neglect or exploitation, in that there is no resulting injury or adverse effect, and the risk for harm is minimal. Exploitation involving amounts lesser than $50 per incident or less than $50 total in 60 calendar days that are not indicative of serious risk or adverse consequences will be addressed by the provider as reportable staff misconduct. The provider is required to reimburse the person supported regardless of the amount of money involved.

7)

8)

9)

10)

Provider Manual, Chapter 18 Protection from Harm Department of Intellectual and Developmental Disabilities, State of Tennessee Final: 5-31-2012, Effective Date: June 1, 2012

18-6

18
B. Time Frames Applicable to Reporting Incidents Table 18.2. Provides a summary of DIDD reporting requirements, including the time frames for reporting and where the report is to be directed.
TYPE OF INCIDENT / EVENT Death NOTIFY AS SOON AS POSSIBLE NOTIFY AS SOON AS POSSIBLE AND NO LATER THAN FOUR HOURS Regional Office Administrator on Duty (AOD) for all deaths DIDD Investigations Hotline (If death is suspicious, (abuse or neglect involved), or if unexpected or unexplained)

NEXT BUSINESS DAY

Legal Representative (document all attempts)

RIF to DIDD Central Office Notice of Death Form and RIF to Regional Director RIF to ISC Agency/Support Coordinator

Alleged or suspected abuse, neglect, or exploitation

Legal Representative (document all attempts)

DIDD Investigations Hotline Department of Human Services (DHS) Adult Protective Services or Department of Childrens Services (DCS) Child Protective Services If criminal activity: Law Enforcement

RIF to DIDD Central Office RIF to ISC Agency/Support Coordinator

Serious Injury of Known/Unknown Cause

Legal Representative (document all attempts)

If unknown, DIDD Investigations Hotline DHS Adult Protective Services or DCS Child Protective Services

RIF to DIDD Central Office RIF to ISC Agency/Support Coordinator

Suspicious Injury (i.e suspicious as caused by abuse or neglect)

Legal Representative (document all attempts)

DIDD Investigations Hotline DHS Adult Protective Services or DCS Child Protective Services

RIF to DIDD Central Office RIF to ISC Agency/Support Coordinator

Provider Manual, Chapter 18 Protection from Harm Department of Intellectual and Developmental Disabilities, State of Tennessee Final: 5-31-2012, Effective Date: June 1, 2012

18-7

18
TYPE OF INCIDENT / EVENT Reportable Medical Incident NOTIFY AS SOON AS POSSIBLE NOTIFY AS SOON AS POSSIBLE AND NO LATER THAN FOUR HOURS Regional AOD if: Unplanned Hospitalization NEXT BUSINESS DAY Legal Representative (document all attempts) RIF to DIDD Central Office RIF to ISC Agency/Support Coordinator

Reportable Behavioral Incident Missing Person Sexual Agression Criminal Conduct

Legal Representative (document all attempts)

Regional AOD for: Any hospitalization resulting from a behavior or psychiatric incident, or any behavioral incident with Law Enforcement or Mental Health Mobile Crisis Team involvement at the scene or in person Any incarceration

RIF to DIDD Central Office RIF to ISC Agency/Support Coordinator

Reportable Staff Misconduct Incident

Legal Representative (document all attempts)

RIF to DIDD Central Office RIF to ISC Agency/Support Coordinator

Request for Emergency Service Approval outside of regular DIDD business hours

Regional AOD

1)

Submission of Reportable Incident Forms: The front page of the DIDD Reportable Incident Form must be reviewed by the agency Incident Management Coordinator and then securely submitted to the DIDD Central Office and the ISC Agency/Support Coordinator within one (1) business day of the time the incident occurred or was discovered.

DIDD recognizes that on occasion two or more provider agencies may witness a Reportable Incident. The provider with primary responsibility for the person supported at the time of the incident has
18-8

Provider Manual, Chapter 18 Protection from Harm Department of Intellectual and Developmental Disabilities, State of Tennessee Final: 5-31-2012, Effective Date: June 1, 2012

18
the obligation to report. Provider policy should include a provision for obtaining written confirmation that the primary provider has filed an incident report with DIDD. When support coordinators/case managers or other non-primary providers are the initial reporter of an incident, a copy of the DIDD Reportable Incident Form is sent to the primary provider of the person supported as soon as possible and in all cases, within one (1) business day.

2)

Immediate Notification Via the DIDD Investigation Hotline: Providers are required to notify immediately, via the DIDD Investigation Hotline all reports of alleged or suspected abuse, neglect, exploitation and serious injury of unknown cause. Deaths of persons supported that are questionable or suspicious and appear to be a result of abuse or neglect need to be called into the hotline as well. Immediate means as soon as possible (ASAP) and in all cases, within four hours of the incident or its discovery. In instances when provider staff is uncertain if an incident qualifies for immediate notification to the DIDD Investigation Hotline, it is expected that the provider will contact the hotline in order to consult with an investigator. Additional Notification Requirements: In addition to filing Reportable Incidents with DIDD, providers must ensure that: Legal representatives of persons supported must always be notified as soon as possible once the decision is made to investigate an incident for alleged abuse, neglect, or exploitation; Legal representatives of persons supported are notified as soon as possible of all Reportable Incidents; notice is documented on the Reportable Incident Form, unless the legal representative indicates in writing that notification is to be provided only in limited circumstances; If, despite diligent efforts, legal representative notification is not achieved within twenty-four (24) hours, documentation reflects efforts made and the date/time of notification and method whereby notification was achieved; Support coordination providers/DIDD case managers of persons supported receive copies of filed DIDD Reportable Incident Forms as soon as possible, and in all cases within one (1) business day; Law enforcement officials are notified as soon as possible, but in all cases within (4) four hours, of Reportable Incidents when there is reason to believe a crime may have been committed (if uncertain as to whether law enforcement officials should be notified, consultation with the DIDD Director of Investigations or designee may be initiated);
18-9

3)

Provider Manual, Chapter 18 Protection from Harm Department of Intellectual and Developmental Disabilities, State of Tennessee Final: 5-31-2012, Effective Date: June 1, 2012

18
Provider staff are considered mandated reporters, therefore, The Department of Childrens Services (DCS), Division of Child Protective Services is notified as soon as possible, but no later than four (4) hours following the incident or discovery of the incident when persons supported under the age of eighteen (18) are alleged to have been the victim of abuse, neglect or exploitation (TCA 37-1-403 & 37-1605); and Provider staff are considered mandated reporters, therefore, The Department of Human Services (DHS), Division of Adult Protective Services is notified as soon as possible, but no later than four (4) hours following the incident or discovery of the incident when persons supported eighteen (18) years of age or older are alleged to have been the victim of abuse, neglect or exploitation (TCA 71-6-103 (b) (1) &
(TCA 71-6-103 (2) (c) .

It should be noted that the definitions of abuse, neglect or exploitation used by other state agencies and organizations, as well as timeframes for reporting, may be different from those used by DIDD. C. Incident Review and Corrective/Preventive Action Requirements 1) Designation of an Incident Management Coordinator: Providers must designate a management staff person to serve as the Incident Management Coordinator. The Incident Management Coordinator will have primary responsibility for ensuring provider compliance with this chapter. Specific responsibilities of the Incident Management Coordinator include: Reviewing incidents for timely and appropriate response; Ensuring that incidents have been reported or referred to the DIDD Investigation Hotline as required; Ensuring that Reportable Incident forms have been made legible (typed) and are complete and submitted to DIDD Central Office as required; Ensuring that documentation of the submission of Reportable incident forms is maintained; Ensuring that recommendations associated with Reportable Incidents and DIDD investigations are addressed; Serving as chair of the Incident Review Committee; and Completing or ensuring the completion of trend studies of Reportable Incidents.

2)

Incident Review Committees: Residential, day and personal assistance providers must establish an Incident Review Committee with a defined membership and meeting schedule. The Incident Review Committee may be an independent committee or a sub-committee of another operational provider committee. Independent providers and very small providers, including
18-10

Provider Manual, Chapter 18 Protection from Harm Department of Intellectual and Developmental Disabilities, State of Tennessee Final: 5-31-2012, Effective Date: June 1, 2012

18
microboards, may elect to share an Incident Review Committee with another provider(s) if appropriate steps are taken to maintain confidentiality, such as obtaining signed confidentiality agreements from each Committee member or redacting information provided to the committee. 3) Incident Review Committee Membership: DIDD requires inclusion of at least two (2) provider management personnel. DIDD also requires inclusion of supervisory staff and Direct Support Professional supervisor, Direct Support Professional or designee. Beyond these requirements, the provider has discretion in determining the appropriate membership of the Incident Review Committee; however, larger provider agencies should consider members who are persons supported, their family members or legal representatives and members who serve on the provider board of directors/advisory committee. Incident Review Committee Functions: Incident Review Committee functions include: Monitoring to ensure appropriate reporting of incidents; Reviewing and providing recommendations as necessary regarding provider incident reports, DIDD completed investigation reports and provider incident reviews, including reportable staff misconduct incidents; Ensuring implementation of corrective actions and recommendations pertaining to Reportable Incidents; Identifying trends regarding reportable incidents; Identify individual risk issues for prevention of harm.

4)

5)

Incident Review Committee Meeting Schedule: The Incident Review Committee is expected to meet at least every other week. Meetings of the Incident Review Committee may be deferred in the event that there is no pending business before the Committee. Because recommendations are followed to closure, pending business is not limited to recently filed Reportable Incident Forms. Independent providers and very small providers may request to be exempted from the scheduled meeting requirement by requesting such exemption in writing to the Regional Director, who will forward the request to the Commissioner for consideration. This exemption must be approved annually. However, in all cases, regardless of any exemption, there should be evidence that all required incident review and follow-up activities are completed in a timely and appropriate manner. Trend Analyses of Reportable Incidents: Provider Incident Review Committees are responsible for reviewing trends and patterns related to Reportable Incidents, including substantiated reports of abuse, neglect and exploitation. Providers must implement procedures for the completion of an annual written analysis of the trends and patterns related to Reportable Incidents, including substantiated reports of abuse, neglect, and exploitation.
18-11

6)

Provider Manual, Chapter 18 Protection from Harm Department of Intellectual and Developmental Disabilities, State of Tennessee Final: 5-31-2012, Effective Date: June 1, 2012

18
The written annual trend report must be available to DIDD staff who may request the report. This report must be sufficient in detail to provide a minimum of the following: Increasing and decreasing incidence rates of specific types of Reportable Incidents (including abuse, neglect and exploitation); Increasing and decreasing incidence rates of Reportable Incidents that resulted in serious injuries; Persons supported having higher than average numbers or multiple cases (of similar type allegations) of Reportable Incidents and/or substantiated reports of abuse, neglect and exploitation; Programs, and homes (as applicable) having higher than average numbers or multiple cases (of similar type allegations) of Reportable Incidents and/or substantiated reports of abuse, neglect and exploitation; Individual direct support staff and program/home supervisors (as applicable) having been involved in higher than average numbers or multiple cases (of similar type allegations) of Reportable Incidents and/or substantiated reports of abuse, neglect, and exploitation.

7)

Incident Review Committee Minutes: Incident Review Committee meeting minutes describing committee discussion, recommendations, determinations and actions must be recorded and kept on file by the provider. Minutes must also reflect the date and time of the meeting, the meeting agenda and the members present. The provider agency has discretion regarding the format of Incident Review Committee minutes, but must ensure that the minutes contain the required elements. Final determinations and actions taken regarding Reportable Incidents are to be documented on or as an addendum to the DIDD Reportable Incident Form.

18.4. Investigation of Abuse, Neglect and Exploitation Allegations Incidents of alleged abuse, neglect and exploitation, as well as serious injuries of unknown cause and injuries or deaths suspicious of having been a result of abuse or neglect must be reported to DIDD per the timelines in Table 18.2.b Time Frames Applicable in Reporting Incidents in order to provide a means of safety and protection both to the alleged victim, as well as to other potential victims. All providers must develop and implement a system for timely reporting and responding to allegations of abuse, neglect and exploitation. A. Responsibility for Conducting Investigations: 1) DIDD investigators are responsible for conducting investigations into allegations of abuse, neglect, and exploitation towards persons supported which involve DIDD employees, staff of contracted agencies, contracted employees, volunteers, or others affiliated with person supported through DIDD. DIDD investigators also investigate serious injuries of unknown
18-12

Provider Manual, Chapter 18 Protection from Harm Department of Intellectual and Developmental Disabilities, State of Tennessee Final: 5-31-2012, Effective Date: June 1, 2012

18
cause, suspicious injuries, and suspicious deaths (i.e. those possibly involving abuse, or neglect). 2) Incidents beyond DIDD jurisdiction shall be referred to the appropriate entity; i.e. Adult or Child Protective Services, Health Related Boards or local or state law enforcement. DIDD may conduct investigations into failure to report incidents in a timely manner, as outlined in this chapter. Except for the incidents described above, provider agency staff shall conduct all other reviews of reportable incidents; however, DIDD reserves the right to conduct an investigation into any incident.

3)

4)

B.

Requirements for Investigation of Allegations Involving the Provider Executive Director/Chief Executive Officer or Other Provider Management Staff: In cases when DIDD investigates the Executive Director/Chief Executive Officer or other Provider Management staff, the DIDD Investigation Report and DIDD Summary of Investigation Report will be sent to the Board Chair for not-for-profit providers and to the owner or corporate executive responsible for supervision of the local CEO of for-profit providers. The Board Chair or owner/corporate executive will be required to respond to final investigation reports that are substantiated.

C.

Administrative Staffing Actions During Active Investigations: If there is an allegation of physical or sexual abuse, the provider is required to place any and all staff whose conduct may have contributed to the alleged abuse, on leave or assign such employees duties that do not involve direct care of persons supported, direct supervision of persons supported or supervision of other direct care staff, pending the completion of the DIDD investigation. If the provider believes that any involved staff should not be placed on leave, or reassigned, the provider agency may file a written request for waiver of this requirement to the DIDD Central Office Director of Investigations or designee. Nevertheless, as stated above, if there is an allegation of physical or sexual abuse involved staff must be placed on leave or reassigned duties that do not involve direct care of persons supported until a decision on the waiver request is received from DIDD. For allegations other than those described in the previous paragraph, the providers policy will guide all administrative staffing actions during the investigative process. While the provider is not required to place the staff on administrative leave, the provider shall ensure that adequate steps are taken to assure the protection and safety of the alleged victim and other persons supported. For added assurance that people are protected, the providers policy will be reviewed during the investigative process.

Provider Manual, Chapter 18 Protection from Harm Department of Intellectual and Developmental Disabilities, State of Tennessee Final: 5-31-2012, Effective Date: June 1, 2012

18-13

18
Regardless of the staff leave/reassignment, the provider should instruct all staff that the circumstances of the allegation are not to be discussed with anyone except the assigned DIDD investigator. D. DIDD Distribution of Investigation Reports and Summary of Investigation Reports: 1) DIDD will send a final DIDD Investigation Report, as well as, a DIDD Summary of Investigation Report to the provider(s) responsible for the person(s) supported involved. The DIDD Summary of Investigation Report will be sent to the support coordination provider/DIDD case manager for all persons supported involved in the incident. The provider will be expected to document reasonable attempts to notify alleged perpetrator(s) of the outcome of the investigation. Within fifteen (15) business days of receipt of the DIDD Summary of Investigation Report, the summary shall be discussed with the person(s) supported involved to the extent possible (if a legal representative has been appointed, the legal representative shall be invited to participate), with such discussion conducted by a representative of the provider who supports the person. The provider will document the date and time of this discussion and the efforts to coordinate the meeting with the legal representative, as applicable.

2)

3)

4)

E.

Requesting a Review of DIDD Final Investigation Report: Providers (including support coordinators/case managers) and persons supported or legal representatives may request a review of the DIDD Final Investigation Report by: 1) 2) 3) 4) Filing a written request for review with the DIDD Central Office Director of Investigations, or designee; Filing within fifteen (15) business days of receipt of the DIDD Final Investigation Report (requests will not be considered outside this timeframe); Filing on the DIDD Review of Investigation Form and include all referenced information; and Filing by mail, fax or secure e-mail.

The review process is not an appeal; however, it is a process to review the accuracy of a Final Investigation Report when there is a disagreement with the conclusion or a question that the integrity of an investigation may have been compromised.

Provider Manual, Chapter 18 Protection from Harm Department of Intellectual and Developmental Disabilities, State of Tennessee Final: 5-31-2012, Effective Date: June 1, 2012

18-14

18
A disagreement with the conclusion or question of integrity must be based on new or additional evidence not addressed in the DIDD Final Investigation Report. A DIDD Final Investigation Report shall not be reviewed without evidence submitted to support the disagreement with the conclusion or evidence submitted to support the questioned integrity. DIDD will respond in writing to requests to review investigations with a final decision within thirty (30) days of receipt of the request to review the investigation, unless it is determined that further investigation is warranted. If further investigation is warranted, an interim response will be issued, notifying the complainant or entity requesting review that further investigation is underway. A final decision will be issued upon completion of the additional investigation. In most cases this will occur within forty-five (45) days. F. Provider Response to DIDD Final Investigation Reports: Regardless of any pending request for review of a DIDD investigation, the provider agency is required to respond to any DIDD Final Investigations where there is a substantiated allegation in writing (via mail or e-mail) within fourteen (14) days. Upon receipt of the substantiated DIDD Final Investigation Report, the provider will review the report and develop a plan of correction relevant to the incident(s) investigated and substantiated. The response to the investigated incidents shall include, but is not limited to: 1) 2) 3) 4) 5) What has been done to safeguard the person; What procedures, if any, have been developed and implemented for protecting people from further abuse, neglect, or exploitation; If the incident was reported to DIDD in an untimely manner what has been done to address late reporting; Copies of any staff disciplinary actions; and Copies of the notifications of the outcome of the investigation sent to staff allegedly involved in the incident.

Provider response to a substantiated investigation will be reviewed and additional information may be requested of the provider if the follow-up is incomplete. For unsubstantiated investigations: No plan of correction is required, but the agency is responsible for notifying staff allegedly involved in the incident of the outcome of the investigation and for addressing any additional incident information. In the case of any investigation, DIDD staff will conduct follow-up to ensure that all appropriate actions have been taken.

Provider Manual, Chapter 18 Protection from Harm Department of Intellectual and Developmental Disabilities, State of Tennessee Final: 5-31-2012, Effective Date: June 1, 2012

18-15

18
G. Corrective/Preventive and Disciplinary Actions: Providers must ensure that appropriate actions are taken to achieve correction and/or prevention of issues identified as a result of Reportable Incidents, investigations and risk assessments, including questions, requests and recommendations from the Abuse/Neglect Prevention Committees (ANPC). Recommendations are to be acted upon and necessary corrective/preventive actions are to be taken in a timely manner. Provider documentation must be sufficient to describe any recommendations for corrective/preventive actions made by provider staff or committees and any actions taken to address recommendations provided by internal or external sources. Providers shall maintain and make available for DIDD review, evidence of response to all investigations including any follow-up on incidental information.

18.5. Provider Policy Requirements Pertaining to Protection from Harm: All providers are expected to develop Protection from Harm policies that address the various health, safety and welfare systems for the persons receiving services. Policies required include, but are not limited to: A. Provider personnel policy must include a description of progressive disciplinary actions that will occur when substantiated reports of abuse, neglect and exploitation identify provider staff as perpetrators or when other types of staff misconduct occur (DIDD Personnel Disciplinary Guidelines are available to providers for use in developing appropriate disciplinary procedures and standards). Requirements for Provider Reportable Incident and Abuse, Neglect and Exploitation Policy: Provider policy should ensure that when Reportable Incidents occur and involve persons supported, the agency has effective procedures for addressing the situation promptly and appropriately and for minimizing the future risk of a similar incident or event. Although policy for different providers may vary in certain respects, all such policies must be compliant with DIDD requirements in the eight basic areas listed below: 1) 2) 3) 4) Incidents that are defined as Reportable Incidents that must be reported to the DIDD Central Office; Reportable Incidents that must be reported immediately (within four hours) to the DIDD Investigation Hotline; Review, follow-up and closure of Reportable Incidents; Requirements for notification of entities external to the provider organization and DIDD of the occurrence of Reportable Incidents and of pending DIDD investigations; Timely response to Reportable Incidents and DIDD investigations; Trend studies of Reportable Incidents and substantiated reports of abuse, neglect, and exploitation;
18-16

B.

5) 6)

Provider Manual, Chapter 18 Protection from Harm Department of Intellectual and Developmental Disabilities, State of Tennessee Final: 5-31-2012, Effective Date: June 1, 2012

18
7) 8) Risk assessments/reviews of persons supported, community homes/programs or other situations/circumstances which trend studies identify as presenting high protection and safety risks; and Immediate Response to Safety and Health Risks Associated with Reportable Incidents: Providers must implement policy to ensure immediate response to the safety and health risks of persons supported, staff and others associated with each reportable incident. Such actions may include, but are not limited to: a) b) c) d) Obtaining needed medical attention for persons supported, staff or others who are or could be injured or harmed Immediately correcting any physical hazard that may have contributed to the incident; Immediately attending to staff conduct that may have contributed to the incident; Notifying the persons support coordinator/case manager of the incident, including the need to obtain approval for additional services or supports or the need for funding to complete physical plant or adaptive equipment repairs, adaptations or replacement, as warranted; and Consulting with the support coordinator/case manager regarding initiating planning to arrange for any counseling or psychiatric care that may be needed by the person supported due to the trauma of being the victim of an incident (e.g., rape counseling).

e)

C.

Provider policy may require direct support staff to contact a supervisor prior to contacting the DIDD Investigation Hotline. If initial supervisory contact is required, the policy must also specify that no staff will suffer any adverse consequence if he/she chooses to report directly to the DIDD Investigation Hotline. It should also be noted that providers will be held accountable for any delays in filing reports to the DIDD Investigation Hotline that result from provider internal procedures. Provider policy should specify the responsibilities of all staff in regard to reporting incidents timely and accurately, cooperating with DIDD investigators, including providing requested information timely, ensuring accurate documentation of Reportable Incidents and investigations and documenting corrective/preventive actions. Provider policy must specify that the falsification of incident reports and/or related documentation, the filing of false allegations, the provision of false or misleading information during an investigation or the withholding of information during an investigation by any staff person may be cause for severe disciplinary actions, including legal or other administrative measures as appropriate.

D.

E.

Provider Manual, Chapter 18 Protection from Harm Department of Intellectual and Developmental Disabilities, State of Tennessee Final: 5-31-2012, Effective Date: June 1, 2012

18-17

18
F. Provider policy must specifically state that: Any person subject to this policy who retaliates against another person for his or her involvement as a reporter, witness or in any other capacity related to incident management and/or investigations of abuse, neglect and exploitation shall be subject to disciplinary action, including possible termination. Such actions may also result in legal or other administrative measures as appropriate. Provider Policy: All providers are required to develop and implement an internal written policy that addresses how administrative staffing actions are handled with regard to investigations. This includes alleged perpetrators identified initially as well as those identified at any point during the investigative process. Staff alleged to have committed physical or sexual abuse are required to be placed on leave or be assigned duties that do not involve direct care of persons served, direct supervision of persons served or supervision of other direct care staff pending the outcome of the investigation. For all other allegations of abuse, neglect and exploitation, the provider policy must outline specific provider actions to be taken to ensure the protection and safety of the alleged victim and all people receiving services who may come in contact with the alleged perpetrator. H. Providers policy must ensure the confidentiality of the following: DIDD Reportable Incident Form; incident follow-up and review documentation; and DIDD investigation reports. Confidentiality of this information must be ensured through secure storage of documents and reports in a location separate from the records of the person supported.

G.

Provider Manual, Chapter 18 Protection from Harm Department of Intellectual and Developmental Disabilities, State of Tennessee Final: 5-31-2012, Effective Date: June 1, 2012

18-18

CHAPTER 19 QUALITY MANAGEMENT

19.1.

Introduction Ensuring quality in the provision of services and supports is the responsibility of all partners in the service delivery system. State and federal governments are responsible for oversight of such programs to ensure that the services funded are meeting the needs of service recipients. Providers who establish contracts with the state are required to provide services in accordance with program standards and in accordance with individualized plans created for each service recipient. Providers must have a process for conducting self-assessments as specified in Chapters 6. and 18. Self-assessment is the process by which the provider identifies issues affecting the quality of services provided, as well as areas of operation resulting in non-compliance. Providers must react to self-assessment findings by determining the causative factors and taking action to improve quality or compliance. Service recipients and their families, legal representatives, and advocates have a role in assuring quality by participating in the service planning process, ensuring that their needs are met, and taking advantage of available options for recourse when services and supports do not meet service recipient needs or when unintended events or incidents occur.

19.2.

Quality Management Activities External to DIDS 19.2.a. Federal Quality Management: The Centers for Medicare and Medicaid Services (CMS), within the United States Department of Health and Human Services, is responsible for ensuring the quality of Medicaid waiver programs. CMS approves waiver applications submitted by the state. Approved waivers define the services the state will provide and specify provider qualifications and state administrative responsibilities. The approved waiver requires the state to make a number of assurances to CMS, including an assurance to protect the health, safety, and welfare of service recipients. Once approved, the waiver application serves as a contract between CMS and the state. CMS approves new waivers for a period of three (3) years and waiver renewals for a period of five (5) years.

Provider Manual, Chapter 19: Quality Management Division of Intellectual Disabilities Services, State of Tennessee Published March 15, 2005; Revised effective June1, 2010

19-1

CMS monitors the state for compliance with federal assurances on an ongoing basis. Monitoring focuses on ensuring that the state has the capacity to identify and remediate performance issues related to individual service recipients, providers, and the system as a whole. CMS relies upon data provided by the state to document compliance with each of the federally-required waiver assurances. For each waiver assurance, the state has developed CMS-approved performance measures for which data must be collected, analyzed and reported each month via specified monitoring processes. Federally mandated waiver assurances are: 1) Administrative Authority: The Single State Medicaid Agency must exercise administrative authority over all waiver programs operating within the state; 2) Level of Care: The state must have effective processes for determining that individuals are eligible for services prior to enrollment and remain eligible thereafter; 3) Qualified Providers: The state must ensure access to services provided by a network of service providers that meet qualifications specified in the approved waiver document as well as state-specific licensure, certification, and other programmatic requirements; 4) Service Planning: The state must have processes in place to effectively identify service recipient needs and plan for delivery of services and supports to meet identified needs; 5) Health and Welfare: The state must assure that waiver services, combined with other available services and supports for which the service recipient may be eligible, result in ongoing maintenance of the service recipients health, safety and welfare; and 6) Fiscal Accountability: The state must ensure that federal funds expended are utilized to provide payment for necessary services rendered in accordance with an approved service plan. Performance measure data is aggregated and analyzed monthly, quarterly, and/or annually by the state, with reporting to CMS at regular intervals (reporting frequency is determined by CMS). Data reported to CMS includes compliance percentages for each performance measure, remediation activities completed, and timeframes required for remediation. CMS requires 100% compliance for each performance measure. When performance issues are identified that result in less than 100% compliance, prompt remediation is required to bring compliance up to 100%. Federal audits or investigations may be triggered for reasons unrelated to routine waiver monitoring. Service recipient or family member complaints, provider complaints, or issues presented by advocates or advocacy organizations may result in a federal inquiry or investigation. In addition to CMS, the Office of the Provider Manual, Chapter 19: Quality Management Division of Intellectual Disabilities Services, State of Tennessee Published March 15, 2005; Revised effective June1, 2010
19-2

Inspector General (OIG) and the Office of Civil Rights (OCR) are federal agencies that may conduct audits or investigations at the state level. Court-appointed monitoring entities are responsible for measuring compliance with federal court-ordered requirements. For Arlington Remedial Order Class members, a single Court Monitor has been appointed to perform annual reviews of agencies that provide services and supports to class members. In addition, the Court Monitor follows individual class member status and collaborates with the state to ensure that adequate supports and services are provided in accordance with Arlington court orders. For Clover Bottom/Greene Valley Settlement Agreement Class members enrolled in the Statewide Waiver, the court-appointed Quality Review Panel conducts annual community reviews of providers in each region to determine compliance with court-ordered requirements applicable to Settlement Agreement class members. 19.2.b. State Medicaid Agency Quality Management: The contract for federal funding of waiver programs (the approved waiver application) is between CMS and the State Medicaid Agency. The State Medicaid Agency in Tennessee is the Bureau of TennCare. The Bureau of TennCare is responsible for administrative oversight of all Medicaid waiver programs. The Bureau of TennCare contracts with DIDS to manage the day-to-day operations involved in making quality waiver services available to eligible service recipients. TennCare performs a number of administrative oversight activities to evaluate DIDS performance as the operational lead agency and to evaluate DIDS and provider agency compliance with state and federal rules, regulations, and policies. TennCare administrative oversight activities include: 1) TennCare Annual State Assessments: TennCare may conduct, in addition to other activities, an annual state assessment of each waiver program. These assessments will involve a review of a sample of service recipients enrolled in each DIDS waiver program. Annual state assessments typically include onsite visits at service delivery sites to interview service recipients and direct support staff, assess home environments, review service recipient records, and observe service delivery. Onsite visits to provider agency offices are conducted to review service recipient medical and other records. Additional information may be obtained from DIDS regarding claims adjudication, service authorizations, incidents and investigations, resolution of complaints and appeals, and DIDS quality assurance activities. 2) Look-Behind Surveys: TennCare may conduct look-behind surveys to confirm DIDS survey findings or to validate the adequacy and timeliness of DIDS remediation strategies. Look-behind surveys involve review of a portion of the service recipient sample used during the original DIDS survey. Provider Manual, Chapter 19: Quality Management Division of Intellectual Disabilities Services, State of Tennessee Published March 15, 2005; Revised effective June1, 2010
19-3

3) Follow-along Surveys: TennCare may conduct follow-along surveys to ensure that DIDS survey processes are implemented in accordance with the CMS-approved waiver and TennCare-approved DIDS policies. During follow-along surveys, TennCare staffs go with the DIDS survey team to observe as they are conducting provider surveys or individual record reviews. 4) Focused Surveys: Focused surveys are utilized to determine the extent or prevalence of identified issues. TennCare selects a sample of waiver service recipients for focused surveys. Some of the service recipients are selected from the DIDS sample population reviewed during DIDS surveys or individual record reviews, while others are individuals who were not previously reviewed. 5) Utilization Reviews: Utilization Reviews are post-payment audits to determine if documentation exists to support the claims that the provider submitted for payment and to ensure that the appropriate policies and procedures are followed for provider reimbursement. 6) Complaint Tracking: TennCare may receive complaints from service recipients, family members, providers, advocates, or other interested parties. Complaints may be related to the quality of waiver services provided, access to waiver services, payment of provider claims, or other issues. Complaints received by TennCare are referred to DIDS for review and remediation, as appropriate. TennCare tracks the status of the complaint until adequate resolution has occurred. 7) DIDS Provider Survey Review: TennCare receives copies of all DIDS provider survey reports for review. Follow-up activities related to remediation of survey findings are also reviewed. 8) Incident and Investigation Review: DIDS provides copies of all completed investigation reports to TennCare for review of findings and remediation activities. 9) Data Review: TennCare analyzes DIDS data reports to determine performance measure compliance and adequacy of remediation of findings and time frames. 10) Policy Approval and Interpretation: TennCare reviews and approves all DIDS policies, provider publications, service recipient publications, and other informational materials applicable to waiver programs prior to implementation. In addition, TennCare obtains CMS interpretation of federal rules and regulations, provides interpretation of TennCare rules, and assists in interpreting other state laws and rules as needed. 11) Interagency Meetings: Interagency meetings are held on a monthly basis, including the Interagency Policy Meeting (for discussion of outstanding policy and other issues), the Quality Issues Meeting (for discussion of individual findings and remediation), and the Protection from Harm Meeting (to discuss investigation outcomes, trends, and corrective strategies). TennCare staff participate in monthly DIDS State Quality Provider Manual, Chapter 19: Quality Management Division of Intellectual Disabilities Services, State of Tennessee Published March 15, 2005; Revised effective June1, 2010
19-4

Management Committee (SQMC) Meetings (to engage in discussion of trends and systemic quality improvement strategies). Ad hoc meetings are held as needed for discussion and decision making related to specific issues that cannot be adequately addressed during routinely scheduled meetings. When DIDS requests documentation to support a response to a TennCare finding, providers are required to provide such documentation to DIDS for TennCare review within ten calendar days. Providers will be required to provide documentation validating that adequate remediation activity has occurred and that corrective actions have been implemented to prevent subsequent related findings. TennCare findings may result in sanctions or recoupments. 19.2.c. Quality Monitoring Activities Conducted by Other State and Federal Agencies: Monitoring activities conducted by other state agencies that may involve DIDS providers or require the cooperation of DIDS providers include: 1) Licensure surveys and complaint investigations conducted by the Department of Mental Health and Developmental Disabilities (DMHDD); 2) Licensure surveys and complaint investigations of home care organizations and professional support services providers conducted by the Department of Health (DOH); 3) Audits conducted by the Tennessee Office of the Comptroller to evaluate the Bureau of TennCares performance in administering the waiver program; and 4) Abuse, neglect, and exploitation investigations conducted by the Department of Childrens Services, Division of Child Protective Services or the Department of Human Services, Division of Adult Protective Services. 5) Regional Financial Reviews conducted by the Centers for Medicare and Medicaid Services (CMS) 19.3. Overview of the DIDS Quality Management System (QMS) The QMS measures quality in terms of achieving outcomes that are important to and important for service recipients. The primary purpose of the QMS is to provide a mechanism for achieving continuous improvement in both the quality of services and the performance of the service delivery system. In addition, the QMS measures compliance with state and federal requirements to ensure ongoing availability of federal funding, assists in documenting compliance with federal court orders, and provides information that contributes to effective utilization of resources. Quality management is not a static process; there is no beginning or end point. Rather, it is an ongoing circle of measurement, discovery, action/implementation, and re-measurement to determine the effectiveness of Provider Manual, Chapter 19: Quality Management Division of Intellectual Disabilities Services, State of Tennessee Published March 15, 2005; Revised effective June1, 2010
19-5

strategies employed for improvement of the system. Illustration 19.3. provides a graphic presentation of the QMS circle: Illustration 19.3. The Quality Management System Circle

Measures of Quality Remediation

Data Collection, Analysis & Reporting

Validation Quality Improvement

19.3.a. QMS Principles: Management System:

The following principles guide the Quality

1) The system must produce improvement(s) in the delivery of services; 2) All tools, processes, and protocols developed must be implemented statewide; 3) All tools, processes, and protocols developed must be applicable to and effective for all persons receiving Medicaid waiver-funded services; 4) The system should include the least amount of duplicative processes as possible; 5) The system must include a database capable of collecting and producing reliable information for analysis and reporting purposes; 6) Reports describing QM activities and trend analysis must be widely available; 7) The QM system must identify deficiencies and opportunities for improvement; 8) The QM system must highlight positive practices; 9) The QM system must employ targeted interventions and strategies designed to address the causes of identified issues and concerns; and 10) The QM system must include effective sanctioning options for serious health and safety issues identified and failure to correct quality and compliance issues in a timely and sustainable way. 19.3.b. QMS Activities and Data Sources: Efficient and effective technology systems are essential to the timely collection and production of performance measure data used to evaluate the service delivery system. Ongoing analysis of systemic performance is an essential component to continuous quality improvement. In addition, quality management data allows DIDS to assess service Provider Manual, Chapter 19: Quality Management Division of Intellectual Disabilities Services, State of Tennessee Published March 15, 2005; Revised effective June1, 2010
19-6

recipient satisfaction with services, document compliance with federal court orders, monitor the effectiveness of policy and training initiatives, and ensure adequate fiscal management of the service delivery system. DIDS quality management processes include: 1) Provider Performance Surveys: Regional Quality Assurance (QA) Survey Teams conduct annual provider reviews to evaluate compliance with the three-way provider agreement and overall provider performance. Provider performance data is utilized to identify both individual provider and systemic issues, develop systemic improvement strategies, provide CMS-required performance measure data, and assist in documenting compliance with federal court orders 2) Individual Waiver-Specific Record Reviews: DIDS QA staffs conduct individual record reviews for a sample of service recipients in each waiver program. CMS-required performance measure data is collected, analyzed and acted upon when there are findings. 3) Fiscal Accountability Review (FAR): FAR audits provide information and data used to evaluate the overall financial status of the provider network, including provider competency in adequately documenting the provision of services to support claims submitted. Data pertaining to CMS-required performance measure data is collected, analyzed and acted upon when there are findings during FAR audits. 4) Service Recipient Satisfaction Surveys: Through a DIDS contract, the People Talking to People survey is conducted gathering information from a sample of service recipients from each waiver program. Survey data provides a view of the service delivery system from the perspective of people receiving services. CMS-required performance measure data is collected, analyzed and acted upon when there are findings during People Talking to People surveys. 5) Incident and Investigation Data Analysis: Data derived from the Incident and Investigation database is utilized to identify and address individual service recipient and systemic health, safety, and welfare issues Data collected documents compliance with CMS-required performance measures and federal court orders as well as provides DIDS with decision tools. 6) Complaint Resolution Tracking: The complaints database is maintained by DIDS Central and Regional Office Complaint Resolution staff. The database provides information about the types of complaints received, the entities that submit complaints, and DIDS success in achieving timely resolution of complaint issues. CMS-required performance measure data is derived from the Complaints Database and analyzed for systemic issues and trends. 7) Provider Enrollment Data Analysis: Provider enrollment data provides information relative to provider network adequacy and the effectiveness of provider recruitment efforts. CMS-required performance measure data is Provider Manual, Chapter 19: Quality Management Division of Intellectual Disabilities Services, State of Tennessee Published March 15, 2005; Revised effective June1, 2010
19-7

captured in the Provider Enrollment Database, analyzed and acted upon when there are findings. 8) Death Reviews: Regional Death Review Committees evaluate all deaths of unexplained or suspicious cause. The Death Review process results in recommendations that include both individual provider and systemic prevention strategies. More detailed descriptions of QMS activities are provided in the subsequent sections of this chapter. 19.3.c. QMS Data Analysis: Analysis of data is done at all levels of the system through data aggregation, review of aggregated data for trends, and determination of the prevalence of the trends. Findings may be: 1) Individual Findings that are related to a specific service recipient or event; 2) Provider-Level Findings that can be attributed to events or circumstances that affect only those service recipients receiving services from a single provider; or 3) Systemic Findings that can be attributed to events or circumstances affecting all service recipients in a particular region or throughout the state. 19.3.d. QMS Remediation of Findings: Remediation must occur at all levels of the system. Individual service recipient findings will require provider and/or DIDS remediation actions. DIDS goal is to achieve remediation of individual findings within 30 days of discovery in most situations. DIDS will perform follow-up validation reviews involving a sample of individual remediation actions. In addition, TennCare reviews and validates individual remediation of findings. Provider-level findings will typically require development or revision of a provider quality improvement plan which specifies strategies for achieving adequate remediation of findings and preventing subsequent related findings. Depending on the nature of the findings, implementation of the provider quality improvement plan may be monitored through follow-up or focused reviews, reassessment during the next scheduled Provider Performance Survey, Agency Team monitoring/technical assistance, or provider submission of documentation supporting quality improvement plan implementation. Systemic findings will typically require longer time periods to determine the cause of the systemic finding and develop system-wide remediation strategies. Systemic improvement strategies will be proposed by DIDS and discussed with TennCare during monthly quality management meetings (if applicable to waiver providers and/or service recipients). TennCare will monitor implementation of Provider Manual, Chapter 19: Quality Management Division of Intellectual Disabilities Services, State of Tennessee Published March 15, 2005; Revised effective June1, 2010
19-8

DIDS systemic improvement strategies via review of supporting documentation and data, status updates during interagency meetings, and/or focused surveys. 19.4. DIDS Provider Performance Surveys Provider Performance Surveys are conducted to determine provider outcomes related to Quality Domain indicators, determine provider compliance with the three-way provider agreement, and determine compliance with federallymandated waiver assurances and related performance measures. 19.4.a. Quality Domains: Provider performance is evaluated via the Provider Performance Survey process, through outcome measurement in ten (10) Quality Domains. The Quality Domains are: 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) Access and Eligibility; Individual Planning and Implementation; Safety and Security; Rights, Respect, and Dignity; Health; Choice and Decision-Making; Relationships and Community Membership; Opportunities for Work; Provider Capabilities and Qualifications; and Administrative Authority and Financial Accountability.

19.4.b. Survey Tools: Outcomes and indicators related to each quality domain have been incorporated into DIDS Provider Performance Survey Tools. Individual survey tools have been developed for different provider types. Copies of current survey tools applicable to specific provider types are available on the http://tennessee.gov/dids/quality_assurance/survey_inst.html DIDS website at http://tennessee.gov/dids/quality_assurance/survey_inst.html. Tools include two areas of focus: evaluation of services and supports received by a sample of individual service recipients and assessment of the providers ability to ensure an adequately trained workforce, develop an effective management structure, and develop and implement policies and practices that are personcentered and quality focused. Survey results highlight both exemplary performance and opportunities for improved compliance and/or quality of service. 19.4.c. Frequency of Surveys: DIDS QA staffs conduct annual surveys of all residential and day service agencies, support coordination agencies, home care organizations (including those with professional support services licensure for clinical service provision) and personal assistance agencies. Independent clinical service providers (licensed/certified clinical service practitioners who do not employ additional staff) are surveyed at least every three (3) years. Less frequent surveys may be conducted for provider agencies demonstrating ongoing proficient or exceptional performance in overall operation. DIDS may determine that more Provider Manual, Chapter 19: Quality Management Division of Intellectual Disabilities Services, State of Tennessee Published March 15, 2005; Revised effective June1, 2010
19-9

frequent surveys are necessary to evaluate provider performance in ensuring service recipient health, safety, and welfare or to determine resolution of serious compliance issues. 19.4.d. Consultative Surveys: DIDS QA staffs conduct initial consultative surveys for new agencies that have initiated service provision but have not previously participated in a Provider Performance Survey. A consultative survey is considered an informal survey process intended to give the new provider experience with the survey process and knowledge of compliance issues and needed improvements. The provider will be required to correct any serious health and safety issues identified during a consultation survey. After the consultation survey is completed, the provider will participate in annual DIDS Provider Performance surveys. 19.4.e. Sampling Methodology: A ten percent (10%) representative sample of service recipients will be selected for onsite review during each Provider Performance Survey, with a minimum of four (4) and a maximum of fifteen (15) service recipients selected. The provider will be given a list of service recipients selected for the initial sample on the first day of the survey. Sample size may be increased if issues are identified within the sample population and more information is needed to determine the scope of the issue. 19.4.f. Preparing for a Provider Performance Survey: A Provider Performance Survey schedule is developed prior to the beginning of each survey year. Providers will be notified at that time of the approximate date that DIDS plans to begin the agencys Provider Performance Survey. For providers that support service recipients in more than one region, Regional QA staff will make arrangements, when possible, to complete the survey jointly. Approximately sixty (60) days before the start of the survey, DIDS will send written notice to the provider of the actual date the survey will begin. The provider must complete the following activities prior to the survey: 1) Submit requested pre-survey information to DIDS at least thirty (30) days prior to the survey start date; 2) Identify a staff member as DIDS contact during the survey process; 3) Notify all service recipients, involved family members, and legal representatives, as applicable, of the upcoming survey; and 4) Notify all service recipients, involved family members, and legal representatives, as applicable, of the survey teams availability to discuss the survey processes or services received during the course of the survey Providers shall be allowed to determine the best method of distributing information about the survey. Examples of acceptable methods for information distribution include individual correspondence, articles in provider newsletters, announcements posted at service sites, and email announcements. Provider Manual, Chapter 19: Quality Management Division of Intellectual Disabilities Services, State of Tennessee Published March 15, 2005; Revised effective June1, 2010
19-10

19.4.g. On-site Provider Performance Survey Procedures: Surveys begin with a meeting between key provider staff and the survey team. During the initial meeting, participants will discuss the logistics of the survey. The provider may utilize the initial meeting to provide general information about the organization, including management and quality improvement strategies that have been implemented since the last survey. Following the initial meeting, survey activities will begin. Throughout the survey, survey team members will interact with provider staff to ask questions and request needed information. Surveyors will act in accordance with the following during the survey: 1) Initial observations will be considered in light of additional relevant information that is presented or discovered during the course of the survey. 2) Identified issues that are corrected prior to the end of the survey will be included in survey results, with notation of expedient corrective action. 3) Immediate jeopardy issues (that have caused or have potential to imminently cause harm to the service recipient) identified during a survey will require expedient provider corrective action (Section 19.6. describes immediate jeopardy situations and protocols in greater detail). 4) Reporting protocols will be followed if unreported incidents are discovered, including notification of DIDS investigators as appropriate. When survey activities are completed, survey team members will participate in a conciliation process to determine the providers level of performance based on all information collected and reviewed during the survey. The conciliation process involves determining whether quality domain indicators were met, not met, or not applicable. Performance is evaluated using a numerical range scale beginning with the lowest possible rating (most deficient performance) and ending with the highest possible rating (most exemplary performance). The point scale used to determine performance ratings will be noted on the current survey tool, which is available on the DIDS website or upon request from any DIDS office. The survey will conclude with an exit conference. During the exit conference, the survey team will review major findings. Under most circumstances, the written survey report will be made available during the exit conference. When circumstances require further review of specific issues, the survey report will be issued when review is completed. A copy of the final report will be sent to the provider agencys Board Chair. 19.4.i. Provider Response to Provider Performance Surveys: The provider agency executive director shall be held responsible for ensuring that the internal quality improvement plan is revised to address survey findings, as appropriate. In addition, the provider must evaluate self-assessment capabilities and develop Provider Manual, Chapter 19: Quality Management Division of Intellectual Disabilities Services, State of Tennessee Published March 15, 2005; Revised effective June1, 2010
19-11

quality improvement strategies that allow prompt identification and correction of compliance issues. 19.4.j. Provider Requested Reviews of Provider Performance Survey Results: Providers may request review of findings cited during a survey and included in the written survey report. Review requests may be submitted to the appropriate DIDS Regional Director of Quality Assurance. If the provider is dissatisfied with the results of the review, a second review may be initiated by submitting a written request to the DIDS Deputy Commissioner stating the reason a second level review is being requested. The Deputy Commissioner or designee will respond to the request as expeditiously as possible, in most cases, within 30 days. Response times will vary depending upon the number and complexity of issues presented with the review request. All review requests should specify findings to be reviewed and should be accompanied by any documentation available to support requested changes in survey findings. For each step, the provider will have ten (10) days from the date of receiving the survey report or written notification of a determination to initiate or continue the review process. 19.5. Individual Waiver-Specific Record Reviews Individual Record Reviews are conducted during each waiver year to collect data demonstrating compliance for three (3) of the six (6) federally-mandated waiver assurances: Level of Care, Service Planning, and Health and Welfare. Individual Record Reviews are conducted by DIDS Regional QA staff. 19.5.a. Sampling Methodology: During each waiver year, a statistically valid random sample of individual service recipients will be selected for review from each waiver program. Sampling methodology will be available on the DIDS website. 19.5.b. Review Process: For each service recipient selected, a record review will be conducted by DIDS QA staff utilizing a data collection instrument designed based on federally-mandated waiver assurances and CMS-approved performance measures. The current data collection instrument is available on the DIDS website. 19.5.c. Remediation of Findings: Designated DIDS Regional Office staff will report findings to the appropriate remediation entities (designated DIDS staff and/or appropriate provider management staff). Appropriate remediation strategies will be implemented. DIDS Regional and Central Office Compliance staff will report findings, remediation activities, and remediation timeframes. A Provider Manual, Chapter 19: Quality Management Division of Intellectual Disabilities Services, State of Tennessee Published March 15, 2005; Revised effective June1, 2010
19-12

sample of remediation actions will be validated by designated DIDS Regional Office staff and by TennCare Quality Management staff to ensure successful and timely remediation of findings. 19.6. Immediate Jeopardy The immediate jeopardy protocol will be followed by DIDS survey staff or other DIDS employees who identify immediate jeopardy issues while on-site at a service delivery location. 19.6.a. Issues Warranting Initiation of the Immediate Jeopardy Protocol: Immediate jeopardy issues include, but are not limited to: 1) Serious medication errors not previously detected or corrected; 2) Lack of follow-up for major medical issues; 3) Failure to follow dietary instructions resulting in choking or imminent risk of choking; 4) Little or no food in the home or little or no food appropriate to a service recipients special diet; 5) Serious mismanagement of service recipient funds; 6) Identification of major risk factors in absence of a plan to address the risk; or 7) Serious environmental hazards. 19.6.b. Immediate Jeopardy Protocol: When immediate jeopardy is identified, the following actions shall occur: 1) The DIDS employee identifying the immediate jeopardy situation will contact the agency director to provide verbal notice of the immediate jeopardy situation; 2) The DIDS employee identifying the immediate jeopardy situation or other DIDS staff available will notify the DIDS Regional Director or designee of the immediate jeopardy situation; 3) Designated DIDS Regional Office staff will issue a written immediate jeopardy notice to the provider describing the situation and time frame by which actions must be taken to ensure the service recipients health and safety; 4) Designated Regional Office staff will send a copy of the immediate jeopardy notice to the service recipients support coordinator/case manager; 5) The provider will notify the service recipients legal representatives and/or involved family members; 6) DIDS staff will remain on-site as necessary until the immediate jeopardy situation has been resolved sufficiently to ensure the service recipients health and safety; Provider Manual, Chapter 19: Quality Management Division of Intellectual Disabilities Services, State of Tennessee Published March 15, 2005; Revised effective June1, 2010
19-13

7) Designated Regional Office staff will validate and document corrective actions taken; and 8) Survey scores and ratings will be affected by immediate jeopardy findings during a survey, even when timely corrections are implemented. 19.7. Service Recipient Satisfaction Surveys Service recipient satisfaction surveys provide information about the quality of services and supports directly from the people who receive them. The service recipient perspective is a valued and essential component of the QMS. Service recipient and/or family member interviews are utilized to obtain information about the impact of services and supports on quality of life during Provider Performance surveys and/or other monitoring processes. 19.7.a. Provider Initiated Service Recipient Satisfaction Surveys: Provider agencies are required to conduct service recipient surveys and use the information obtained to improve the quality of services and supports. For support coordination agencies, evaluation of service recipient satisfaction with independent support coordination services occurs with completion of required service documentation forms described in Chapter 4, Section 4.8. Other provider agencies are required to conduct an annual survey, the results of which are reviewed during DIDS Provider Performance Surveys. 19.7.b. The People Talking to People Survey: DIDS contracts with an external entity to administer the annual People Talking to People (PTP) Survey. The current PTP survey format is available on the DIDS website. The PTP survey involves face-to-face interviews with service recipients and/or family members conducted by an independent evaluator employed by the contractor. The contractor works with the DIDS PTP Director to collect and analyze survey data, and produce an annual PTP Survey Report. Trends are reported statewide, by region, and by waiver program. PTP Survey data is utilized to document compliance with CMS-approved performance measures related to the Service Planning and Health and Welfare federally-mandated waiver assurances. PTP data is also used to identify systemic issues and develop systemic quality improvement strategies. 19.8. Incident Management and Complaint Resolution Incident management requirements are discussed in detail in Chapter 18. Complaint resolution processes are discussed briefly in Chapter 18 and in more detail in Chapter 2. Both complaint and incident/investigation data is utilized to monitor compliance with the federally-mandated Health and Welfare assurance and related CMS-approved performance measures. The Incident and Investigation (I&I) database also provides information relevant to court compliance and provider performance. I&I information is used to determine if Provider Manual, Chapter 19: Quality Management Division of Intellectual Disabilities Services, State of Tennessee Published March 15, 2005; Revised effective June1, 2010
19-14

more frequent provider monitoring or provider technical assistance is warranted. 19.8.a. Complaint Resolution Data: Complaints about services and supports may be made at either the DIDS Central or Regional Office. Complaints are generally handled at the regional level; however, the DIDS Central Office Director of Complaints Resolution tracks all complaints and oversees the system to ensure timely and satisfactory resolution. A Complaints Database tracks each complaint through resolution, providing data about the types of complaints submitted, the entities submitting complaints, resolution activities employed, and timeframes required to achieve resolution. Providers are required to establish a complaint resolution process to address complaints submitted by service recipients and families. Further information about the provider complaint resolution process is found in Chapter 18, Section 18. 19.8.b. Incident and Investigations Data: Incident and investigation data is maintained by the DIDS Protection from Harm Unit, utilizing the Incident and Investigations (I&I) database. The I&I database produces the following data: 1) Types and numbers of critical incidents statewide, by region, by waiver, and by provider; 2) Number of investigations completed statewide, by region, by waiver and by provider; and 3) Rates of substantiated investigations statewide, by region, by waiver, and by provider. 19.9. Death Review Death reviews are conducted by DIDS Regional Death Review Committees for all suspicious, unexpected, and unexplained deaths. The Death Review policy, available on the DIDS website, guides the death review process. 19.9.a.: The Regional Office Preliminary Death Review: The Preliminary Death Review is completed by the Regional Director or designee, the Regional Compliance Director or designee, and the Regional Nursing Director or designee when deaths are reported. The purpose of the preliminary Death Review is to determine if the death is suspicious, unexpected, or unexplained. When such criteria are met, investigation, Clinical Death Summary, and DIDS Death Review shall be initiated. 19.9.b. Providers Death Review: Provider Death Reviews must be initiated when a service recipient is receiving residential services (e.g., Supported Living, Residential Habilitation, Medical Residential Services, or Family Model Residential Support) at the time of death. The purpose of the residential Provider Manual, Chapter 19: Quality Management Division of Intellectual Disabilities Services, State of Tennessee Published March 15, 2005; Revised effective June1, 2010
19-15

providers death review is to identify any conditions or practices that require immediate intervention in order to protect other individuals from similar untoward events. Examples of such conditions or practices might include environmental hazards, a delay in emergency response or in seeking medical intervention, or abusive or neglectful conduct on the part of staff or others. The providers death review is not expected to resolve all outstanding issues or result in conclusions as to the cause of death, but may be used to identify questions or concerns to be addressed in subsequent investigations and proceedings. The review may be conducted in accordance with the providers own policies and procedures. The review may be formal or informal; however, a description of events surrounding the death and identification of known or likely contributing factors must be included. Completed Providers Death Reviews must be submitted to the appropriate Regional Director. 19.9.c. Clinical Death Summaries: DIDS Regional Nurses complete Clinical Death Summaries for all class members whose deaths occur while receiving waiver services. Clinical Death Summaries are completed for all suspicious, unexpected, or unexplained deaths, whether the service recipient was a class member or not. Clinical death summaries shall be completed within thirty (30) days of the death. 19.9.d. DIDS Death Review: DIDS Death Review Committees are comprised, at a minimum, of a physician who was not involved in the care of the service recipient and who was not involved with the provider agency; the registered nurse who completed the Clinical Death Summary; the provider agencys executive director; at least one provider staff member who is familiar with the service recipients health status, history, and the course of events prior to death; and the support coordinator or case manager. The Regional Compliance Director (or designee), will serve as the Committee Chair. Additional members (e.g., the primary care physician, the DIDS investigator, the agency Nursing Director) may be added as needed. The purpose of DIDS death reviews is to conduct a comprehensive analysis of the relevant facts and circumstances, including the medical care provided, to identify practices or conditions which may have contributed to the death, and to make recommendations, where necessary, to prevent similar occurrences. Death reviews are completed within forty-five (45) days of the service recipients death. The DIDS Regional Compliance Director will make all arrangements for the Death Review Committee meeting, including issuing notice to the provider agencys executive director five (5) days in advance of the scheduled meeting and distributing death review packets to meeting participants. A follow-up meeting may be scheduled following the initial DIDS Death Review meeting if additional review is needed. Follow-up Death Review meetings shall occur if requested by the DIDS Deputy Commissioner or any two members of the committee. Provider Manual, Chapter 19: Quality Management Division of Intellectual Disabilities Services, State of Tennessee Published March 15, 2005; Revised effective June1, 2010
19-16

Death Review Committee activities will be documented in meeting minutes. Minutes will be submitted in draft form to participants, who will be allowed to submit corrections prior to finalization. Provider agency staffs who receive copies of draft and final meeting minutes shall maintain the documents in a secure location. 19.9.e. Response to Death Review Committee Recommendations: The provider agencys executive director or designee shall submit a written response to Death Review Committee recommendations to the Regional Office Compliance Director within thirty (30) calendar days of receipt. The response shall include either: 1) A complete plan for implementing each recommendation, including timeframes for implementation; or 2) Alternative actions proposed to address the problems or issues identified. 19.10. Regional Agency Teams Regional Agency Teams are responsible for follow-up activities related to DIDS Provider Performance Surveys and other quality monitoring processes. Agency Teams conduct Targeted Elements Assessments utilizing the Targeted Elements Assessment (TEA) Tool. The TEA Tool is composed of selected indicators from the Provider Performance Survey Tool. TEA Tools applicable to different provider types are posted on the DIDS website. DIDS Regional Quality Management Committees determine the need for Agency Team technical assistance/follow-up and the frequency of agency team contact based on the nature of provider performance issues identified, considering the severity, scope, and duration of the compliance or quality issues. Agency teams report the status of corrective plan implementation and quality/compliance improvements to the Regional Quality Management Committee in subsequent monthly Quality Management meetings. 19.11. Technical Assistance Technical assistance may be requested by the provider or be recommended or mandated by DIDS. Technical assistance is provided by Agency Teams or by ad hoc teams formed to provide specialized technical assistance. Technical assistance may involve help with analyzing causative factors, identifying resources available to the provider, developing corrective plans, and/or measuring improvements achieved with implementation of corrective actions. 19.11.a. Requested Technical Assistance: Requests for technical assistance must be directed to the Regional Office Director of Operations. If identified technical assistance needs cannot be met by the Regional Office, the Central Office will be Provider Manual, Chapter 19: Quality Management Division of Intellectual Disabilities Services, State of Tennessee Published March 15, 2005; Revised effective June1, 2010
19-17

so advised. The provider agency will be notified in writing as to whether the requested technical assistance can be provided by the Regional or Central Office and if so, when the requested technical assistance is expected to begin. If staff resources do not permit provision of the requested technical assistance within a reasonable time frame, DIDS will advise of other known alternatives that may be available to address the providers technical assistance needs. 19.11.b. Recommended Technical Assistance: DIDS may recommend technical assistance when: 1) Immediate jeopardy situations of limited scope, frequency, and severity are identified; 2) An overall performance rating of Fair is determined during a Provider Performance Review; 3) A non-compliance rating is determined for areas related to individual planning and implementation; safety and security; health; and/or provider capabilities and qualifications; 4) A Provider Performance Survey or other DIDS monitoring activity identifies significant weakness in providing a particular service/program, though substantial compliance may have been achieved for other services/programs provided; 5) Multiple issues are identified through monitoring activities conducted by entities external to DIDS; 6) Financial issues are identified that could be indicative of or result in serious financial problems if not evaluated and resolved; or 7) Other identified issues or trends that are indicative of potential problems that, if not resolved, could result in health and safety issues. Providers with identified performance issues will receive written notice of the reason(s) why and issues for which technical assistance is recommended, and must accept or decline participation within the timeframe specified in the notice. Failure to respond timely will be interpreted as a refusal. Written provider responses must be directed to the Regional Office Director of Operations. All identified performance issues must be addressed and work toward compliance begun within ninety (90) business days even if the provider declines technical assistance. If compliance is not achieved, other administrative actions may be taken, including mandated technical assistance and up to an including termination of the providers agreement.

19.11.c. Mandated Technical Assistance: Mandated technical assistance may be required when there is a pattern of failure to assure the health, safety, and welfare of people receiving services. Situations warranting mandated technical assistance include, but are not limited to: Provider Manual, Chapter 19: Quality Management Division of Intellectual Disabilities Services, State of Tennessee Published March 15, 2005; Revised effective June1, 2010
19-18

1) Identification of immediate jeopardy issues that are significant in terms of scope, frequency, or severity; 2) An overall performance rating of Serious Concerns or Significant Deficiencies is determined during a Provider Performance Review 3) Provider Performance Surveys identifying non-compliance in areas related to individual planning and implementation; safety and security; rights, respect, and dignity; health; and/or provider capabilities and qualifications; 4) Provider Performance Surveys identifying repeat findings that have not been adequately resolved or have not been adequately addressed through ongoing quality improvement strategies; 5) Issuance of provisional licensure by the Department of Mental Health and Developmental Disabilities, the Department of Health, or other licensing entities; or 6) Identification of financial issues that threaten the ongoing financial viability of the agency. Provider Executive Directors and Board Chairs will receive written notice of the reason(s) for which technical assistance is mandated, including time frames for achieving compliance or resolving quality issues. A copy of the initial Agency Team Plan for providing technical assistance will be attached. The Provider must exhibited tangible evidence of amelioration of all identified performance issues within ninety (90) days. If compliance is not achieved, other administrative actions may be taken, including termination of the provider agreement. Financial sanctions may be imposed due to provider non-compliance. 19.11.d. DIDS Technical Assistance Provision: DIDS mandated technical assistance will be provided be at no cost to the provider. Agency Team staff will contact the provider agency to make arrangements for providing mandated technical assistance. 19.11.e. Providers may choose to receive mandated technical assistance from a technical assistance entity other than DIDS. Any costs incurred for reimbursement of such an entity shall be the providers responsibility. When a technical assistance entity other than DIDS is utilized, the provider must obtain approval from the Regional Quality Management Committee. To obtain approval, the provider must: 1) Notify the Regional Office Director of Operations of the entity selected within ten (10) business days of mandated technical assistance notice (receipt will be presumed to be five calendar (5) days from the mailing date of the notice); 2) Agree to participate in Agency Team monitoring visits at a frequency specified by the DIDS Regional Quality Management Committee; Provider Manual, Chapter 19: Quality Management Division of Intellectual Disabilities Services, State of Tennessee Published March 15, 2005; Revised effective June1, 2010
19-19

3) Submit the technical assistance plan for achieving compliance, including the indicators or measures for tracking progress and demonstrating improved compliance; and 4) Report data monthly documenting progress in achieving compliance. DIDS must approve the technical assistance plan. All or part of the plan may be accepted or rejected. In the event that the plan is not approved as written, DIDS will issue a written notice to the provider indicating why all or part of the plan was unacceptable and what revisions must be made to avoid additional DIDS action. Provider response is required within ten (10) business days of receipt. 19.11.f. Technical Assistance Termination: terminated when: Technical Assistance may be

1) The provider has achieved compliance as determined by the Regional Quality Management Committee; or 2) Other types of sanctions are warranted due to the providers unwillingness to participate in implementation of the technical assistance plan, including administration of TEA assessments at the frequency specified. 3) The provider agreement is terminated. 19.12. Provider Recoupments and Sanctions DIDS may directly impose sanctions or may recoup funds based on findings identified through DIDS, TennCare, and/or other external monitoring processes, in accordance with the terms of the three-way provider agreement. DIDS may also advise other state licensing entities, as appropriate, of findings directly identified through DIDS monitoring processes. 1912.a Recoupments: Recoupment means recovery of money paid to a provider due to the providers failure to comply with TennCare or DIDS requirements for service provision or documentation of such. a. Reasons for recoupment by the DIDS shall include but not be limited to: 1) Absent or inadequate documentation to show that a billed service was provided; Provision of a service by a provider that did not meet DIDS or TennCare/Medicaid provider qualifications applicable to HCBS waiver services or other DIDS, state, or federal provider qualifications applicable to state-funded services, including services performed by staffs who have not completed background or registry checks, or who have not completed all applicable training requirements;
19-20

2)

Provider Manual, Chapter 19: Quality Management Division of Intellectual Disabilities Services, State of Tennessee Published March 15, 2005; Revised effective June1, 2010

3)

Action or inaction by the provider that causes DIDS to use state funds to pay for a service for which Medicaid Federal Financial Participation (FFP) would otherwise have been available; or Any circumstance in which the provider received reimbursement to which the provider was not entitled.

4)

19.12.b. Sanctions: Sanctions are financial or other measures imposed on a provider for failure to comply with TennCare/Medicaid or DIDS rules, regulations, or policies. a. Reasons for imposition of sanctions by the DIDS shall include failure to comply with: 1) The TennCare/DIDS provider agreement applicable to the provision of HCBS waiver services or other TennCare/Medicaid, DIDS, or federal requirements applicable to Medicaid HCBS waiver services, including services performed by staffs who have not completed background or registry checks, or who have not completed all applicable training requirements; A DIDS contract applicable to the provision of services statefunded by DIDS or other DIDS or state requirements applicable to state-funded services; or State and federal laws, rules, regulations, and policies.

2)

3) b.

Sanctions may include, but are not limited to, the following: 1) 2) A written warning to correct the deficiency; Mandated technical assistance (the provider shall be responsible for costs associated with technical assistance provided by entities other than DIDS); A moratorium on providing services to other than existing service recipients; A moratorium on providing additional services or expansion of the providers service area; A financial sanction; Termination of the DIDS provider agreement for cause or for convenience; or DIDS assumption of management responsibility and control directly or through a DIDS designated entity (the provider shall be responsible for costs associated with contracting and external management entity).
19-21

3) 4) 5) 6) 5)

Provider Manual, Chapter 19: Quality Management Division of Intellectual Disabilities Services, State of Tennessee Published March 15, 2005; Revised effective June1, 2010

Provider Manual, Chapter 19: Quality Management Division of Intellectual Disabilities Services, State of Tennessee Published March 15, 2005; Revised effective June1, 2010

19-22

20
CHAPTER 20 PROVIDER CLAIMS SUBMISSION AND PROCESSING

20.1.

Introduction

This chapter provides an overview of the DMRS claims processing system, as well as, responsibilities of providers in submitting claims for services rendered. 20.2. Description of the Claims Processing System: Medicaid waiver and DMRS statefunded individual services are processed via a claims processing system having the following features: 1) All services are based on a fee for service; 2) All payments for services are on a reimbursement basis; 3) All billings for the prior month are due to DMRS by the due date indicated on the DMRS Agency Services Report; and 4) Billings for services are by individual, for specific services that are authorized by the Regional Office. 20.2.b. Defined Individualized Service Need and Established Rates: Each service is described in terms of service units with a rate established for each unit of service provided. Services may have daily, monthly or annual maximum authorizations. Payments will not be made in excess of these established maximum rates without the express written authority of the DMRS Deputy Commissioner or designee. 20.2.c. Individual Support Plans (ISP): The support coordinator/case manager is responsible for submitting a Individual Support Plan (ISP) to the Regional Office for each service recipient (the ISP is discussed in Chapter 3). The ISP is the document used to identify and request authorization of individual service needs services, including the amount (number of units), frequency (how often the service is needed) and duration (time period services are needed). ISPs may be submitted at any time throughout the year and must be updated at least annually. ISPs must be submitted and approved prior to the provision of services, with the exception of emergency services. Emergency services are approved through the Regional Administrator on Duty (AOD) pager system, which is described in greater detail in Chapter 18. (see contact numbers in Appendix B). Emergency services are those that are necessary immediately to avoid serious detriment to a service recipients health and safety.

Provider Manual, Chapter 20 Provider Claims Submission and Processing Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

20 - 1

20
20.3. Provider Responsibilities Related to Reimbursement of Claims Provider responsibilities include: 1) Submission of documents and requests required for establishment as a provider within the claims processing system; 2) Submission of accurate and timely monthly billings for provision of authorized services; 3) Submission of timely rebilling or correction; 4) Submission of documentation as required to justify units of service billed; 5) Submission of additional claims processing information as requested by the DMRS Regional or Central Offices; 6) Notification of the Regional Office in the event of errors, omissions or additions shown on the Agency Services Report prior to submission to DMRS; 7) Notification of the Regional Office in the event that a service recipients Medicaid, Medicare or Social Security numbers are incorrect; 8) Notification of the Regional Office regarding needed provider record updates or corrections on the claims processing system; and 9) Notification of the Regional Office regarding reassignments of service sites for service recipients receiving DMRS program services. 20.4. Claims Processing Requirements: The following requirements must be met prior to receiving reimbursement for services: 1) Licensure, if required, must be verified; 2) An approved ISP authorizing services for the appropriate dates must be entered into the claims processing system database for each service recipient for whom a claim is submitted; 3) An Agency Number Assigned by DMRS; 4) A valid site code; 5) An executed DMRS Provider Agreement; 6) A federal identification number (For sole proprietorships or limited partners, this is the federal employer identification number. For individuals who are authorized as providers, this may be the individuals social security number.) 20.4.a. Agency Numbers: In order for DMRS to authorize services for any service recipient, the provider must be assigned a DMRS Agency Number. This five-digit agency number is unique to the provider and does not change. The agency number is used to prepare billing and invoice statements as well as to make direct deposits to the providers account. The provider will need to furnish the name of the organization, the billing address, a business fax and phone

Provider Manual, Chapter 20 Provider Claims Submission and Processing Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

20 - 2

20
number, an e-mail address, the name of the chief executive officer/executive director, and the name of the Board chair or agency owner. Providers serving more than one region should have a different number in each region. 20.4.b. Agency Site Codes: Each provider will also have a site code assigned by the DMRS to record information specific to the providers billing address. These site codes start with the letters AG and include the last three digits of the agency number. The AG Site Code should list the actual address where payment is sent for services billed by that agency and information for any other communication from DMRS to the provider. 20.4.c. Service Site Codes: Every site where a provider renders services must have a separate site code to identify the location by type and address. The Central Office of the DMRS assigns the site number. The service site code is used to track the specific location of each service authorized by DMRS. Service site codes are necessary for tracking information such as residence address and incident data. The following requirements apply to service site codes: 1) Several types of services could occur at the same site; however, each type of service would require a separate site code; 2) Every service is authorized to occur at a specific site specified in the ISPif a service recipient moves, service site changes must be reported to ensure reimbursement of services; 3) Site codes must be assigned prior to receipt of services at the site location; consequently, providers must report service site changes to the Regional Office as soon as the change is anticipated and no later than the actual date of location change; 4) Any site code that has been used for reimbursement must be retained; however, providers must inform the Regional office of site codes that are invalid, out of date or no longer useful; and 5) A therapy, nursing and personal assistance site address is the address of the office that staff work froma site code is not assigned to each staff persons home. 20.4.d. Site Name: The name of the site is used as a shortcut. For residential and supported living services, the site name should be brief but meaningful, such as street name of the site. For other type of sites, the city or county may be used as the site name.

Provider Manual, Chapter 20 Provider Claims Submission and Processing Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

20 - 3

20
20.5. Service Authorization DMRS Regional Offices are responsible for approval of ISPs to authorize services and supports. The service authorization process is described in Chapter 2. The Regional Office may authorize all or part of the services requested on an ISP. Entries into the billing system are made by the Regional Office based on approved services. This produces a history of all approved services for payment purposes. 20.5.a. Service Limits: Services are reimbursed in accordance with limits approved in the ISP. DMRS will not provide payment for services provided in excess of the authorized limits. 20.5.b. Retroactive Requests for Service Authorization: Payment of retroactive service authorization requests is not provided. 20.6. Claims Processing 20.6.a. The Agency Services Report: The Agency Services Report is the official billing document for services used to process claims in the DMRS system. The DMRS Central Office prepares this report monthly and distributes it to each provider billing for services rendered. The Agency Services Report details the services approved for each service recipient that may be billed by the provider. Recipients are listed in alphabetical order, with all approved services listed for each. Service additions or changes that have occurred since the billing document was prepared may not appear on the Agency Services Report. Providers should verify the additions with the Regional Office and complete an Additions, Re-bills and Corrections form. The Agency Services Report will not be prepared for providers of ancillary services unless the provider also provides day, residential, support coordination, personal assistance, therapy, behavior or nursing services. Ancillary services are billed separately. 20.6.b. Timeliness and Accuracy of Claims: Claims must be accurate. The provider must maintain documentation to justify all service units billed. Claims must be submitted in accordance with the due date shown on the Agency Services Report. Claims deadlines cannot be extended. 20.6.c. Corrections to the Agency Services Report: Any corrections to names, Social Security Numbers or Medicaid Numbers must be communicated to the Regional Office. Such changes may only be made by DMRS Regional Office staff. The Regional Office should be contacted if changes need to be made for claims submitted, but not yet paid.

Provider Manual, Chapter 20 Provider Claims Submission and Processing Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

20 - 4

20
20.6.d. Corrections and Late Billing: Corrections or late billings must be submitted in a timely manner. If correction is needed more than 90 days after the initial billing cycle, corrections must go through the Regional Office for approval and submission for payment. 20.6.e. Rebilling: Providers should use the Adjustment Form when it is necessary to re-bill for correction of prior billing error or resubmission of additional information due to previous denial of a claim. Initial billings for a service must be made within ninety (90) calendar days of the month of service. Rebilling should occur as soon as possible. Claims over ninety (90) days old must have adequate justification and go through the Regional Office for approval. The following requirements apply when rebilling: 1) Only the service recipients for whom rebilling is necessary should be listed; 2) Payment made in error or in excess of the amount owed should be reversed by entering negative payments and units; 3) Accurate billing information should be entered after correcting erroneous payments; 4) Any required documentation must be submitted with re-billed claims; and 5) Notes and/or other information that helps to describe the nature of the correction requested are appreciated. 20.6.f. The Detailed Adjustments and Late Actuals Statement (DALAS): The DALAS form will accompany the Agency Payment Report to provide details regarding re-billed or corrected claims. The DALAS also reflects any payment changes due to errors by DMRS or updated information provided by the Regional Offices. The DALAS shows adjustments grouped alphabetically by service recipient. If adjustments have been made for multiple time periods, adjustments will be shown in chronological order beginning with the latest time period. 20.6.g. Monthly Payment of Routine Claims: Services are compensated in accordance with monthly billing statements. DMRS makes payments at the end of each month for the preceding month. If the claims are submitted late, payment will be made during the following month. 20.6.h. Denial of Claims: Claims documents are compared to services authorized and entered on the system for the month the billing is received. If the appropriate information is not available in the claims processing database, the claim will be denied. Providers may contact the Regional Office for questions regarding the denial of claims and information regarding resubmission of the claim.

Provider Manual, Chapter 20 Provider Claims Submission and Processing Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

20 - 5

20
20.7. Financial Reporting Requirements

20.7.a. Independent Audit: Providers receiving $500,000 or more in aggregate state and federal funds must conduct an independent audit of the organization. Copies of this audit must be submitted to the Tennessee Office of the Comptroller and to the DMRS Central Office. 20.7.b. Uniform Cost Report: Residential and day providers serving five (5) or more service recipients must complete a Uniform Cost Report to be submitted to the DMRS Central Office. 20.8. Provider Rates Current provider rate schedules will be posted on the DMRS website. Paper copies may be requested from any DMRS office.

Provider Manual, Chapter 20 Provider Claims Submission and Processing Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

20 - 6

GLOSSARY OF TERMS

Abuse The knowing infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Action Plan The portion of the ISP that outlines things that must be accomplished to meet the persons individual needs. Activities of Daily Living (ADL) Tasks a person would normally do for themselves if they were able, such as eating, bathing, dressing, personal hygiene, and meal preparation (excluding cost of food). Additional Activity/Contact Sheet A form used to record support coordination/case management face-to-face visits, home visits, provider onsite visits, meetings, telephone contacts, e-mail correspondence, and written correspondence or fax transmittals beyond the routine contacts that are conducted. Administrative Law Judge A hearing officer who presides over appeal conflicts between providers of services or beneficiaries and Medicaid contractors. Administrative Services Staff Staff responsible for performing functions necessary to operate and maintain a service business. Administrator on Duty (AOD) An assigned staff person that is responsible for accessing on-call case management staff to respond to any case management needs that arise during hours/days when state offices or provider agencies are not open. Adult Dental Services (Statewide Waiver) Adult Dental Services shall mean accepted dental procedures which are provided to adult enrollees (i.e., age 21 years or older) as specified in the plan of care and for which there is no coverage for adults through the Medicaid State Plan/TennCare program. Adult Dental Services may include fillings, root canals, extractions, the provision of dentures, and other dental treatments to relieve pain and infection. Anesthesia services provided in the dentists office and billed by the dentist shall be included within the definition of Adult Dental Services. Adult Dental Services shall not include hospital outpatient or inpatient facility services or related

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-1

GLOSSARY OF TERMS

anesthesiology, radiology, pathology, or other medical services in such setting. Adult Dental Services shall exclude orthodontic services. Please refer to Chapter 15 of this manual. Advanced Directives A written statement such as a living will, a durable power of attorney for health care, or a do not resuscitate order related to the provision of health care when the individual is incapacitated. Adverse Action Includes, but is not limited to, delay, denial, reduction, suspension or termination of benefits, as well as, any other acts or omissions which impairs the quality, timeliness or availability of such benefits. Advocacy Organization An organization with trained staff who work with individuals and/or families to promote services and supports typically related to a central cause or condition. Advocacy organizations providing services for people with mental retardation ensure that the individual and/or family can effectively express his/her preferences, understand available services and supports and that individual rights are protected. Advocate A person, whose primary focus is on another persons wants and needs, protects the persons rights, power and authority and supports the person to gain competency, self-determination and respect. Agency An administrative structure and the persons within that structural entity defined by law, charter, license, contract or agreement that may be delivering services to persons with mental retardation and developmental disabilities. American Heart Association (AHA) A national voluntary health agency whose mission is to reduce disability and death from cardiovascular diseases and stroke. www.americanheart.org American Journal of Health-System Pharmacy (AJHP) (formerly known as American Journal of Hospital Pharmacy) AJHP publishes papers on the advancement of rational drug therapy in organized health-care settings, drug information, professional issues, health care delivery, and societal trends. www.ashp.org

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-2

GLOSSARY OF TERMS

American Occupational Therapy Association (AOTA) AOTA is the nationally recognized professional association of approximately 35,000 occupational therapists, occupational therapy assistants, and students of occupational therapy. www.aota.org American Physical Therapy Association (APTA) APTA is a national professional organization representing more than 63,000 members. Its goal is to foster advancements in physical therapy practice, research and education. www.apta.org American Red Cross Humanitarian organizations led by volunteers that provide relief to victims of disasters and help people prevent, prepare for, and respond to emergencies. www.redcross.org Americans with Disabilities Act (ADA) A law enacted in 1990 that established a comprehensive national mandate for the elimination of discrimination on the basis of disability in employment, state and local government, public accommodations, commercial facilities, transportation and telecommunications. Ancillary Services Services that pertain specifically to dental, vision, and mental health and include intermittent services such as environmental modifications and supplies. Annual ISP Review and Update Preparation Form A form used to document the ISP pre-planning and planning activities. Refer to Appendix D of this manual. Annual Recertification The process approved by the Bureau of TennCare by which the enrollees physician or a QMRP accesses the medical necessity of continuation of waiver services and certifies in writing that the enrollee continues to require waiver services. Annual Re-evaluation Form The form approved by the Bureau of TennCare to be used by a physician or QMRP to document a persons continued need for waiver services. Appeals Please refer to Chapter 2 of this manual.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-3

GLOSSARY OF TERMS

Arlington Remedial Order Order entered on September 6, 1994, in the matter United State of America v. State of Tennessee, et.al. (Arlington), U.S. District Court, WD Tenn. No. 92-2062-D/A, establishing requirements for the provision of services to current, future, and certain former residents of Arlington Developmental Center. Arlington Waiver The federally approved HCBS Medicaid Waiver Program for persons who meet the Tennessee Medicaid financial and medical eligibility criteria for care in an ICF/MR facility and who are class members certified in the matter United States of America v. State of Tennessee, et.al. (Arlington Developmental Center). Assessments Professional and/or clinical evaluations of persons receiving or waiting to receive state and federally funded DMRS services to determine the reason for a change in health status or failure of the person to make progress. Audiologist A person who practices audiology, or one holding oneself out to the public by any title or description of services incorporating the words audiologist, audiology, audiological, hearing center, hearing clinic, hearing clinician, hearing therapist, or any similar titles or descriptions of service. Background Checks A law enacted in 1997 by the Tennessee Legislature that requires provider agencies to conduct criminal, work history and personal background checks on employees, contractors or volunteers whose job functions include direct contact with or responsibility for DMRS service recipients. Behavior Analysis The science of behavior change; the study of the functional relations between behavior and environmental events. Behavior Analyst A professional providing behavioral services independently who has been approved to provide services through the Operational Administrative Agency and the Bureau of TennCare and meets one of the following: 1) licensed in the State of Tennessee for the independent practice of psychology; 2) a qualified mental health professional licensed in the State of Tennessee with a scope practice that includes assessment, diagnosis and treatment of behavioral disorders;

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-4

GLOSSARY OF TERMS

3) certification by the Behavior Analyst Certification Board (BCBA) as a behavior analyst and demonstrated evidence of six (6) months experience in providing behavior services to persons with mental retardation or developmental disabilities; or 4) a professional with a masters degree in behavior analysis, psychology, special education or related field with a minimum of twelve (12) hours of graduate level courses in behavior analysis. All applicants must demonstrate evidence of twelve (12) months experience in providing behavior services to persons with mental retardation or developmental disabilities.

Behavior Respite Services Services that provide respite for an Enrollee who is experiencing a behavioral crisis that necessitates removal from the current residential setting in order to resolve the behavioral crisis. Behavior Services Defined as: 1) Assessment and amelioration of enrollee behavior that presents a health or safety risk to the enrollee or others or that significantly interferes with home or community activities; 2) determination of the settings in which such behaviors occur and the events which precipitate the behaviors; 3) development, monitoring and revision of crisis prevention and behavior intervention strategies; or 4) training of caregivers who are responsible for direct care of the enrollee in the prevention and intervention strategies. Please refer to Chapter 12 of this manual. Behavior Specialist A professional providing behavioral services under the clinical supervision of a DMRS approved behavior analyst, who has been approved to provide services through the Administrative Lead Agency and the Bureau of TennCare and who meets the designation as: (1) a qualified mental retardation professional (QMRP); or (2) certification by the Behavior Analyst Certification Board (BCBA) as an associate behavior analyst. All applicants must demonstrate evidence of twelve (12) months experience in providing behavior services to persons with mental retardation or developmental disabilities. Behavior Support Plan (BSP) Planned behavioral interventions to reduce behavior that presents a health or safety risk to the individual or others or that significantly interferes with home or community activities and increases alternative replacement behaviors.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-5

GLOSSARY OF TERMS

Behavioral Health Organization (BHO) A type of managed care contractor approved by the Tennessee Department of Finance and Administration to deliver mental health and substance abuse services to TennCare enrollees under the TennCare Partners Program. Behavioral Respite Services Services that provide respite for an enrollee who is experiencing a behavioral crisis that necessitates removal from the current residential setting in order to resolve the behavioral crisis. Please refer to Chapter 12 of this manual. Best Practice Guidelines Adopted practices or services that have been demonstrated to be effective and accountable. Billing Calendar A day by day summary account of the actual time to determine billable units of service for reimbursement. Biopsychosocial BIO (medical) medical, psychiatric, medication reactions, syndromes, neurological state PSYCHO (logical) current psychological characteristics and skill deficits SOCIAL environmental, interpersonal, programmatic, physical Brown Settlement Agreement Consent decree entered on June 17, 2004, in the matter Beth Ann Brown et.al. v. Tennessee Department of Finance and Administration, et.al., U. S. District Court, MD Tenn. No. 3:00-0665 (Judge Echols) establishing requirements for provision of services to Tennessee residents with mental retardation eligible for Medicaid services under the ICF/MR program who have been placed by the DMRS on a waiting list for services. Bureau of TennCare The single state agency designated by Tennessee law to administer the State medical assistance program as provided for in Title XIX of the Social Security Act as amended (P.L. 89-97), or as provided by any federal waiver received by the State that waives any or all of the provisions of Title XIX. Business Days The official state government standard working days of Monday through Friday 8:00 a.m. through 4:30 p.m. Central Time, excluding official state holidays.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-6

GLOSSARY OF TERMS

Calendar Days Each twenty-four hour day of the week in each calendar month, including Saturdays, Sundays and state and federal holidays. Cardiopulmonary Resuscitation (CPR) Basic life support that involves opening the airway, providing artificial breathing, and assisting circulation until definitive treatments can restore spontaneous cardiac, pulmonary, and cerebral functions. Caregiver A paid or unpaid person who performs activities of daily living needs for persons with mental retardation and developmental disabilities. Case Manager An individual who assists the enrollee or potential enrollee in gaining access to needed Waiver and other Medicaid State Plan services as well as other needed services regardless of the funding source; develops the initial interim Plan of Care and facilitates the development of the enrollees Plan of Care, monitors the enrollees budget, and authorizes alternative emergency back-up services for the enrollee if necessary. Caseload Maximums Refers to the maximum number of persons receiving DMRS services that a support coordinator can be assigned to provide support coordination or case management services to. Caseloads Refers to the total number of persons receiving DMRS services that a support coordinator has been assigned to provide support coordination or case management services to. Category of Need A waiting list category describing the immediacy of needs for individuals (i.e., crisis, urgent, active or deferred) who request services from the Division of Mental Retardation Services. Centers for Medicare and Medicaid Services (CMS) (formerly known as HCFA) The agency within the United States Department of Health and Human Services that is responsible for administering Title XVIII, Title XIX and Title XXI of the Social Security Act. Certification Date The initial date or approved from date on the PAE application signed by a physician certifying an individuals medical necessity need of waiver services.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-7

GLOSSARY OF TERMS

Certified Nursing Assistant (CNA) A person who has successfully completed a nursing assistant training program and is registered with the Department of Health. Certified Nursing Technician (CNT) A person who has successfully completed a nursing technician training program and is registered with the Department of Health. Circle of Support (COS) A group of selected individuals who meet or otherwise share information on a regular basis to help the focus person accomplish personal life goals and become an active member in the community. Circle of Support Membership Individuals, who have been chose by the focus person and who have agreed to participate as members of the COS, whose roles are to assist the focus person in voicing ideas and opinions regarding the options for meeting needs that are discussed at the focus persons ISP Planning Meeting. Class Members An individual meeting the requirements in the definition of the class in either People First of Tennessee, et.al. v. Clover Bottom Developmental Center, et.al., U.S. District Court, MD Tenn. No. 3:95-1227, consol. With No. 3:96-1056 (Judge Echols), United States of America v. State of Tennessee, et. al. (Arlington), U.S. District Court, WD Tenn. No. 92-2062-D/A, or Beth Ann Brown et.al. v. Tennessee Department of Finance and Administration, et.al., U.S. District Court, MD Tenn. No. 3:00-0665 (Judge Echols) so as to be entitled to the benefits provided pursuant to court order(s) in those lawsuits. Clinical Diagnosis Identification of a disease by history, physical examination, laboratory studies and radiological studies. Clinical Service Contact Note Please see Contact Note definition Clinical Unit Reference Checklist Please refer to Appendix D. Clinicians Health care professionals with expertise in patient care rather than research or administration.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-8

GLOSSARY OF TERMS

Clover Bottom/Greene Valley Settlement Agreement (CB/GV) Consent Decree entered on uly 3, 1997, in the matter People First of Tennessee, et.al.. v. Clover Bottom Developmental Center, et.al., U.S. District Court, MD Tenn. No. 3:95-1227, consol. with No. 3:96-1056 (Judge Echols), establishing requirements for the provision of services to current and certain former residents of Clover Bottom Developmental Center, including Harold Jordan Center; Greene Valley Developmental Center; and Nat T. Winston Developmental Center. Communication Device Any device with letters, pictures, or words that lets patients with impaired physical and verbal ability express themselves. Community Based Day Services Community based day services enable the service recipient to participate in meaningful and productive activities in integrated settings with other community members who may or may not have disabilities. Community Transition Refers to when a person moves from one community residential provider to another. Competency Based Training Training courses completed by persons who demonstrate knowledge of the content offered during the training by passing a test or demonstrating the ability to perform a task. Competent An individual who has decision-making capability. Comprehensive Individual Record An individual record maintained by the primary provider that contains all inclusive information specific to the individual receiving services such as, an individuals ISP, supports and services currently receiving, medical records, etc. Conservator A person or persons appointed by the court to provide partial or full supervision, protection and assistance of the person or property or both of a disabled person age 18 and over. Consumer Directed Supports Services, equipment or supplies not otherwise available to the individual through the Medicaid State Plan or other community resources that address an identified need, including those that improve and maintain the individuals opportunities for full membership in the community.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-9

GLOSSARY OF TERMS

Contact Notes Written documentation of time in and time out provided by provider agencies or professional providers each time contact is made with the person receiving services for the purpose of providing a service or performing a related activity. Contracted Professionals Professional and/or licensed staff that is not employed by a provider, but provides services to service recipients in accordance with a written contract. Core Training Training that must be completed by persons working with any service recipient within thirty (30) days of employment. Please refer to Table 7.2. Crisis Prevention Plan Written instructions for direct care staff on prevention of a crisis using protective strategies and how staff should respond should a crisis occur. Cross-Training The training of selected community agency staff in the individualized needs of the individual transitioning from a Developmental Center to the community or from one community residential provider to another. Customized Equipment Refers to equipment constructed from diverse and usually standardized parts. Examples of customized equipment are: custom hand splints, custom positioning and seating equipment, custom communication systems, or modifications to standard equipment. Day Habilitation Facility A non-residential facility, which offers a variety of habilitative activities to adults with mental retardation. Such habilitative activities may range from training activities in independent living to vocational skills, depending on the needs of the service recipient being served. This includes adult developmental training, work activity, and scheduled workshop programs; but does not include job placement and supported employment programs. Day Habilitation Licensure Regulations Please refer to Appendix C of this manual. Day Services Day Services shall mean individualized services and supports that enable an enrollee to acquire, retain or improve skills necessary to reside in a community-based setting; to participate in community activities and utilize community resources; to acquire and maintain employment; and

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-10

GLOSSARY OF TERMS

to participate in retirement activities. Therapeutic goals and objectives shall be required for enrollees receiving Day Services. Please refer to Chapter 10 of this manual. Dental Services (Arlington Waiver) Dental Services shall mean accepted dental procedures which are provided to adult enrollees (i.e., age 21 years or older) as specified in the plan of care and for which there is no coverage for adults through the Medicaid State Plan/TennCare program. Dental Services may include preventive dental services, fillings, root canals, extractions, periodontics, the provision of dentures, and other dental treatments to relieve pain and infection. Anesthesia services provided in the dentists office and billed by the dentist shall be included within the definition of Dental Services. Dental Services shall not include hospital outpatient or inpatient facility services or related anesthesiology, radiology, pathology, or other medical services in such setting. Dental Services shall exclude orthodontic services. Please refer to Chapter 15 of this manual. Department of Childrens Services (DCS) The state agency responsible for administering Tennessees Child Protective Services program. Department of Education (DOE) The lead state agency responsible for administering the Early Intervention Program and implementing the Individuals with Disabilities Act. Department of Health (DOH) The state agency responsible for licensing professional support providers who choose to participate as providers in the DMRS programs, including Physical and Occupational Therapists, Speech Language Pathologists, and Nurses. Department of Human Services (DHS) The state agency under contract with the Bureau of TennCare to determine eligibility for individuals applying for TennCare Medicaid, except for those determined to be eligible for SSI benefits by the Social Security Administration. Department of Mental Health and Developmental Disabilities (DMHDD) The state agency responsible for the provision of services to individuals with neurobiological brain disorders, mental illnesses and developmental disabilities. DMHDDs Office of Licensure is responsible for licensing residential, day, respite, host family and in-home supports providers who choose to participate in the DMRS programs. Developmental Center A private or state-run ICF/MR that provides residential and habilitation services to persons with mental retardation and developmental disabilities.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-11

GLOSSARY OF TERMS

Developmental Center Transition Refers to when a person chooses to move from an intermediate care facility for the mentally retarded to a community residential provider. Developmental Center Transition Closure Meeting A meeting held for the purpose of ensuring that all tasks identified in the persons ITP have been completed as assigned and to develop a schedule for required visitation and post-transition monitoring. Developmental Center Transition Meeting A meeting attended by the individual transitioning from a developmental center to the community, Regional Office and Developmental Center transition staff, support coordinator, COS members, advocates and providers for the purpose of finalizing the persons ITP. Dietetics/Nutrition Practice The integration and application of scientific principles of food, nutrition, biochemistry, physiology, management and behavioral and social sciences in achieving and maintaining health through the life cycle and in the treatment of disease. Methods of practice include, but are not limited to, nutritional assessment, development, implementation and evaluation of nutrition care plans, nutritional counseling and education, and the development and administration of nutrition care standards and systems. (T.C.A. 63-25-103) Dietitian/Nutritionist Dietitian and nutritionist may be used interchangeably and means a health care professional practicing dietetics/nutrition and licensed under T.C.A. 63-25. (T.C.A. 63-25-103) Direct Services Functions that have not been included as part of the support coordination waiver definition but are included as part of the service definition for other services and have therefore been prohibited for a support coordinator to perform, such as transporting a person or finding a home or job for a person. Direct Support Staff/Direct Support Professional Persons employed, trained and paid by an agency to provide for the day-to-day care and support of persons participating in DMRS services (also referred to as direct support staff). Direct Support Staff Early Intervention Staff who provides hand-on, face-to-face assistance to children with disabilities on a routine or as needed basis.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-12

GLOSSARY OF TERMS

Direct Therapy Services Services which must be provided face-to-face with hands on assistance provided by the therapist or therapy assistant to the service recipient. Discharge Summary A summary of information regarding the service recipient that contains information such as, the persons name, summary of services provided, status of action and person at the time of discharge, recommendations on how to maintain the current status of the person, indicators for re-referrals (if appropriate) and the providers signature and date. Division of Mental Retardation Services (DMRS) The state agency within the Tennessee Department of Finance and Administration that is responsible for oversight and operational administration of state-funded and Medicaid-funded service programs for people with mental retardation. Division of Rehabilitation Services (DRS) The Department of Human Services Division of Rehabilitation Services helps disabled persons become self-sufficient, gain employment, or receive timely and accurate decisions on their applications for disability benefits. www.state.t.us/humanserv/DRS.html DMRS Agency Teams DMRS regional teams consisting of two (2) or more staff assigned to one (1) or more provider agencies for the purpose of assuring resolution to provider performance issues that are identified during Quality Assurance Surveys or other quality monitoring processes. Agency Teams shall assess ongoing compliance between formal Quality Assurance surveys by performing Targeted Elements Assessments, by planning and providing information and technical assistance to providers, by collecting data to determine the effectiveness of technical assistance efforts and by evaluating the effectiveness of provider actions taken to resolve performance issues. DMRS Application Form Please refer to Appendix D. DMRS Application Packet Please refer to Appendix D. DMRS Central Office The Central Office of the Division of Mental Retardation Services located in Nashville, Tennessee.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-13

GLOSSARY OF TERMS

DMRS Family Model Residential Supports Initial Site Survey A survey completed by DMRS staff to ensure the home meets the service recipients needs and that the family and service recipient are compatible and well matched. Please refer to Appendix D. DMRS Family Model Residential Supports Monitoring Tool A tool developed by DMRS that providers are required to use when performing monthly supervisory visits to service recipients homes. Please refer to Appendix D. DMRS Intake Process a/k/a DMRS Registration Process A process that has been established by DMRS to allow Regional Office case managers to assess and assist individuals to register and request services from DMRS. DMRS Internal Operating Policies Policies established and implemented by DMRS for use in its Central and Regional Offices. DMRS QA Survey Reports The process of determining via application of standardized survey instruments at specified intervals, a providers compliance with the applicable requirements set forth in state and federal laws, rules, regulations and policies as referenced in the executed provider agreement. DMRS Regional Offices The local offices of DMRS located in the three grand regions of the state (East, Middle and West). DMRS Resource Manual A document developed by DMRS to assist providers in meeting requirements related to particular services. Such manuals often include information about provider resources, suggested policies, best practice guidelines, and other helpful information. DMRS Review of Expansion Requests Checklist Please refer to Appendix D. DMRS Review of Investigation Form Please refer to Appendix D. DMRS Substantiated Abuse and Neglect List DMRS centralized record system that contains persons who have been substantiated on complaints of abuse and neglect.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-14

GLOSSARY OF TERMS

Do Not Resuscitate (DNR) An order or advanced directive made by a person that requests CPR not be performed in the event the persons heart stops or the person stops breathing. DRS Vocational Evaluation Form A Division of Rehabilitation Services form that consists of two parts: The Situational Job Assessment and the Summary of General Job Requirements. Drugs and/or Medications Substances intended for use in diagnosis, care, mitigation, treatment, or prevention. Dual Diagnosis/Co-Occurring Disorder/Comorbid Disorder Terms denoting the co-existence of mental retardation and a mental health disorder. Durable Medical Equipment Equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of illness or injury, and is appropriate for use in the home. Early Intervention Refers to the IDEA Part C, which is a program for infants and toddlers aged birth to three years who meet certain eligibility criteria. Early Periodic Screening Diagnosis and Treatment (EPSDT) Screening in accordance with professional standards, inter-periodic screening and diagnostic services to determine the existence of physical or mental illness or conditions in recipients under age 21; and health care treatment, and other measures, described in 42 USC 1396(a) to correct or ameliorate any defects and physical and mental illnesses and conditions discovered. EPSDT is now referred to as Tennder Care. Education Services Consultation provided by a licensed nurse to the service recipient or primary family caregiver concerning a chronic condition. (Chapter 0940-5-38) Elderly or Vulnerable Abuse Registry A registry maintained by the Tennessee Department of Health that is required by state law and federal regulations and contains information of persons who have abused, neglected, or misappropriated personal property. www2.state.tn.us/health/abuseregistry/index.html

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-15

GLOSSARY OF TERMS

Electronic Benefit Transfer Cards (EBT) An on-line system in which food stamp and cash assistance benefits are stored in a central computer database and electronically accessed by customers at a point-of-sale machine via reusable plastic cards. In Tennessee, these EBT cards are called Benefit Security Cards. Eligibility The process whereby an individual is determined to be eligible for coverage through the HCBS Medicaid Waiver Program. Emergency First Aid The administration of immediate care to an injured or acutely ill person before the arrival of a physician or ALS unit and transport to either a physicians office or hospital emergency department. Emergency Medical Condition A medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to potentially result in: (1) placing the persons health in serious jeopardy; (2) serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or part. Employment Based Day Services Employment Based Day Services facilitate access and support activities such as competitive employment, self-employment, enclaves and work crews. Employment Supports Supports provided to a person with disabilities to help them obtain and maintain competitive employment. Enclave Enclave means a work unit provided by a licensed vocational program consisting of two (2) or more service recipients working in a normal, competitive work setting. The setting focuses on assessment, training, and work experience with pay. End of Life Issues Refers to choices and decisions on how an individual prefers their life to end, which includes decisions in legal, medical, and spiritual matters (e.g., right to accept or refuse medical treatment, including the use of breathing tubes, feeding tubes, and CPR; cremation or burial; and creating a Last Will and Testament.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-16

GLOSSARY OF TERMS

Enrollee A Medicaid eligible who is enrolled in the Home and Community Based Services Waiver for the Mentally Retarded and Developmentally Disabled. Enrollment The process by which an eligible individual becomes enrolled in the HCBS Medicaid Waiver Program. Environmental Accessibility Modifications Environmental Accessibility Modifications shall mean only those interior or exterior physical modifications to the enrollees place of residence which are required to ensure the health, welfare and safety of the enrollee or which are necessary to enable the enrollee to function with greater independence. Please refer to Chapter 14 of this manual. Evaluations Appraisals of the health, including medical, dental, or mental, or status of an individual based on specific criteria. Exemption Criteria Criteria developed by the DMRS and approved by the TennCare Division of Developmental Disability Services and the CMS that allows certain individuals that meet a defined crisis criteria to be exempted from the federally imposed moratorium on new enrollment into the HCBS Waiver. Expedited Appeal An appeal for time-sensitive services that must be resolved by hearing and a written hearing decision (initial order) within thirty-one (31) days from the date the appeal is received by the Bureau of TennCare. Exploitation (Misappropriation of Property) The deliberate misplacement, exploitation, or wrongful, temporary or permanent use of belongings or money without consent (consent obtained from a service recipient lacking the capacity to consent will not be considered as obtaining consent). Face-to-Face Monitoring Visit Form A form used to document the required support coordination/case management contacts. Refer to Appendix D of this manual.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-17

GLOSSARY OF TERMS

Face-to-Face Therapy Services Therapy services that occur face-to-face with the person receiving services to develop or evaluate the persons therapy treatments and/or face-to-face therapy services provided to facilitate participation in activities specified in the persons ISP (plan of care) that cannot be accomplished/implemented by direct support staff. Face-to-Face Visits Monitoring visits that are conducted in person by the support coordinator to observe the person receiving DMRS services in varied service environments to ensure overall quality of the services and supports being provided. Facility Based Day Services Facility based day services are provided in a licensed day habilitation facility. Fair Hearing Please refer to Chapter 2 of this manual. Fair Labor Standards Act (FLSA) The Fair Labor Standards Act establishes minimum wage, overtime pay, record keeping and child labor standards affecting full and part-time workers. Please refer to Appendix C of this manual. Family Model Residential Support Family Model Residential Support shall mean a type of residential service having individualized services and supports that enable an enrollee to acquire, retain or improve skills necessary to reside successfully in a family environment in the home of trained caregivers other than the family of origin. The service includes direct assistance as needed with activities of daily living (e.g., bathing, dressing, personal hygiene, eating, meal preparation excluding cost of food), household chores essential to the health and safety of the enrollee, budget management, attending appointments, and interpersonal and social skills building to enable the enrollee to live in a home in the community. It may also include medication administration as permitted under Tennessees Nurse Practice Act. Please refer to Chapter 9 of this manual. Family Support Goods and services needed by families to care for their family members with a severe or developmental disability and to enjoy a quality of life comparable to other community members. Family Support Program A coordinated system of family support services administered by the DMRS directly or through contracts.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-18

GLOSSARY OF TERMS

Federal Bureau of Investigation (FBI) The Federal Bureau of Investigation (FBI) is the investigative arm of the US Department of Justice. The FBIs investigative authority can be found in Title 28, Section 533 of the US Code. www.fbi.gov Federal Fair Housing Act Title VIII of the Civil Rights Act of 1968 (Fair Housing Act), as amended, prohibits discrimination in the sale, rental, and financing of dwellings, and in other housing-related transactions, based on race, color, national origin, religion, sex, familial status (including children under the age of 18 living with parents or legal custodians, pregnant women, and people securing custody of children under the age of 18), and handicap (disability). Federal Financial Participation (FFP) The Federal Governments share of a states expenditure under the Title XIX Medicaid Program. Financial Audit Reports Audit reports issued by or on behalf of the internal audit unit of DMRS based on the findings of announced/unannounced financial audits of DMRS providers. Financial Eligibility Appeal A formal appeal submitted to the DHS by or on behalf of a person that requests a fair hearing due to the person having been notified by DHS that they are not financially eligible for Medicaid Services. Financially Eligible A person who has been approved by the DHS or the SSA to be financially eligible to have Medicaid make reimbursement for covered services. First Aid Training Training in the immediate and temporary care given to persons who are in an accident or who have a sudden illness before a physician or other qualified health personnel arrives to provide treatment. First Amendment Rights The basic rights of all Americans that states Congress Shall Make No Law Respecting the Establishment of Religion, or Prohibiting the Free Excersice Thereof; or Abridging the Freedom of Speech, or of the Press; or the Right of the People Peaceably to Assembly, and To Petition the Government for a Redress of Grievances. (American Library Association)

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-19

GLOSSARY OF TERMS

Focus Person The person who receives or will receive DMRS services. Follow Along Services Follow Along Services are for individuals who need minimal support on a job in the community. Individuals are able to sustain employment with natural supports at the work site and only need an agency to provide oversight through regular contacts. The provider agency is required to make two face-to-face contacts per month. One contact must be at the work site unless indicated in the ISP. However, more contacts may be necessary if problems occur that may endanger the individuals employment. The provider agency is responsible for helping individuals develop relationships with co-workers, sustain employment and support career advancement at the work site. Freedom of Choice An individuals right to choose whether they want to receive services in the HCBS Medicaid Waiver Program or in an ICF/MR and also the right to select any provider that has a provider agreement with DMRS and the Bureau of TennCare that is available, willing and able to provide the services needed. Generic Community Services Services provided in a community by persons or entities that are not funded with DMRS, state or federal dollars (Generic Community Services and Supports are commonly referred to as Natural Supports). Grier Appeal A formal appeal submitted to the Bureau of TennCare by or on behalf of a person enrolled in a Waiver program that requests a fair hearing due to the person having been notified by DMRS that a service has been denied, suspended, terminated, delayed or reduced. Grier Order A class action lawsuit filed against the State of Tennessee that resulted in a court ordered settlement agreement allowing persons enrolled in the TennCare Medicaid Program to appeal any adverse action related to the ability to receive medical services within the TennCare Program. Guardian A person or persons appointed by the court to provide partial or full supervision, protection and assistance of the person or property or both of a person under the age of 18. Guide to Physical Therapist Practice

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-20

GLOSSARY OF TERMS

The American Physical Therapy Associations document that explains physical therapy scope of practice, preferred practice patterns, and appropriate utilization of services. Habilitative Services Habilitative services means services, including occupational therapy, physical therapy, and speech therapy, provided to a service recipient to acquire, retain or improve skills necessary to reside in a community-based setting. Health A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. Health Care All of the services made available by medical professionals to promote, maintain, or preserve life and well being and having as its major objectives: to relieve pain; treat injury, illness, and disability; and provide comfort and hope. Health Care Management and Oversight To take all necessary actions to ensure that the individual receiving DMRS services has the best possible health and health care. Health Insurance Portability and Accountability Act (HIPAA) A federal law amended in 1996 that pertains to a persons right to have personal health records maintained in a confidential manner. Health Oversight Form Please refer to Appendix D of this manual. Health Passport A document that provides a description of health-related information that the person and the persons legal representative, family members and/or advocate believe to be important in representing the persons health history and current health status. Health Related Events Information concerning things that occur in ones health, such as when a person is hospitalized for medical or psychiatric care, when a person is taken to an emergency room, when a person has a DNR order or when a person has a significant new health related issue. Health Status The existing state or condition of a persons physical, mental and/or emotional health.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-21

GLOSSARY OF TERMS

Heimlich Maneuver A technique for removing a foreign body, such as food bolus, from the trachea or pharynx, where it is preventing air flow to and from the lungs. (Tabers Cyclopedic Medical Dictionary) Home and Community Based Services Waiver (HCBS Waiver) The HCBS Waiver project approved for Tennessee by CMS to provide services to a specified number of Medicaid-eligible individuals who have mental retardation or developmental disabilities and who meet the criteria for Medicaid reimbursement of care in an ICF/MR. Home Care Organization As defined by T.C.A. 68-11-201 and by Rule 1200-48-.01 home care organization means any entity which is staffed and organized to provide home health services, hospice services, or home medical equipment services to patients on an outpatient basis in either their regular or temporary place of residence. HUD Section 8 Safety Checklist A checklist used by the U.S. Department of Housing and Urban Development to inspect single family homes and apartments for minimum safety, fire safety and accessibility standards. DMRS uses this checklist to determine if supported living homes are safe for occupancy by service recipients. Human Rights Committee A group of appointed persons responsible for ensuring that appropriate mechanisms and safeguards are in place to promote and protect individual rights and that any limitation of rights will not occur without due process. Immediate Family Immediate family includes the enrollees minor and adult children, step-children, adopted children, brothers, sisters, parents, adoptive parents, and spouses of these persons. (DHS Rule 1240-3-3) Incentive Payments Monies paid to an employer to encourage or subsidize the employers participation in a supported employment program. Independent Providers Providers who are typically licensed professionals and obtain professional support services licensure to practice independently or establish contracts with other providers to render a specific type of service.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-22

GLOSSARY OF TERMS

Independent Support Coordination Agencies (ISC) A DMRS provider whose sole function is to provide support coordination as defined in Chapter 4 of this manual. Individual Profile A completed form sent to prospective provider agencies serving the area in which an individual chooses to live that documents an individuals vision, preferences, and the supports needed to live an ordinary life in the community. Individual Rights Please refer to Chapter 2 of this manual. Individual Specific Training Training provided to direct care staff that is specific to the individual served, including relevant information about the persons overall health status and diagnosed medical conditions. Individual Support Plan (ISP) An individualized written plan that identifies enrollee preferences, capacities, needs and resources and that identifies supports and services to meet such needs; and by which enrollees and their families are assisted to access Waiver and other necessary services. Individual Support Plan Amendment Refers to revisions that occur after the persons initial ISP is finalized, such as the persons outcomes or goals having changed, services or service providers having changed, significant changes in the persons health status or the ISP no longer reflecting the persons preferred lifestyle. Individual Support Plan Planning Meeting Meetings required to be held, at minimum, upon enrollment in the DMRS service programs and thereafter once every twelve (12) calendar months, for the purpose of developing and initializing the persons ISP and thereafter to review the effectiveness of the persons current ISP and make needed revisions to update all parts of the persons ISP. Individual Support Plan Planning Team A team comprised of COS members, the support coordinator/case manager and other providers involved in developing and implementing the persons ISP. Individual Support Plan Update Refers to the annual process of systematically reviewing a persons entire ISP with the ISP Planning Team and making revisions to reflect any changes that have occurred during the past year.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-23

GLOSSARY OF TERMS

Individual Transition Plan (ITP) A document that describes the necessary preparations and activities needed to be completed before, during and after an individual transitions from an ICF/MR to a community placement, and includes the supports and services needed in the community, who will provide the supports and services and the personal preferences and vision the individual has for his/her future. Individual Transportation Services Individual Transportation Services shall mean non-emergency transport of an enrollee to and from approved activities specified in the enrollees plan of care. Please refer to Chapter 16 of this manual. Individuals with Disabilities Education Act (IDEA) A federal law that requires public schools to make available to eligible children, birth through twenty one (21) years of age, with disabilities a free appropriate public education in the least restrictive environment appropriate to their individual needs. Informal Support Networks Any person, including family, friends and neighbors, who provide unpaid support to a person with mental retardation and developmental disabilities. Informed Consent A voluntary agreement made by a well-advised and mentally competent patient to receive treatment after the patients health care provider has provided full disclosure of information regarding the material risks, benefits of the proposed treatment, alternatives, and consequences of no treatment, so that the patient can make an intelligent, or informed choice. Initial Support Coordination Transition Meeting A meeting held for the purpose of the selected support coordinator to get to know the person and their legal representative and family members (as appropriate) and to gather information that will be used in the transition planning process. Inpatient Hospitals A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and non-surgical) and rehabilitation services by or under the supervision of physicians, to patients admitted for a variety of medical conditions. (CMS Definition) Inpatient Psychiatric Admission The admission of an individual into a facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness by or under the supervision of a physician.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-24

GLOSSARY OF TERMS

Integrated Work Site Integrated work sites provide individuals with an opportunity to work with non-disabled workers at a job in the community. This integration helps promote normal relationships with co-workers and business customers and establishes natural supports, that help maintain supports necessary to help sustain employment. Intelligence Quotients (IQ) A persons intellectual functioning level determined by a standardized intelligence test. OR An estimate of intellectual status in terms of an index determined by dividing the mental age in months by the chronological age in months and reducing the result to a percentage. Interim Services Temporary services provided and funded with state dollars until such a time as DMRS receives approval from the federal government to operate a Self-Determination Medicaid Waiver. Intermediate Care Facility for the Mentally Retarded (ICF/MR) A licensed facility approved for Medicaid vendor reimbursement that provides specialized services for individuals with mental retardation or related conditions and that complies with current federal standards and certification requirements for ICF/MRs. Intermediate Care Facility for the Mentally Retarded Level of Care ICF/MR Level of Care means a person would require care in an institution without the provision of waiver services. Involuntary Disenrollment The termination of a persons eligibility to participate in the HCBS Medicaid Waiver Program as determined by the DMRS and approved by the TennCare Division of Developmental Disability Services. Involuntary Disenrollment Appeal A formal appeal submitted to the Bureau of TennCare by or on behalf of a person that requests a fair hearing due to the person having been notified by DMRS or the Bureau of TennCare that they are no longer eligible to receive any services in a Waiver Program. Issue Reporting and Tracking Form A form used to record and report items marked no on the checklists contained in the Face-toFace Monitoring Visit form, the Monthly ISP Status Review form, the Periodic Review form, or the Semi-annual Satisfaction Survey form. Refer to Appendix D of this manual.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-25

GLOSSARY OF TERMS

Job Coach The person who will provide the support to an individual or individuals once a job has been developed. The job coach will provide support, training and adaptation on the job through the orientation, skill acquisition and job stabilization phases of employment. The job coach fades his or her support only when it is no longer needed. The services of a job coach may be requested when there are changes to the job or problems occur related to employment issues at or outside of the work site. The job coach establishes essential communication between the employee, the company, and the agency. It is through the efforts and commitment of the job coach that Tennessee is able to implement the Employment First initiative. Law A constitution, statute, regulation, rule, common law or any other State action having the force or effect of law. OR The combination of those rules and principles of conduct promulgated by legislative authority, derived from court decisions and established by local custom. Lay Person Someone who is not specially trained to provide health care services. Lay Terms To describe a complex or technical issue in words that the average person without professional training in the subject area can understand or in a way that the person is most likely to understand. Legal Representative A person who has been appointed by a court of competent jurisdiction under applicable law to represent a disabled person in making decisions regarding legal, financial, health care and other personal matters, as specified in the court order. Licensed Physician A graduate of an accredited medical school authorized to confer upon graduates the degree of doctor of medicine (M.D.) who is duly licensed in Tennessee, or an osteopathic college authorized to confer the degree of doctor of osteopathy (D.O.) and who is licensed to practice osteopathic medicine in Tennessee. T.C.A. 33-1-101(15) Licensure Act for Communication Disorders and Sciences The statute governing the practice of Communication Disorders and Sciences in Tennessee as codified at Title 63, Chapter 17 of the Tennessee Code Annotated. Licensure Survey Reports Reports issued by the Tennessee Department of Mental Health and Developmental Disabilities Office of Licensure concerning the results of announced/unannounced inspections and follow-up inspections of licensed facilities.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-26

GLOSSARY OF TERMS

Limited Conservatorship A person or persons appointed by the court to make decisions on specific issues only, such as expenditure of personal funds or health related services, for a person age 18 and over. Limited Guardianship A person or persons appointed by the court to make decisions on specific issues only, such as expenditure of personal funds or health related services, for a person under the age of 18. Major Life Activities Major life activities means: 1) self-care; 2) receptive and expressive language; 3) learning; 4) mobility; 5) self-direction; 6) capacity for independent living; or 7) economic self-sufficiency. (Chapter 0940-5-38) Major Life Events An occurrence in a persons life that has the potential to result in the development of stress, such as the death of a parent, family member, or close friend. Manual Restraint Holding an individuals limbs or body contingent upon a persons behavior using an approved manual restraint procedure so that movement is restricted or prevented for sixty (60) seconds or more, not to exceed fifteen (15) continuous minutes. Take downs (physically forcing the individual to the ground or other surface) or any form of horizontal restraint (physically forcing an individual to lay in a horizontal position) is prohibited. For the purposes of this manual, the following are not considered manual restraint: 1) Holding a persons limbs or body as part of a specific medical, dental, or surgical procedures that has been authorized by an appropriate health care professional. 2) Holding a persons limbs or body to provide support for the achievement of functional body positions and equilibrium, such as supporting someone to walk, achieving a sitting or standing position. 3) Holding a persons limbs or body to prevent him or her from accidentally falling. 4) Use of response blocking or redirection, contingent upon behavior; or use of graduated physical guidance as part of an approved intervention; 5) Holding a persons limbs or body for less than sixty (60) seconds using a method approved by the agency so that movement is restricted or prevented.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-27

GLOSSARY OF TERMS

Mechanical Restraint The application of a device to any part of a persons body that restricts or prevents movement or normal use/functioning of the body or body part to which it is applied. Mechanical restraint must not impair or inhibit visual or auditory capabilities or prevent or impair speech or other communication modalities. Only approved mechanical restraint devices may be used. For purposes of this manual, the following are not considered mechanical restraints: 1) Devices designed by an appropriate professional that are used to provide support to achieve functional body alignment or body positions. 2) Stretcher belts, one-piece safety belts, bed rails, and transportation safety belts intended to prevent a person from accidentally falling. 3) Devices authorized by an appropriate health care professional to aid in the treatment of an acute medical condition. Mechanical Restraint Devices With appropriate approvals, the following mechanical restraint devices may be used. This includes finger, hand, arm or elbow splints; and gloves or mitts that restrict or prevent movement. The following mechanical restraint devices and practices are prohibited: 1) Restraint vests, camisoles, body wraps; 2) Devices that are used to tie or secure a wrist or ankle to prevent movement; 3) Restraint chairs or chairs with devices that prevent movement; and 4) Removal of a persons mobility aids, such as wheelchair or walker. Medicaid The federal- and state-financed, state-run program of medical assistance pursuant to Title XIX of the Social Security Act. OR The major source of public funding for long-term services and supports provided in home and community settings. Medicaid State Plan The plan approved by the Centers for Medicare and Medicaid Services which specifies the covered benefits for the Medicaid program in Tennessee. Medical Eligibility Appeal A formal appeal submitted to the Bureau of TennCare by or on behalf of a person that requests a fair hearing due to the person having been notified by the Bureau of TennCare that they are not medically eligible to participate in the HCBS Medicaid Waiver Program. Medical History A systematic record of past events as they relate to a person and his or her medical background.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-28

GLOSSARY OF TERMS

Medical Residential Services Medical Residential Services shall mean a type of residential service provided in a residence where all residents require direct skilled nursing services and habilitative services and supports that enable an enrollee to acquire, retain, or improve skills necessary to reside in a communitybased setting. Medical Residential Services must be ordered by the enrollees physician, physician assistant, or nurse practitioner, who shall document the medical necessity of the services and specify the nature and frequency of the nursing services. The enrollee who receives Medical Residential Services shall require direct skilled nursing services on a daily basis and at a level which can not for practical purposes be provided through two or fewer daily skilled nursing visits. The service includes direct assistance as needed with activities of daily living, household chores essential to the health and safety of the enrollee, budget management, attending appointments, and interpersonal and social skills building to enable the enrollee to live in a home in the community. It also may include medication administration as permitted under Tennessees Nurse Practice Act. Please refer to Chapter 9 of this manual. Medical Screenings Evaluating patients for diseases, such as cancer, heart disease, or substance abuse before they become clinically obvious. Medically Eligible A person who has a PAE that has been certified by a physician and that has been approved by the Bureau of TennCares Division of Developmental Disability Services Medically Necessary Medically Necessary shall mean services or supplies provided by an institution, physician, or other health care provider that are required to identify or treat an enrollees illness or injury and which are: 1) Consistent with the symptoms or diagnosis and treatment of the enrollees condition, disease, ailment, or injury; and 2) Appropriate with regard to standards of good medical practice; and 3) Not solely for the convenience of an enrollee, physician or other provider; and 4) The most appropriate supply or level of services which can safely be provided to the enrollee. When applied to the care of an inpatient, it further means that services for the enrollees medical symptoms or condition require that the services cannot be safely provided to the enrollee as an outpatient. 5) When applied to TennCare Medicaid enrollees under twenty-one (21) years of age, services shall be provided in accordance with EPSDT requirements including federal regulations as described in 42 CFR Part 441, Subpart B, and the Omnibus Budget Reconciliation Act of 1989.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-29

GLOSSARY OF TERMS

Medication Administration Providing for the ingestion, application, injection of medications, inhalation or rectal or vaginal insertion of medication, including over the counter and prescription drugs, according to the written or printed directions of the attending physician or other authorized practitioner or as written on the prescription label and making a written record thereof with regard to each medication administered, including the time and amount taken, but administration does not include judgment, evaluation or assessment. Medication Administration Monitoring Periodic review, observation, direction, and evaluation of an unlicensed individuals knowledge, skills, and performance related to the functions and activities provided for in the Department of Health Rules, Chapter 1200-20-12. Medication Administration of Unlicensed Personnel The training curriculum developed and used by the DMRS to train unlicensed staff who provide DMRS services to persons with mental retardation and developmental disabilities the necessary skill and training to administer certain medications as approved by the DOH. Medication Administration Record (MAR) An approved form required to be completed by the person who administers both prescribed and over- the-counter medication to persons receiving DMRS services and that documents the schedule and dosing of medication given. Please refer to Appendix D of this manual. Medication Variance Report Refer to Appendix D of this manual. Medication Errors An occurrence when medication is given in a way that is not consistent with how it was ordered by the doctor (given to the wrong person, omitted, given at the wrong time, wrong dose given, wrong medication given, given by the wrong route or not prepared according to order). Medication Pass Observation Form Refer to Appendix D of this manual. Medication Self-Administration Using prescription medication in a manner directed by the prescribing practitioner with limited assistance or direction, if necessary, of program or facility staff, in accordance with DMRS standards. Limited assistance includes, but is not limited to, reminding when to take medications, encouragement to take, reading medication labels, opening bottles, handing to the individual, and reassurance of the correct dose.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-30

GLOSSARY OF TERMS

Mental Health A state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity. Mental Illness A term that describes a broad range of mental and emotional conditions characterized by disturbances in an individuals thoughts, emotions or behavior. Mental Illness can refer to a wide variety of disorders ranging from those causing mild distress to those that severely impair an individuals ability to function. Mental Retardation 1) TennCare Definition--Significantly sub-average intellectual functioning with an IQ of 70 or below on an individually administered IQ test; 2) Title 33 Definition--Substantial limitations in functioning as shown by significantly sub-average intellectual functioning that exists concurrently with related limitations in two (2) or more of the following adaptive skill areas: communication, self-care, home living, social skills, community use, self-direction, health and safety, functional academics, leisure, and work; and that are manifested before eighteen (18) years of age. Microboard A nonprofit corporation devoted solely to the care of only one person. Mixed Caseloads Refers to a support coordinator being assigned a mixture of persons who are class members and non-class members to provide support coordination and case management services to. Mobile Crisis Unit A team of individuals that can be accessed 24 hours a day, 7 days a week to respond to individuals experiencing a psychiatric emergency or to provide accessibility to persons in mental or emotional distress and to agencies and/or individuals who are dealing with individuals in such distress. Modified Diet A food diet that has been adjusted to include or exclude certain foods for the purpose of meeting a persons special needs, such as the recommendations of food that contains low cholesterol, low salt, low fat, etc. Monthly ISP Status Review Form A form used to document support coordination/case management monthly reviews of the persons ISP. Refer to Appendix D of this manual.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-31

GLOSSARY OF TERMS

Monthly Reviews A written summary of the service recipients progress towards implementing the various Plans of Care and related portions of the ISP, including action steps, achievement of outcomes and the identification of any barriers that have presented during the month. Moratorium The prevention, by the federal or state government, of new persons to enroll and receive mental retardation services by a particular provider or agency or through the Home and Community Based Services Medicaid Waiver Program until certain quality assurance measures have been met. Multimodal Assessment and Treatment Addresses environmental, psychological, medical, and psychiatric assessment and treatment. Natural Supports People, places and support mechanisms that already exist or can be created to provide supports to service recipients (sometimes referred to as generic supports). National Supported Employment Consortium (SEC) The SEC is designed to critically evaluate supported employment programs nationally and to provide technical assistance on exemplary programs and practices to state and local agencies. www.worksupport.com Neglect The failure of staff to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness to a person(s) receiving services, which results in injury or probable risk or serious harm. Notice of Denial A notice required to be sent to any person for whom service was denied that includes an explanation of why the service was denied, how to appeal the denied service and how long the person has to appeal the denial. Nurse Practitioner Nurse practitioner means a Tennessee licensed registered nurse with a masters degree or higher in a nursing specialty and has a national specialty certification as a nurse practitioner. (Rules of the Tennessee Board of Nursing 1000-4-.02(5))

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-32

GLOSSARY OF TERMS

Nursing Facility A facility which primarily provides to residents skilled nursing care and relate services for the rehabilitation of injured, disabled, or sick persons, or on a regular basis, health related care services above the level of custodial care to other than mentally retarded individuals. (CMS Definition) Nursing Plan of Care Identifies the nursing activities to be performed and the amount, frequency and anticipated duration of services required. Nursing plan of care as related to nursing waiver hours is dependent on the physician order for skilled nursing. This plan must be incorporated into the ISP. Nursing Services Nursing Services shall mean skilled nursing services that fall within the scope of Tennessees Nurse Practice Act and that are directly provided to the enrollee in accordance with a plan of care. Nursing Services shall be ordered by the enrollees physician, physician assistant, or nurse practitioner, who shall document the medical necessity of the services and specify the nature and frequency of the nursing services. Nursing Services shall be provided face-to-face with the enrollee by a licensed registered nurse or licensed practical nurse under the supervision of a registered nurse. Nursing assessment and/or nursing oversight shall not be a separate billable service under this definition. Therapeutic goals and objectives shall be required for enrollees receiving nursing services. Please refer to Chapter 15 of this manual. Nursing Supervision Administrative rule 1000-1-04 of the Tennessee Board of nursing defines assisting and adequate supervision and describes the tasks usually delegated to assistive personnel. The Nurse Practice Act of Tennessee TCA 63-7 defines the practice of professional nursing. Nutrition Services Nutrition Services shall mean assessment of nutritional needs, nutritional counseling and education of the enrollee and of caregivers responsible for food purchase, food preparation, or assisting the enrollee to eat. Nutrition Services must be provided in accordance with therapeutic goals and objectives specified in a plan of care developed by a dietitian or nutritionist. A dietitian or nutritionist who provides Nutrition Services must provide services within the scope of licensure and must be licensed as required by the State of Tennessee. Nutrition Services are intended to promote healthy eating practices and to enable the enrollee and direct support professionals to follow special diets ordered by a physician, physician assistant, or nurse practitioner. Please refer to Chapter 15 of this manual.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-33

GLOSSARY OF TERMS

Occupational and Physical Therapy Practice Act The statute governing the practice of occupational and physical therapy in Tennessee as codified at Title 63, Chapter 13 of the Tennessee Code Annotated. Occupational Therapist A person currently licensed as such by the Tennessee Board of Occupational and Physical Therapy Examiners. Occupational Therapy Aid A person who assists in the practice of occupational therapy under the direct supervision of an occupational therapist or occupational therapy assistant and whose activities do not require professional or advance training in the basic anatomical, biological, psychological, and social sciences involved in the practice of occupational therapy. Occupational Therapy Assistant Any person who has met the qualifications for certified occupational therapy assistant and holds a current, unsuspended or un-revoked, certificate which has been lawfully issued by the Committee of Occupational Therapy. Such person assists and works under the supervision of a certified occupational therapist. Occupational Therapy Services Occupational Therapy Services shall mean diagnostic, therapeutic, and corrective services, which are within the scope of state licensure. Occupational Therapy services provided to improve or maintain current functional abilities, as well as, prevent or minimize deterioration of chronic conditions leading to a further loss of function are also included within this definition. Please refer to Chapter 13 of this manual. Operational Administrative Agency The approved agency with which the State Medicaid Agency contracts for the administration of the day-to-day operations of the Home and Community Based Services Waiver for the Mentally Retarded and Developmentally Disabled. Oral Hygiene Activities Preventive measures to avoid pathological conditions of the teeth and oral cavity (i.e., brushing the teeth/gums and using if appropriate dental floss daily). Orders Instructions from a health care provider specifying patient treatment and care.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-34

GLOSSARY OF TERMS

Orientation and Mobility Training Orientation and Mobility Training shall mean assessment of the ability of an enrollee who is legally blind to move independently, safely, and purposefully in the home and community environment; orientation and mobility counseling; and training and education of the enrollee and of caregivers responsible for assisting in the mobility of the enrollee. Please refer to Chapter 14 of this manual. Out of State Personal Assistance Services Please refer to Chapter 16 of this manual. Out of State Residential Services Please refer to Chapter 9 of this manual. Outcomes Measures Health care quality indicators that gauge the extent to which health care services succeed in improving patient health. Overnight Hours Hours of the day during which it would be expected that service recipients in a particular home would be asleep, requiring the least amount of staff support. Patient Liability The amount of a persons income determined by the DHS to be collected each month to help pay for their long term care services. Peak Hours Hours of the day during which service recipients would be expected to be awake and engaged in activities requiring the most staff support. Performance Measures Quantitative measures of the quality of care provided by a health plan or provider that consumers, payers, regulators and others can use to compare the plan or provider to other plans and providers. Periodic Review Form A form required to be completed every third month during the ISPs face-to-face visit. Please refer to Appendix D of this manual. Person-Centered Planning A process which is focused on the person who receives or will receive services in terms of who they are, what they want in life, and how their goals may be accomplished.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-35

GLOSSARY OF TERMS

Personal Allowance Funds A portion of a service recipients personal funds that belongs to the service recipient and is kept in the service recipients home and is reserved for the purchase of personal items, such as clothing, grooming supplies, entertainment equipment, leisure activities, refreshments during community activities, or other personal items desired by the service recipient. Personal Assistance Services Personal Assistance shall mean the provision of direct assistance with activities of daily living (e.g., bathing, dressing, personal hygiene, eating, meal preparation excluding cost of food), household chores essential to the health and safety of the enrollee, budget management, attending appointments, and interpersonal and social skills building to enable the enrollee to live in a home and community. It also may include medication administration as permitted under Tennessees Nurse Practice Act. Please refer to Chapter 16 of this manual. Personal Emergency Response System (PERS) A Personal Emergency Response System shall mean a stationary or portable electronic device used in the enrollees place of residence, which enables the enrollee to secure help in an emergency. The system shall be connected to a response center staffed by trained professionals who respond upon activation of the electronic device. The system shall be limited to those who are alone for parts of the day and who have demonstrated mental and physical capability to utilize such a system effectively. Please refer to Chapter 16 of this manual. Personal Funds Individual financial resources, including earned and unearned income (e.g., trust funds), that are used by or on behalf of a service recipient to pay for necessary personal expenses. Personal Funds Management The accountability of personal funds belonging to a service recipient by a person designated as having responsibility for managing these funds. Please refer to Chapter 6 of this manual. Personal Support Services Personal support services means one or more of the following services provided to a service recipient in the individuals regular or temporary residence, in addition to assistance with major life activities. Include but are not limited to: 1) Self-care assistance with tasks such as eating, dressing, toileting, bathing, mobility, transfer assistance and other services and supports to maintain health and wellness; 2) Household assistance with tasks such as housekeeping, laundry, meal planning, meal preparation, shopping, bill paying, and use of telecommunication devices; 3) Personal assistance to access community activities such as transportation, social, recreational or other personal activities; and 4) Education services. (Chapter 0940-5-38)

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-36

GLOSSARY OF TERMS

Physical Abuse Physical acts or actions knowingly directed toward a person receiving supports, with resulting physical harm, pain or mental anguish to the service recipient. Any use of restraint prohibited by DMRS (takedown, prone/horizontal restraint) by service providers. Physical Examination Examination of the body by auscultation, palpation, percussion, inspection and olfaction. Physical Signs Physical signs that are apparent to the observer (i.e., can be seen, heard, measured, or felt by the diagnostician). Physical Status Review An instrument used by a registered nurse or other designated professional staff to determine level of risk and define the required health services and supports. Physical Status Review Guidelines Please refer to Appendix E of this manual. Physical Therapist A person currently licensed as such by the Tennessee Board of Occupational and Physical Therapy Examiners. Physical Therapy Aides Aides, technicians and transporters trained by and under the direction of physical therapists who perform designated and supervised routine physical therapy tasks. Physical Therapy Assistant Any person who has met the qualifications for licensed physical therapist assistant and holds a current, unsuspended, or un-revoked license that has been lawfully issued by the committee of Physical Therapy. Physical Therapy Assistants perform physical therapy procedures and related tasks that have been selected and delegated only by the supervising physical therapist. Physical Therapy Services Physical Therapy Services shall mean diagnostic, therapeutic and corrective services, which are within the scope of state licensure. Physical Therapy services provided to improve or maintain current functional abilities, as well as, prevent or minimize deterioration of chronic conditions leading to a further loss of function are also included in this definition. Please refer to Chapter 13 of this manual.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-37

GLOSSARY OF TERMS

Physician Assistant Physician assistant means an individual who renders services, whether diagnostic or therapeutic, that are acts constituting the practice of medicine or osteopathic medicine and, but for the provisions of 63-6-204 and 63-9-113 could only be performed by a licensed physician. (TCA 63-19-102(5)) Physician Ordered Diet a/k/a Doctor Prescribed Diet Additions or deletions of particular food and/or drink items based on an order from the persons primary care physician. Physician Services Services provided by an individual licensed under state law to practice medicine or osteopathy. Plan of Care An individualized written plan of care (ISP) which describes the medical and other services (regardless of funding source) to be furnished to the enrollee, the Waiver service frequency, and the type of provider who will furnish each Waiver service and which serves as the fundamental tool by which the State ensures the health and welfare of the enrollees, and in accordance with Standards for Home Care Organizations Providing Professional Support Services Rules. Policy An exact stated course or method of action adopted and pursued by an organization which guides and determines present and future decisions and actions of that organization. Post Transition Visitation Schedule A schedule developed by the support coordinator that documents the dates for all required announced and unannounced visits following the transition of a person from an ICF/MR into the community. Post Transition Visits Face-to-face monitoring visits required to be performed by the support coordinator following the transition of a person from an ICF/MR into the community. Practitioner One who has met the professional and legal requirements necessary to provide a health care service, such as a physician, nurse, dentist, dental hygienist, or physical therapist. Pre-Admission Evaluation (PAE) The assessment form used by the State Medicaid Agency to document the current medical and habilitative needs of an individual with mental retardation and to document that the individual meets the Medicaid level of care eligibility criteria for care in an ICF/MR.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-38

GLOSSARY OF TERMS

Pre-Move Checklist A form that documents a home site visit has occurred by the Regional Office transition staff and identifies any problems found and corrected prior to the individual transitioning from the Developmental Center into the home. Please refer to Appendix D of this manual. Pre-Service Training The initial training that must be completed before working alone with any service recipient. Please refer to Table 7.2. Primary Care Services to diagnose and treat illness and injury, as well as, preventive health care services. Primary care promotes early identification and treatment of health problems, which can help to reduce unnecessary complications of illness or injury and maintain or improve overall health status. Primary Care Physician (PCP) A physician responsible for supervising, coordinating, and providing initial and primary care to patients; for initiating referrals for specialist care; and for maintaining the continuity of patient care. A primary care physician is a physician who has limited his practice of medicine to general practice or who is a Board Certified or Eligible Internist, Pediatrician, Obstetrician/Gynecologist, or Family Practitioner. The PCP may be represented by a physician extender such as a Nurse Practitioner or Physician Assistant. Primary Caregiver One who provides care to a dependent or partially dependent person and can be a professional or family member. Primary Diagnosis Diagnosis of the most important disease process or the underlying disease process afflicting a patient. Primary Provider A persons primary provider is typically their residential provider; however depending on the supports and services a person receives, the primary provider could be the day services provider, personal assistant provider or support coordination/case management provider. Privacy Notice A notice that is required to be sent to all persons who participate in the HCBS Medicaid Waiver Program that explains the persons privacy rights as specified in HIPAA.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-39

GLOSSARY OF TERMS

Procedure Established directions for daily operations that include defined steps and courses of action as well as methods or instructions Professional Support Services Nursing, occupational, physical or speech therapy services provided to individuals with mental retardation or developmental disabilities pursuant to a contract with the state agency financially responsible for such services. Professional Support Services Organization A provider licensed in accordance with the Department of Healths rule 1200-8-31-.01 to provide nursing, occupational therapy, physical therapy or speech therapy services to individuals with mental retardation or developmental disabilities pursuant to execution of a provider agreement with DMRS and TennCare. Program Support Staff Staff who do not provide direct, hands-on services, but are responsible for oversight, supervision or support of staff with direct support responsibilities or for management activities necessary to maintaining a business. Program Support Staff Early Intervention Staff who do not provide direct, hands-on services to children with disabilities, but are responsible for oversight, supervision or support of staff with direct support responsibilities or for management activities necessary to maintaining a business. Promulgation The official publication of new law or regulation, by which it is put into effect. Protected Health Information (PHI) Individually identifiable health information transmitted or maintained in any form or medium, which is held by a covered entity or its business associate. Identifies the individual or offers a reasonable basis for identification. Is created or received by a covered entity or an employer Relates to a past, present, or future physical or mental condition, provision of health care or payment for health care. Protected Rights Basic human rights of persons with mental retardation guaranteed to be protected by law.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-40

GLOSSARY OF TERMS

Protection and Safety Plan A component of the providers management plan designed to assist providers in preventing harm to service recipients and staff through an ongoing program of self-assessment targeted at identification and correction of potentially dangerous conditions or circumstances before they result in harm. Protective Equipment The application of a device to any part of a persons body that prevents tissue damage or other physical harm due to a persons behavior. Protective equipment must not restrict or prevent movement or the normal use/functioning of the body or body part to which it is applied. Protective equipment must not impair or inhibit visual or auditory capabilities or prevent or impair speech or other communication modalities. For purposes of this manual, the following are not considered protective equipment: 1) Devices designed by an appropriate professional that are used to provide support to achieve functional body alignment or body positions. 2) Stretcher belts, one-piece safety belts, bed rails, and transportation safety belts intended to prevent a person from accidentally falling. 3) Devices used as a part of or following a specific medical, dental, or surgical procedures (e.g., goggles following eye surgery). 4) Devices used to prevent or minimize harm to a person due to a physical condition (e.g., helmet for seizures).

Protective Equipment Devices With appropriate approvals, the following protective equipment devices may be used: 1) Helmets, with or without face guards; 2) Gloves or mitts; 3) Goggles; 4) Pads work on the body that prevent tissue damage but do not restrict movement; 5) Clothing or adaptive equipment specially designed or modified that does not restrict movement. Provider Any person, institution, agency or business concern providing medical care services or goods authorized under the Department of Finance and Administration holding, where applicable, a current valid license to provide such services or to dispense such goods. (Bureau of TennCare General Rules)

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-41

GLOSSARY OF TERMS

Provider Administrative Plan A formal written plan required to be developed by providers who contract with the DMRS and is inclusive of the Internal Quality Assurance Plan, Management Plan, Safety Plan, and Supervision Plan Provider Agreement An agreement between the DMRS, the Department of Finance and Administration, the Bureau of TennCare and any potential approved provider that dictates the terms and conditions a provider must meet to receive compensation or reimbursement for services rendered.. Provider Application Form Please refer to Appendix D.

Provider Application Packet Contact Information Please refer to Appendix D. Provider Approval Criteria Please refer to Appendix D. Provider Internal Quality Assurance/Quality Improvement Plans A formal written plan developed by providers that address the issues identified during the selfassessment process and is focused on resolution of systemic issues at the provider level. Please refer to Chapter 19 of this manual. Provider Management Plan A formal written plan required by providers that describe how the provider conducts business to ensure a successful operation and compliance with applicable DMRS program requirements. The plan describes how the provider implements policies and procedures to assure the health, safety and welfare of service recipients. Provider Orientation A process that provides new approved providers with an overview of the DMRS system as well as the expectation DMRS has for all new providers. Provider Self Assessment A process developed by providers that should identify systemic issues and initiate corrective actions before such issues are identified by the state and federal agencies responsible for monitoring provider service provision.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-42

GLOSSARY OF TERMS

Provider Service Expansion An expansion of services by providers from the initially approved geographical area to other regions. Provider Supervision Plan A formal written plan required to be developed by providers who contract with the DMRS that addresses supervisory functions of a providers employees, contractors or volunteers who are responsible for the supervision of a DMRS service recipient. Prudent Lay Person A reasonable individual who possesses an average knowledge of health and medicine. Psychiatry/Psychiatrist A licensed physician who specializes in assessment, diagnosis, treatment and prevention of mental illnesses and emotional problems. Because of extensive medical training, the psychiatrist understands the bodys functions and the complex relationship between mental illness and other medical illnesses. The psychiatrist is thus the mental health professional and physician best qualified to distinguish between physical and psychological causes of both mental and physical distress. Psychologist Practice of Psychologist means the observation, description, evaluation, interpretation, and modification of human behavior by the application of psychological principles, methods, and procedures, for the purpose of preventing or eliminating symptomatic, maladaptive, or undesired behavior and of enhancing interpersonal relations hips, work and life adjustment, personal effectiveness, behavioral health, and mental health. Practice of psychologist includes, but is not limited to, psychological testing and the evaluation or assessment of personal characteristics, such as intelligence, personality, abilities, interests, aptitudes, and neuropsychological functioning; counseling, psychoanalysis, psychotherapy, hypnosis, biofeedback, and behavior analysis and therapy; psychological diagnosis and treatment of mental, emotional and nervous disorders or disabilities, alcoholism and substance abuse, disorders of habit or conduct, as well as, of the psychological aspects of physical illness, accident, injury, or disability; case management and utilization review of psychological services; and psychoeducational evaluation, therapy, remediation, and consultation. Psychological services may be rendered to individuals, families, groups, and the public. Practice of psychologist is construed within the meaning of this definition without regard to whether payment is received for services rendered. T.C.A. 6311-203(a)

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-43

GLOSSARY OF TERMS

Psychotropic Medication A potent drug that affects psychic function, behavior, or experience and can result in serious and irreversible side effects. Psychotropic drugs include anti-depressants, anti-anxiety drugs, sedative-hypnotics and anti-psychotics. Qualified Health Care Professional Persons who have met educational requirements and who are licensed as an occupational therapist, physical therapist, speech language pathologist, physician or nurse practitioner. Qualified Mental Retardation Professional (QMRP) An individual who meets current federal standards, as published in the Code of Federal Regulations, for a qualified mental retardation professional; A person who is licensed in the state, if required for the profession, and who is a psychiatrist; physician with expertise in psychiatry as determined by training, education, or experience; psychologist with health service provider designation; psychological examiner, or senior psychological examiner; social worker who is certified with two (2) years of mental health experience or licensed; marital and family therapist; nurse who has a masters degree in nursing who functions as a psychiatric nurse; professional counselor; or if the person is providing service to service recipients who are children, any of the above educational credentials plus mental health experience with children. Quality Assurance (QA) Please refer to Chapter 19 of this manual. Quality Assurance Surveys The process of determining via application of standardized survey instruments at specified intervals, a providers compliance with the applicable requirements set forth in state and federal laws, rules, regulations and policies as referenced in the executed provider agreement. Quality Domains Established provider requirements that are monitored for compliance by the DMRS Quality Assurance staff and represent the basic elements and comprehensive goals for Waiver service delivery as specified in Chapter 19 of this manual. Recouped Funds Previously paid provider payments that are recovered by DMRS as a result of survey, audit, or review processes conducted by the State, Office of the Comptroller, CMS or other federally designated agencies or as a result of the Services Alert process, utilization reviews or other evidence.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-44

GLOSSARY OF TERMS

Referral Form A form required to be completed by either the referring entity or therapy provider and should include sufficient information to allow the therapist to determine the reason for the referral and to determine whether the therapist is able to complete the requested assessment as well as provide any therapy services that may be recommended as a result of the assessment. Refresher Training Training that must be completed within a specified timeframe to ensure staff maintains current knowledge of the content offered in certain required training programs. Please refer to Table 7.2. Regional Office The local offices of the DMRS located in the three grand regions of the state: East, Middle, and West Tennessee. Registered Nurse A person currently licensed as such by the Tennessee Board of Nursing.

Regulation A rule or order, having legal force, issued by state and federal agencies. Rehabilitation Act of 1973 Among other things establishes the appropriation of federally funded grants to assist states in meeting the cost of vocational rehabilitation services for handicapped persons and has defined vocational rehabilitation services provided under this act as any goods or services necessary to render a handicapped individual employable, including, but not limited to, the following: 1) evaluation of rehabilitation potential; 2) counseling, guidance, referral, and placement services; 3) vocational and training services; 4) physical and mental restoration services; 5) maintenance, not exceeding the estimated cost of subsistence, during rehabilitation; 6) interpreter services for the deaf and reader services for the blind; 7) recruitment and training services; 8) rehabilitation teaching services and orientation and mobility services for the blind; 9) occupational licenses, tools, equipment, and initial stocks and supplies; 10) transportation in connection with the rendering of any vocational rehabilitation services; and 11) telecommunications, sensory, and technological aids.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-45

GLOSSARY OF TERMS

Release of Information A consent form signed by a person that receives DMRS services or the persons legal representative if appropriate, that allows the persons records to be transferred from one DMRS provider to another. Reportable Incident Report A DMRS form that has been approved for use in documenting/reporting incidents that have led to serious harm or significant risk of serious harm and all allegations of abuse, neglect or exploitation of people receiving DMRS services. Please refer to Appendix D of this manual. Reportable Medical Incidents Incidents requiring unexpected, non-routine (i.e. those associated with new medical conditions or resulting from acute injury or illness) assessment or treatment in a hospital, in a hospital emergency room or by emergency medical technicians, including any incident or medical illness that requires emergency medical interventions, including cardiopulmonary resuscitation (CPR) or the Heimlich Maneuver. Representative Payee Someone who receives and manages Social Security or SSI benefits on behalf of another person. Request for Provision of Therapeutic Services A DMRS form required to be completed by a therapist upon acceptance of a persons referral for assessment and services. Residence The persons home or dwelling in which the person intends to reside permanently or for an indefinite period, excluding a hospital, nursing facility or ICF/MR, Assisted Living Facilities and Homes for the Aged. Residential Habilitation Residential Habilitation shall mean a type of residential service having individualized services and supports that enable an enrollee to acquire, retain, or improve skills necessary to reside in a community-based setting including direct assistance with activities of daily living (e.g., bathing, dressing, personal hygiene, eating, meal preparation household chores) essential to the health and safety of the enrollee, budget management, attending appointments, and interpersonal and social skills building to enable the enrollee to live in a home in the community. It also may include medication administration as permitted under Tennessees Nurse Practice Act. Please refer to Chapter 9 of this manual.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-46

GLOSSARY OF TERMS

Residential Record Documentation required to be kept in the service recipients home for provision of those services that occur in the residential environment, primarily those provided by direct support staff. Residential Services Please refer to Chapter 9 of this manual. Respite Services Respite shall mean services provided to an enrollee when unpaid caregivers are absent or incapacitated due to death, hospitalization, illness or injury, or when unpaid caregivers need relief from routine care giving responsibilities. Respite may be provided in the enrollees place of residence, in a Family Model Residential Support home, in a Medicaid-certified ICF/MR, in a home operated by a licensed residential provider, or in the home of an approved respite provider. The Respite provider may also accompany the enrollee on short outings for exercise, recreation, shopping or other purposes while providing respite care. Please refer to Chapter 16 of this manual. Respite Care Provider An individual who provides short-term services (thirty (30) days or less) for the purpose of relieving a family member or other caretaker when events/activities are scheduled or when emergency situations arise. Risk Assessment and Planning A way to identify individual risk and create an environment which provides appropriate safeguards and necessary supports while promoting personal growth and independence, as well as, respect of personal choice. Risk Issues Identification Tool A form used to list an individuals identified risk factors. Please refer to Appendix D of this manual. Rule An established and authoritative standard or principle established by the state or federal government that mandates or guides the conduct or actions of all persons or entities that have involvement in the programs or services provided on behalf of persons with mental retardation and developmental disabilities. Rules of Tennessee Chapter 1150-1 Tennessee General Rules Governing the Practice of Physical Therapy.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-47

GLOSSARY OF TERMS

Rules of Tennessee Chapter 1150-2 Tennessee General Rules Governing the Practice of Occupational Therapy. Rules of Tennessee Chapter 1370-1 Tennessee General Rules Governing the Practice of Speech, Pathology and Audiology. Safety Plan An individualized plan by which the Operational Administrative Agency ensures the health, safety, and welfare of enrollees who do not have 24-hour direct care services. Sanctioned Restraints Any approved interventions or mechanical devices used to restrict the movement of an individual or the movement or normal function of a portion of the individuals body, excluding devices used to provide support for the achievement of functional body position or proper balance, or devices used for specific medical and surgical (as distinguished from behavioral) treatment. Self-Advocacy A person who speaks or acts on behalf of themselves or on behalf of other persons regarding issues that may directly affect them and others. Self Determination Waiver The Home and Community Based Services Waiver program approved for Tennessee by the Centers for Medicare and Medicaid Services to provide services to a specified number of Medicaid-eligible individuals on the Waiting List who have mental retardation and who meet the criteria for Medicaid reimbursement of care in an Intermediate Care Facility for the Mentally Retarded. Semi-Annual Satisfaction Survey A form intended to determine the level of satisfaction of a persons legal representative and/or involved family members with the services received, as well as, the level of understanding of the persons options for exercising certain basic rights. Refer to Appendix D of this manual. Semi-Independent Living Services Semi-independent Living is a state-funded residential services option. Semi-independent living provides an option to adult service recipients who do not need direct support staff to live on-site for supervision purposes, but do need intermittent or limited support to remain in a community housing situation. Individuals are eligible for state-funded semi-independent living services only if no more than two-hundred (200) hours per month of staff support are needed. Please refer to Chapter 9 of this manual.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-48

GLOSSARY OF TERMS

Senior Psychological Examiner A senior psychological examiner, while possessing a different scope of practice than a psychologist, shall be considered a health service provider and thereby able to engage in these designated areas of health-related psychological practice without supervision: interviewing or administering and interpreting tests of mental abilities, aptitudes, interests, and personality characteristics for such purposes as psychological evaluation or for educational or vocational selection guidance or placement; overall personality appraisal or classification, psychological testing, projective testing, evaluations for disability or vocational purposes; diagnosis of nervous and mental disorders, personality counseling, psychotherapy, behavior analysis or personality readjustment techniques. T.C.A. 63-11-202(c) Serious Injury Apparent or confirmed physical harm to a person (whether the injury is self-inflicted or inflicted by another person, whether the injury is accidental or not, and whether the cause of the injury is identified or unidentified) requiring assessment and treatment (beyond basic first aid that could be administered by a lay person) in a hospital, in a hospital emergency room, in an urgent care center or from a physician, nurse practitioner, physicians assistant or emergency medical technician. Service Agencies DMRS providers who typically provide a combination of residential and day services and may or may not provide a number of ancillary services.

Service Authorization Request A DMRS form completed and submitted to the DMRS Regional Office to request approval for a service to be provided to a person who participates in the HCBS Medicaid Waiver Program. Service Recipient a/k/a Enrollee An individual, who is receiving service, has applied for service, or for whom someone has applied for or proposed service because the person has mental illness, serious emotional disturbance, or a developmental disability. (T.C.A. 33-1-101(21)) Sexual Abuse Sexual acts or actions knowingly directed toward a person receiving supports, with resulting physical harm, pain or mental anguish to the person receiving services. Sexual Offender Registry Tennessee Bureau of Investigations centralized record system of offender registration, verification, and tracking information. (Public Acts 2004, Chapter No. 921, Section 40-39202(17).)

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-49

GLOSSARY OF TERMS

Skill Training Specific skills which a person must be trained in to meet the service recipients needs. Skilled Care Medical care provided by licensed professionals working under the direction of a physician. Social Security Administration (SSA) The SSA determines eligibility for the SSI program. Social Worker Independent practitioner means a clinical social worker who, by education and experience, is professionally qualified to provide, through autonomous practice, direct diagnostic, preventive and treatment services including psychotherapy in situations in which functioning is threatened or affected by social and psychological stress or health impairment. T.C.A. 63-23-103(a) Sound Medical Decision The process of using all of the available information about a patient and then arriving at a decision concerning the therapeutic plan. Specialized Medical Equipment, Supplies and Assistive Technology Specialized Medical Equipment, Supplies and Assistive Technology shall mean assistive devices, adaptive aids, controls, or appliances which enable an enrollee to increase the ability to perform activities of daily living or to perceive, control, or communicate with the environment. Specialized Medial Equipment, Supplies and Assistive Technology shall be recommended by a qualified health care professional (e.g. occupational therapist, physical therapist, speech language pathologist, physician, or nurse practitioner) based on an assessment of the enrollees needs and capabilities and shall be furnished as specified in the plan of care (ISP). Specialized Medical Equipment and Supplies and Assistive Technology may also include a face-to-face consultative assessment by a physical therapist, occupational therapist, or speech therapist to assure that specialized medical equipment and assistive technology which requires custom fitting meets the needs of the enrollee and may include training of the enrollee by a physical therapist, occupational therapist, or speech therapist to effectively utilize such customized equipment. Please refer to Chapter 14 of this manual. Speech, Language and Hearing Services Speech, Language and Hearing Services shall mean diagnostic, therapeutic and corrective services, which are within the scope of state licensure which enable an enrollee to improve or maintain current functional abilities and to prevent or minimize deterioration of chronic conditions leading to a further loss of function. Please refer to Chapter 13 of this manual.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-50

GLOSSARY OF TERMS

Speech Language Pathologist A person currently licensed as such by the Tennessee Board of Communication Disorders and Sciences. Speech Language Pathology Assistants Any person who has met the minimum qualifications established by the Tennessee Board of Communication Disorders and Sciences for a registered speech language pathologist assistant (Rule 1370-1-.14 of the Rules for Speech Pathology and Audiology) and who works under the supervision of a licensed speech language pathologist. Staff Instructions Written strategies, including step-by-step approaches or guidelines for those tasks or actions that must be implemented by direct support staff employed by the day, residential or personal assistance providers. Staff Notes A written narrative by provider staff that documents a service recipients significant accomplishments, unusual events or occurrences and the service recipients response to activities. Staffing Plan Written plans developed by providers that address compliance with applicable licensure standards, availability of sufficient staff to meet the service needs of the service recipient, as well as the health and safety of the service recipient and availability of back-up staffing when scheduled staff are unable to report to work. Stakeholder Any individual, group or organization with a vested interest and that influences the operation and implementation of the HCBS Medicaid Waiver Program or other DMRS Waivers. Standardized Individual Support Plan Format An ISP template that contains all required elements that must be used in the development of an ISP for every Medicaid Waiver participant. Please refer to Appendix D of this manual. Statewide Waiver The federally approved HCBS Medicaid Waiver Program for persons who meet the Tennessee Medicaid financial and medical eligibility criteria for care in an ICF/MR facility. State Case Managers State employed case management staff who provide information about DMRS programs and services, provide assistance with completing eligibility application forms, gather information to

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-51

GLOSSARY OF TERMS

assess service needs, connect people to generic community services, provide ongoing contact and assistance as needed/requested and will refer people to advocacy organizations and support groups as needed/requested. State-Funded Services Services provided to persons that are reimbursed with funding that comes directly from state dollars and does not include any federal financial participation. State Medicaid Agency The bureau in the Tennessee Department of Finance and Administration which is responsible for administration of the Title XIX Medicaid program in Tennessee. State Plan The Medicaid State Plan as approved by the Health Care Financing Administration for the State of Tennessee. Statute Legislation enacted by any lawmaking body, including legislatures, administrative boards and municipal courts. Any positive enactment to which the state gives the force of a law is a statute, whether it has gone through the usual stages of legislative proceedings, or has been adopted in other modes of expressing the will of the people or other sovereign power of the state.

Subcontractor An individual, organized partnership, professional corporation, or other legal association or entity which enters into a written contract with the Operational Administrative Agency to provide Waiver Services to an enrollee. Subsidy A grant of money from a government to a private enterprise. Supervision Plan A supervision plan required to be developed by providers who employ staff who are responsible for direct supervision of service recipients and should address how the provider accomplishes major supervisory functions. Supplemental Security Income (SSI) Benefits provided through a program administered by the SSA for those meeting program eligibility requirements. OR An income benefit program administered by the SSA for disabled individuals, under age 65, who are unable to engage in any substantial gainful activity. The SSI program is based on financial need established by income and assets requirements.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-52

GLOSSARY OF TERMS

Supplemental Security Income Federal Benefit Rate (SSI/FBR) The Federal Benefit Rate is the maximum dollar amount that persons meeting all eligibility requirements can receive in federal SSI cash benefits on a monthly basis. Support Coordination Case management services that assist the enrollee in identifying, selecting, obtaining, coordinating and using both paid services and natural supports to enhance the enrollees independence, integration in the community, and productivity as specified in the enrollees Plan of Care (ISP). Support Coordination shall be person-centered and shall include, but is not limited to, ongoing assessments of the enrollees strengths and needs; development, evaluation, and revision of the Plan of Care (ISP); assistance with the selection of service providers; provision of general education about the Waiver program, including enrollee rights and responsibilities; and monitoring implementation of the plan of care and initiating individualized corrective actions as necessary (e.g., reporting, referring, or appealing to appropriate entities). Please refer to Chapter 4 of this manual. Support Coordination Record All documentation used and/or generated during the ISP planning process required to be maintained by the support coordinator or case manager. Support Coordinator The person who is responsible for developing the Support Plan and participating in the development of and monitoring and assuring the implementation of the Plan of Care; who provides Support Coordination services to an enrollee; and who meets the qualifications for a Support Coordinator as specified in the HCBS Waiver for the Mentally Retarded and Developmentally Disabled. Supported Employment To assist persons with severe or significant disabilities in obtaining and maintaining community integrated competitive employment through specifically planned supports. Supported Living Supported Living shall mean a type of residential service having individualized services and supports that enable an enrollee to acquire, retain or improve skills necessary to reside in a home that is under the control and responsibility of the enrollee. The service includes direct assistance as needed with activities of daily living (e.g., bathing, dressing, personal hygiene, eating, meal preparation (excluding cost of food), household chores essential to the health and safety of the enrollee, budget management, attending appointments, and interpersonal and social skills building to enable the enrollee to live in a home in the community. It may also include

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-53

GLOSSARY OF TERMS

medication administration as permitted under Tennessees Nurse Practice Act. Please refer to Chapter 9 of this manual. Systemic Issues Provider agency issues that affect or have the potential to affect a number of service recipients. TennCare Bureau The bureau in the Tennessee Department of Finance and Administration which is the State Medicaid Agency and is responsible for administration of the Medicaid program in Tennessee. TennCare Division of Developmental Disability Services A division of the Bureau of TennCare responsible for the direct administration and oversight of the two Medicaid HCBS waivers for persons with mental retardation. TennCare Managed Care Organization An appropriately licensed Health Maintenance Organization approved by the Bureau of TennCare as capable of providing medical services in the TennCare program. TennCare QA Survey Reports A TennCare report of findings issued following a TennCare quality monitoring survey. TennCare Rate Schedule A set of maximum rates that will be used to reimburse providers who render particular services. TennCare Solutions Unit A distinct unit within the Bureau of TennCare responsible for the review of Grier Appeals, including the decision to uphold or overturn the denial. Tennessee Administrative Register (TAR) An official publication of the Tennessee Department of State that is compiled and published monthly. Tennessee Bureau of Investigation TBI is the primary criminal investigative agency for the State of Tennessee. www.tbi.state.tn.us/ Tennessee Code Annotated (T.C.A.) The official, multi-volume publication of the complete text of the Tennessee Code (Statutory Law) with historical notes, cross-references and case notes of legal/judicial decisions construing specific Code sections.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-54

GLOSSARY OF TERMS

Tennessee Council on Developmental Disabilities (DDC) DDC is an office of state government established to implement the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (PL 106-402). The goal of the DD Act is to promote a coordinated and inclusive system of support services for individuals with disabilities in each state and territory. To do this, the council works to improve public policies and systems of service that support and promote the inclusion of individuals with developmental disabilities in their communities. www.state.tn.us/cdd/ Tennessee Employment Consortium (TEC) A committee established through a grant provided by the Tennessee Council on Developmental Disabilities to increase the number of individuals with developmental disabilities employed in the State of Tennessee. Tennessee Labor Laws Tennessee Labor Laws are enforced by the Tennessee Department of Labor and Workforce Development. Please refer to Title 50 of the Tennessee Code Annotated and Appendix B of this manual. www.state.tn.us/labor-wfd/lsdiv.html Tennessees Nurse Practice Act The Tennessee Nurse Practice Act is laid out in Tennessee Code Annotated 63-7-107. Please Refer to Appendix B. Tennessee Uniform Residential and Tenant Act The Tennessee law governing the legal relationships/interactions between individuals or organizations who own rental/lease property and individuals who rent or lease such property (tenants). The National Coordination Council For Medication Error Reporting and Prevention (NCC MERP) An independent body comprised of 25 national and international organizations that meet, collaborate, and cooperate to address the interdisciplinary causes of medication errors and to promote the safe use of medications. www.nccmerp.org The Standards of Practice for Occupational Therapy Requirements for the occupational therapy practitioner (registered occupational therapist and certified occupational therapy assistant) for the delivery of occupational therapy services that are client centered and interactive in nature (American Occupational Therapy Association (AOTA), 1995).

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-55

GLOSSARY OF TERMS

The United States Pharmacopoeia (USP) A non-governmental standards-setting organization that advances public health by ensuring the quality and consistency of medicines, promoting the safe and proper use of medications, and verifying ingredients in dietary supplements. www.usp.org Therapy Related Services Services that may be recommended as a result of a therapy assessment of service recipient functional capabilities or that may require therapy assessment/services to ensure that a proper treatment plan is developed or that appropriate equipment or supplies are procured. Please refer to Chapter 14 of this manual. Third Party Third Party here means a party other than the transferring provider or the receiving provider. Time-Sensitive Refers to a service authorization request that requires a prompt medical response in light of the persons condition and urgency of need, as defined by a prudent lay person. Title 33 (T.C.A. 33) T.C.A. 33 is also known as Title 33 and is the primary state law governing the methods employed in service delivery to people with mental retardation. Train-The-Trainer Courses Courses offered by DMRS to provide a mechanism for providers to develop the resources needed to deliver quality training to employed staff. Training Records Documented signed records that provide verification provider agency staff persons have completed all DMRS training requirements needed to provide support to persons receiving DMRS services prior to working with the person. Transfer The movement of an eligible person from one ICF/MR to another ICF/MR or from an ICF/MR to the HCBS Medicaid Waiver Program. Transfer Form The form approved by the State Medicaid Agency and used to document the transfer of an enrollee having an approved unexpired ICF/MR Pre-Admission Evaluation from the Waiver to an ICF/MR or from an ICF/MR to the Waiver.

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-56

GLOSSARY OF TERMS

Transition The movement of an eligible person from one ICF/MR to a community placement or from one community placement to another community placement. Transition Plan A plan developed prior to a person moving from an ICF/MR into the community and used as the persons plan of care until the ISP is developed. Transportation Services Non-emergency transport of an enrollee to and from approved activities specified in the enrollees plan of care. Treatment Medical, surgical, dental, or psychiatric management of a patient. Treatment Plan The projected series and sequence of treatment procedures based on an individualized evaluation of what is needed to restore or improve the health and function of a patient. Uniform Assessment A standard process established by DMRS that allows information to be collected and compiled regarding a persons capabilities, needs, desired outcomes and goals for the future. Uniform Assessment Instrument A valid and reliable instrument that is to be used by persons who have been trained by a DMRS approved trainer and have met all other training requirements associated for use with this instrument to render initial and follow-up assessments for all individuals receiving or waiting to receive state and federally funded DMRS services. United StatesCode Annotated (U.S.C.A.) The codification by subject matter of the general and permanent laws of the United States. Unlicensed Personnel Staff employed by an agency contracted with the DMRS to provide services to individuals with mental retardation and developmental disabilities who do not have a valid Tennessee license to administer medication. Vehicle Accessibility Modifications Vehicle Accessibility Modifications shall mean interior or exterior physical modifications 1) to a vehicle owned by the enrollee; or

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-57

GLOSSARY OF TERMS

2) to a vehicle which is owned by the guardian or conservator of the enrollee and which is routinely available for transport of the enrollee. Such modifications must be intended to ensure the transport of the enrollee in a safe manner. Replacement of tires or brakes, oil changes and other vehicle maintenance procedures shall be excluded. Please refer to Chapter 14 of this manual. Vehicle Lifts Devices used to make vehicles accessible to persons using wheelchairs or other mobility devices by allowing the person to be lifted from the ground to the interior of the vehicle while using a mobility aid. Vision Services (Arlington Waiver) Vision services shall mean routine eye examinations and refraction; standard or special frames for eyeglasses; standard, bifocal, multifocal, or special lenses for eyeglasses; contact lenses; and dispensing fees for ophthalmologists, optometrists, and opticians. Vision services are available only to service recipients enrolled in the Arlington Waiver. Please refer to Chapter 15 of this manual. Vocational Evaluations An evaluation required to be performed at least once every three years that aids in the process of determining the best three employment options that may be available and to assist in determining the best employment alternative to meet individual needs. Vocational Programs Vocational programs means a program whose primary purpose is to provide services or activities that facilitate an adult service recipient to work at a job or training site of their choice. These services can be facility based or non-facility based and include but are not limited to: supported employment, psychosocial rehabilitation, pre-vocational work units, vocational work assessments, job readiness training, and enclaves. (Chapter 0940-5-34) Vocational Rehabilitation Services (VRS) VRS is a federal/state funded program that provides services to help people with disabilities enter or return to employment. www.state.tn.us/humanserv/VRServices.html

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-58

GLOSSARY OF TERMS

Vocational Training Training received on the job, at a trade school, college or university, or other facility. Voluntary Disenrollment An independent decision made by a person and/or the persons legal representative to discontinue participation in the HCBS Medicaid Waiver Program. Waiting List DMRS maintains two separate waiting lists. One list titled Waiver Waiting List identifies individuals by their identified category of need and indicates these individuals have registered, appear to be eligible and are waiting for Medicaid Waiver services to be provided. The second list titled State Funded Services Waiting List is comprised of individuals who are not eligible for Medicaid Waiver services and are therefore waiting for available state-funded services to be provided. Waiver Funded Services Specific services defined in the HCBS Medicaid Waiver Program that has been approved by the Centers for Medicaid and Medicare Services as eligible for federal financial participation reimbursement. 2350 Form A form used by DHS to obtain financial eligibility verification. 2362 Form This form ensures there has been review and approval of the individuals income for receipt of waiver services. (42 CFR 435.726)

Provider Manual, Glossary Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-59

A
APPENDIX A ACRONYMS
A ACVERP ADA ADC ADL AHA AJHP Academy for Certification of Vision Rehabilitation and Education Professionals Americans With Disabilities Act Arlington Developmental Center Activities of Daily Living American Heart Association American Journal of Health Systems Pharmacy (Formerly known as American Journal of Hospital Pharmacy) Administrative Lead Agency American Occupational Therapy Association Administrator On Duty Adult Protective Services American Physical Therapy Association

ALA AOTA AOD APS APTA

B BCBA BHO BSP BSC Behavior Analyst Certification Board Behavioral Health Organization Behavior Support Plan Behavior Support Committee

Provider Manual, Appendix A Acronyms Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

A-1

A
C CBDC CB/GVSA CFR CMS Clover Bottom Developmental Center Clover Bottom/Greene Valley Settlement Agreement Code of Federal Regulations Centers for Medicare & Medicaid Services (Formerly knows as HCFA) Certified Nursing Assistant Certified Nursing Technician Certified Orientation and Mobility Specialist Circle of Support Cardiopulmonary Resuscitation Child Protective Services Childrens Special Services (Formerly CCS Crippled Childrens Services)

CNA CNT COMS COS CPR CPS CSS

D DCS DDC DHS DMHDD DMRS DNR Department of Childrens Services Tennessee Council on Developmental Disabilities Department of Human Services Department of Mental Health & Developmental Disabilities Division of Mental Retardation Services Do Not Resuscitate

Provider Manual, Appendix A Acronyms Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

A-2

A
D DOE DOH DRS DSP DSS Department of Education Department of Health Division of Rehabilitation Services Direct Suppport Professional Direct Support Staff

E EBT Cards EPSDT Electronic Benefit Transfer Cards Early & Periodic Screening, Diagnosis & Treatment

F FBI FFP FLSA FFP Federal Bureau of Investigation Federal Financial Participation Fair Labor Standards Act Federal Financial Participation

G GVDC Greene Valley Developmental Center

H HCB or HCBS Home & Community Based Services (Medicaid Waiver)

Provider Manual, Appendix A Acronyms Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

A-3

A
H HIPPA HHS HRC Health Insurance Portability & Accountability Act Department of Health & Human Services Human Rights Committee

I ICAP ICF/MR ICF/MR LOC Criteria IDEA IEP Inventory for Client and Agency Planning Intermediate Care Facility for the Mentally Retarded Intermediate Care Facility for the Mentally Retarded Level of Care Criteria Individuals with Disabilities Education Act Individualized Education Program (Provision of IDEA) Intelligence Quotient (Determined by Individual Intelligence Test)
Independent Support Coordinator

IQ

ISC

ISP ITP

Individual Support Plan Individual Transition Plan

J K

Provider Manual, Appendix A Acronyms Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

A-4

A
L LEA Local Education Agency (School District or System) Limited English Proficiency Licensed Practical Nurse

LEP LPN

M MAR MCO Medication Administration Record Managed Care Organization

N O OIG OSHA Office of the Inspector General Occupational Safety and Health Administration P PAE Pre-Admission Evaluation (Required by Medicaid ICF/MR or HCB Waiver Programs and Nursing Homes) Primary Care Physician Person Emergency Response System Protected Health Information Plan of Care

PCP PERS PHI POC

Provider Manual, Appendix A Acronyms Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

A-5

A
P PT PTI Physical Therapy Parent Training & Information Center (Funded under IDEA to provide information & training to parents about special education rights and procedures) PSR PRN Physical Status Review As needed or necessary

Q QA QI QMRP Quality Assurance Quality Improvement Qualified Mental Retardation Professional

R RN Registered Nurse

S SDW Self Determination Waiver SEC SSA SSDI National Supported Employment Consortium Social Security Administration Social Security Disability Income

Provider Manual, Appendix A Acronyms Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

A-6

A
S SSI SSI/FBR Supplemental Security Income Supplemental Security Income Federal Benefit Rate

T TABA TAR TASC TBI TCA TEC TEIS THDA TNCO TSU Tennessee Association of Behavior Analysts Tennessee Administrative Register Tennessee Association of Support Coordinators Tennessee Bureau of Investigation Tennessee Code Annotated Tennessee Employment Consortium Tennessees Early Intervention System Tennessee Housing Development Authority Tennessee Network of Community Organizations TennCare Solutions Unit

U USCA USP United States Code Annotated The United State Pharmacopeia

V VRS Vocational Rehabilitation Services

Provider Manual, Appendix A Acronyms Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

A-7

A
W X

Y Z

Provider Manual, Appendix A Acronyms Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

A-8

B
APPENDIX B
CONTACT INFORMATION

Bureau of TennCare.. 1-800-342-3145 729 Church Street Nashville, TN 37247 Division of Developmental Disability Services 615-532-7355 1-877-224-0219 Family Assistance Service Center. 1-866-311-4287 Call this number for general information regarding TennCare TennCare Solutions..1-800-878-3192 Call this number to file an appeal. TennCare Partners Advocacy 1-800-758-1638 Call this number if your require help with mental health care.

Department of Childrens Services Cordell Hull Building Seventh Floor 425 Fifth Avenue North Nashville, TN 37243-0290

615-741-9701

Department of Education. 615-741-2731 Andrew Johnson Tower Sixth Floor 710 James Robertson Parkway Nashville, TN 37243-0375

Department of Finance and Administration.. 312 Eighth Avenue, North Nashville, TN 37243-0285

615-741-2401

Provider Manual, Appendix C Quick Reference for Rules and Regulations Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

C-1

B
Division of Mental Retardation Services Central Office.615-532-6530 500 Deaderick Street Nashville, TN 37243 Stephen H. Norris, Deputy Commissioner. 615-532-6533 Joanna Damons, Assistant Commissioner Policy/Planning 615-741-6157 Fred Hix, Assistant Commissioner Administrative Services.. 615-532-6543 Larry Latham, Assistant Commissioner Community/ Facility Services.. 615-253-5657 Terry Poff, Budget.. 615-253-3166 Jeff Smith, Chief Financial Officer. 615-532-6535 Tony Troiano, Communications .... 615-253-2236 John Kaufman, Compliance .. 615-532-6542 Paul Greene, Consumer Services .. 615-741-6632 Steve Telpey, General Counsel... 615-532-6526 Barbara Charlet, Information Systems . 615-532-5959 Dr. Adadot Hayes, Medical Director.. 615-253-6711 Donna Allen, Operations .. 615-532-6540 Merlin Littlefield, Planning/Development 615-532-5758 Debra Payne, Protection From Harm..615-253-6885 Pat Nichols, Quality Assurance 615-532-6548 Tami Wilson, Special Assistant to Deputy Commissioner. 615-741-6624 Paula McHenry, Support/Coordination/Case Management 615-532-6545 Brenda Clark, Title VI. 615-253-6811

East Tennessee Regional Office. 865-588-0508

John Craven, Director

Greenbriar Cottage 5908 Lyon View Drive Knoxville, TN 37919 Middle Tennessee Regional Office.615-231-5047 Kathleen Clinton, Director 275 Stewarts Ferry Pike Nashville, TN 37214

Provider Manual, Appendix C Quick Reference for Rules and Regulations Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

C-2

B
West Tennessee Regional Office 901-213-1949 Alan Bullard, Director 8383 Wolf Lake Drive Bartlett, TN 38113

Administrator on Duty (AOD) Pagers East Tennessee Region...1-877-831-1695 Middle Tennessee Region..615-282-4364 West Tennessee Region..1-888-509-1508

Agency Teams David Powers, East Tennessee Region 865-588-0508 Ext. 106 Linda Randall, East Tennessee Region 865-588-0508 Ext. 116 Pat Rees, Middle Tennessee Region.. 615-231-5285 Sandra Clamp, West Tennessee Region 901-213-1950 Dale Parish. 731-421-5013

Appeals David Hudson, East Tennessee Region 865-588-0508 Ext. 117 Pam Romer, Middle Tennessee Region. 615-231-5031 Janet Neihoff, West Tennessee Region. 731-423-5889

Behavior Andy Wood, East Tennessee Region... 865-588-0508 Ext. 104 Bruce Davis, Middle Tennessee Region 615-231-5094 Dr. Craig Hunter, West Tennessee Region 901-213-1930

Complaint Resolution Hotline.1-800-535-9725 Channeth Quemore, East Tennessee Region 865-588-0508 Ext. 228 East Tennessee Hotline...1-888-310-4613 Richard Primm, Middle Tennessee Region... 615-231-5027 Middle Tennessee Hotline..1-800-654-4839 Debbie Hammons, West Tennessee Region 901-213-1837 West Tennessee Hotline.1-800-308-2586

Provider Manual, Appendix C Quick Reference for Rules and Regulations Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

C-3

B
Developmental Centers Arlington Developmental Center.. 901-745-7301 Leon Owens, Chief Officer 11293 Memphis-Arlington Road Arlington, TN 38002-0586 Clover Bottom Developmental Center.. 615-231-5373 Levi Harris, Chief Officer 275 Stewarts Ferry Pike Nashville, TN 37214-0500 Greene Valley Developmental Center.. 423-787-6568 Henry Meece, Chief Officer 4850 East Andrew Johnson Highway Greeneville, TN 37744-0910

Early Intervention Services 1-800-462-8261 East Tennessee Region.. 865-588-0508 Ext 128 Middle Tennessee Region.. 615-231-5050 West Tennessee Region..901-213-1872

Family Support Coordinators. 1-800-535-9725 East Tennessee Region.. 865-588-0508 Ext 128 Middle Tennessee Region.. 615-231-5033 West Tennessee Region. 901-213-1872

Incident Management Amy Owens, East Tennessee Region...865-588-0508 Ext. 136 G.G. Mullins, Middle Tennessee Region...615-231-5037 Doug Clark, West Tennessee Region.731-421-5168

Provider Manual, Appendix C Quick Reference for Rules and Regulations Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

C-4

B
Intake Coordinators Greg Voica, East Tennessee Region... 1-888-531-9876 Darlene Moghadam, Middle Tennessee Region 615-231-5043 Cathy Dunn, West Tennessee Region 901-213-1980

Investigations Rusty Pool, East Tennessee Region...423-787-6441 East Tennessee Hotline...1-800-579-0023 VACANT, Middle Tennessee Region...615-231-5015 Middle Tennessee Hotline..1-888-633-1313 George Pruitt, West Tennessee Region (Arlington)..901-745-7770 (Jackson).731-426-1815 West Tennessee Hotline.1-888-632-4490

ISC Liaisons Caira Garcia, East Tennessee Region.. 865-588-0508 Ext. 126 Pat Rees, Middle Tennessee Region.. 615-231-5285 Sandra Clamp, West Tennessee Region. 901-213-1950 Dale Parrish, West Tennessee Region... 731-421-5013 Sherry Turner, West Tennessee Region. 731-421-5012

MR Hotline. 1-800-535-9725

Nursing Services Ruth Givens, Central Office... 615-532-6547 Marlenia Overholt, Central Office. 615-253-6095 Danny Ricker, East Tennessee Region. 423-787-6633 Bernard McCarthy, Middle Tennessee Region.. 615-231-5445 Linda Sain, West Tennessee Region. 901-213-1920

Provider Agreements/Contracts Bill Cunningham, East Tennessee Region... 865-588-0508 Ext. 107 Sharon Hurt, Middle Tennessee Region 615-231-5032 Janet Fly, West Tennessee Region 901-213-1829

Provider Manual, Appendix C Quick Reference for Rules and Regulations Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

C-5

B
Provider Approvals Central Office Brian Dion.. 615-532-5756 Day, Microboard, PA, Residential Susan Moss 615-253-4632 Behavior Support Corporate, Nursing, Nutrition/Dietitian, OT, Psychiatrist, Psychologist, PT, and SP George Zukotynski. 615-532-1610 Individual BA/BA

Provider Support David Powers, East Tennessee Region. 865-588-0508 Ext. 106 Sandra Wise, Middle Tennessee Region 615-231-5581 Dale Parrish, West Tennessee Region... 731-421-5013

Quality Assurance Nancy Krahenbill, East Tennessee Region... 865-588-0508 Ext. 118 Bernice Swallows, Middle Tennessee Region... 615-231-5001 Beth Roby, West Tennessee Region.. 901-421-5015

Regional Directors John Craven, East Tennessee Region... 865-588-0508 Ext. 129 Kathleen Clinton, Middle Tennessee Region 615-231-5048 Alan Bullard, West Tennessee Region.. 901-213-1949

Therapeutic Services John Richardson, East Tennessee Region 865-588-0508 Ext. 173 Libby Skeggs, Middle Tennessee Region.. 615-231-5443 Dawn Locke, West Tennessee Region... 901-213-1940

Provider Manual, Appendix C Quick Reference for Rules and Regulations Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

C-6

B
Title VI Compliance
Brenda Clark.. 615-253-6811

Title VI Compliance Coordinator Andrew Jackson Building Fifteenth Floor 500 Deaderick Street Nashville, TN 37243 John Birdsong 615-253-6717 Tennessee Title VI Compliance Commission James K. Polk Building First Floor 505 Deaderick Street Nashville, TN 37243 Roosevelt Freeman. 404-562-7881 U.S. Department of Health and Human Services Office for Civil Rights, Region IV Atlanta Federal Center Suite 3B70 61 Forsyth Street, S.W. Atlanta, GA 30303-8909 East Tennessee Region Tammy Green, Regional Monitor.. 423-787-6757 Ext. 109 Wendy Hammontree, Rights Advocate... 423-787-6449 Mike Mailahn, MH/MR Program Specialist. 865-588-0508 Ext. 109 Jill Turpin, Regional Monitor. 865-588-0508 Ext. 131 Middle Tennessee Region Melissa Hafeli, Regional Monitor 615-884-6088 Liz Roberts, Rights Advocate.. 615-231-5446 West Tennessee Region Gracie Bonner, Incident Manager/Rights Advocate 901-745-7384 Elverna Cain, Regional Monitor.. 731-421-5063 Loretta Motley, Training Coordinator. 901-769-7350

Provider Manual, Appendix C Quick Reference for Rules and Regulations Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

C-7

B
Training Alice Taylor, East Tennessee Region... 423-787-6757 Ext. 112 Tina Mount, Middle Tennessee Region. 615-231-5080 Loretta Motley, West Tennessee Region... 901-213-1821

Department of Health...615-741-3111

Cordell Hull Building Third Floor 425 Fifth Avenue North Nashville, TN 37247-0101 East Tennessee Regional Office. 865-588-5656 Middle Tennessee Regional Office 615-640-7100 West Tennessee Regional Office.............. 731-423-6454

Department of Human Services... 615-313-4700 Citizens Plaza Fifteenth Floor 400 Deaderick Street Nashville, TN 37248-0001 Adult Protective Services Chattanooga. 423-634-6624 Knoxville865-594-5685 Memphis901-320-7220 Nashville...... 615-532-3492 Toll-Free (outside above areas).. 1-888-277-8366 Eligibility Janet Larson, East Tennessee Region.. 865-588-0508 Ext. 114 Mosie Lawrence, Middle Tennessee Region.. 615-231-2025 Mosie Lawrence, West Tennessee except Shelby County 615-231-2025 Janet Lawrence, Shelby County 865-588-0508 Ext. 114 Family Assistance Service Center..615-743-2000 1-866-311-4287

Provider Manual, Appendix C Quick Reference for Rules and Regulations Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

C-8

B
Medicare. 1-800-772-1213 Department of Mental Health and Developmental Disabilities 615-532-6500 Cordell Hull Building Third Floor 425 Fifth Avenue North Nashville, TN 37243-0675 East Tennessee Regional Office. 865-594-6551 Middle Tennessee Regional Office 615-532-6590 West Tennessee Regional Office 731-543-7442

Provider Manual, Appendix C Quick Reference for Rules and Regulations Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

C-9

B
Advocacy Organizations
American Association on Mental Retardation...202-387-1968 800-424-3688 444 North Capitol Street NW Suite 846 Washington, DC 20001-1512 Since 1876, the American Association on Mental Retardation (AAMR) has been providing leadership in the field of mental retardation. AAMR is the oldest and largest interdisciplinary organization of professionals (and others) concerned about mental retardation and related disabilities. Over 9,000 members in the U.S. and 55 other countries have chosen AAMR as their association. Over the years, they have developed and refined a mission statement and a sense of purpose, which is summarized in their 13-point Principles.

Arc of Tennessee 615-248-5878 44 Vantage Way Suite 550 Nashville, TN 37228 The Arc of Tennessee is a grassroots, non-profit organization founded in 1952 and is affiliated with the Arc of the United States. The Arc of Tennessee is a membership organization composed of people with mental retardation and other disabilities, their parents, friends, and the professionals who assist them in reaching their goals.

Arc of the United States..301-565-3842 1010 Wayne Avenue Suite 650 Silver Springs, MD 20910 The Arc of the United States is the national organization of and for people with mental retardation and related developmental disabilities and their families. It is devoted to promoting and improving supports and services for people with mental retardation and their families. The association also fosters research and education regarding the prevention of mental retardation in infants and young children.

Provider Manual, Appendix C Quick Reference for Rules and Regulations Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

C-10

B
TASH.410-828-8274 29 West Susquehanna Avenue Suite 210 Baltimore, MD 21204 TASH is an international association of people with disabilities, their family members, other advocates, and professionals fighting for a society in which inclusion of all people in all aspects of society is the norm.

Tennessee Council on Developmental Disabilities..615-532-6615 500 Deaderick Street Nashville, TN 37243 The Tennessee Council on Developmental Disabilities is a State office that promotes public policies to increase and support the inclusion of individuals with developmental disabilities in their communities. The Council works with public and private groups across the State to find necessary supports for individuals with disabilities and their families, so that they may have equal access to public education, employment, housing, health care, and all other aspects of community life.

Tennessee Disability Coalition..615-383-9442 480 Craighead Street Suite 200 Nashville, TN 37204 The Coalition and its member agencies work together to advocate for public policy that ensures self-determination, independence, empowerment, integration and inclusion. From the ADA to Long-Term Care, from Education to Health, from Housing to Employment, from Personal Assistance to Assistive Technology, the Coalition focuses on legislative and administrative supports that improve the lives of individuals with disabilities and their families

Provider Manual, Appendix C Quick Reference for Rules and Regulations Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

C-11

B
Tennessee Disability Pathfinder..615-322-8529 800-640-INFO 1810 Edgehill Avenue Nashville, TN 37212 Tennessee Disability Pathfinder is a comprehensive referral service with telephone, web, and print resources (in English and Spanish) to connect persons with disabilities, family members, and advocates with service providers in Tennessee and with national resources.

Tennessee Technology Access Program..615-532-3122 Citizens Plaza 11th Floor 400 Deaderick Street Nashville, TN 37248 The Tennessee Technology Access Program (TTAP) provides Tennesseans who have disabilities with comprehensive information related to assistive technology. TTAP also provides funding to five regional assistive technology centers across Tennessee. The centers, located in Chattanooga, Jackson, Knoxville, Memphis, and Nashville provide training, evaluation, minority outreach and advocacy services.

Provider Manual, Appendix C Quick Reference for Rules and Regulations Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

C-12

B
CONSERVATORISHIP ORGANIZATIONS

ComCare, Inc. 423-638-3926 P. O. Box 1885 Greeneville, TN 37744-1885 Comcare, Inc., is an adult services agency. They have a contract with the Tennessee Department of Mental Health and Developmental Disabilities to provide statewide guardianship services for persons who are moving out of state residential institutions. They also do some private conservatorships.

Department of Mental Health and Developmental Disabilities 615-532-6767 Cordell Hill Building 5th Floor 425 Fifth Avenue North Nashville, TN 37243 The Department is the state's mental health and developmental disabilities authority and is responsible for system planning, setting policy and quality standards, system monitoring and evaluation, disseminating public information and advocating for persons of all ages who have mental illness, serious emotional disturbance or developmental disability.

Department of Human Services1-888-277-8366 Adult Protective Services 400 Deaderick Street Nashville, TN 37248-0001 Tennessee Department of Human Services, Adult Protective Services staff investigate reports of abuse, neglect (including self-neglect) or financial exploitation of adults who are unable to protect themselves due to a physical or mental limitation.

Provider Manual, Appendix C Quick Reference for Rules and Regulations Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

C-13

B
Tennessee Bar Association615-383-7421 221 Fourth Avenue North Suite 400 Nashville, TN 37219 While the Tennessee Bar Association does not offer legal advice or act as a referral service, we do offer public service information in a variety of areas and offer contacts and links to other useful sources.

Tennessee Commission on Aging and Disability615-741-2056 Andrew Jackson Building 8th Floor 500 Deaderick Street Nashville, TN 37243 The Tennessee Commission on Aging & Disability protects the rights, meets the needs, and preserves the dignity of older Tennesseans and Adults with disabilities needing home and community services through visible and effective advocacy, leadership, and stewardship.

Provider Manual, Appendix C Quick Reference for Rules and Regulations Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

C-14

C
APPENDIX C QUICK REFERENCE FOR RULES AND REGULATIONS
OFFICIAL COMPILATION OF RULES AND REGULATIONS The Tennessee Department of State, Division of Publications publishes the Tennessee Blue Book, Public and Private Acts of the General Assembly, Tennessee Administrative Register, Tennessee Open Appointments Vacancy Report, official compilation/Rules and Regulations of the State of Tennessee and other documents for which the secretary of state is responsible. This division is also responsible for the creation and maintenance of the Department of State's Web site. The Tennessee Department of States website may be accessed at www.state.tn.us/sos

TENNESSEE CODE ANNOTATED Tennessee Code Annotated and the full text of the state constitution are published on the Web by LexisNexis. LexisNexis may be accessed through the States website at www.state.tn.us. At the States home page following the link for LAWS AND JUSTICE. From that page follow LAWS AND RULES, and by following the link for TENNESSEE CODE AND CONSTITUTION, you will be directed to LexisNexis search page for Tennessee. Click the plus (+) or minus (-) signs next to a heading in the table of contents to expand or collapse that heading. Click on a document heading to view the document text.

Provider Manual, Appendix C Quick Reference for Rules and Regulations Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

C-1

D
APPENDIX D FORMS

All forms are being re-designed for electronic capabilities. Please contact the Division of Mental Retardation Services at 615-532-6530 to obtain copies of any form that you may need. As completed and approved, forms will be available on the website at www.state.tn.us/dmrs. Please keep in mind that you will need Microsoft Word version 2000 or greater to access these forms.

Provider Manual, Appendix D Forms Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

D-1

E
APPENDIX E PHYSICAL STATUS REVIEW (PSR) GUIDELINES

I.

PURPOSE The purpose of this document is to establish statewide guidelines on the use of the Physical Status Review (PSR) screening instrument. This instrument establishes the health care risk level for persons with potential health care needs. Once the persons level of risk has been determined, it will be possible to define the required health services and support systems.

II.

SCOPE The purpose of this document is to establish statewide guidelines on the use of the Physical Status Review (PSR) screening instrument. This instrument establishes the health care risk level for persons with potential health care needs. Once the persons level of risk has been determined, it will be possible to define the required health services and support systems.

III.

AUTHORITY Tennessee Code Annotated 33-5-101, 33-5-201, the Remedial Order entered by the United States for the Western District of Tennessee in United States v. State of Tennessee relating to Arlington Developmental Center and the Settlement Agreement entered by the United States District Court for the Middle District of Tennessee in People First v. Clover Bottom, et al. relating to Clover Bottom Developmental Center and the Greene Valley Developmental Center.

Provider Manual, Appendix E Physical Status Review Guidelines Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

E-1

E
IV. DEFINITIONS A. Health Plan: A plan of care developed from an analysis of health related data that identifies specific outcomes with accompanying interventions/action plans. Independent Support Coordinator (ISC): The employee of an agency who contracts with the Division of Mental Retardation Services to arrange and coordinate supports and services for people with mental retardation or developmental disabilities. Individual Support Plan (ISP): The document, which reflects the vision of a persons desired life. It includes the description of the persons current life, functioning and needed supports. It states the outcomes necessary to achieving the persons vision of his/her desired life. The ISP describes the actions, supports and services required, and the persons and providers responsible for the desired outcomes. Individual Transition Plan (ITP): The individualized plan to transfer an individual from a developmental center to a home in the community. It includes the services and supports needed in the community and identifies who will provide these. It reflects the personal preferences and vision of the person transitioning for his/her future. NOT SURE ABOUT THIS STATEMENT Outcomes: Personal outcomes are centered on the person, not programs or program categories. They focus on the items and issues that matter most to the people in their lives. Personal outcomes recognize the connections between the services/supports and interventions and the person. Physical Status Review (PSR): A health-screening instrument used to identify the persons health care risk level. Levels are rated on: (1) Functional Status, (2) Behavior, (3) Physiological, (4) Safety, and (5) Frequency of Service. Based on the persons risk factors a level is assigned, ranging from one (1) through six (6).

B.

C.

D.

E.

F.

V.

GUIDELINES Each person will have a Physical Status Review completed annually and/or when their health status changes.

Provider Manual, Appendix E Physical Status Review Guidelines Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

E-2

VI.

PROCEDURE A. A Physical Status Review (PSR) will be completed for persons at specified intervals. 1. Each person will have an initial PSR established: a. b. 2. Upon admission into DMRS services. When no PSR has been established for current service recipients.

Persons will have a PSR completed at least annually and a review and/or update prior to transition planning. a. No more than 30 days prior to Individual Support Plan (ISP) or Individual Transition Plan (ITP).

3.

A persons PSR and Health Care Plan will be reviewed and updated within 10 working days when a potential health status change occurs, such as: a. b. c. d. Following an acute hospital admission. In the event of a significant change in health status, such as, a recurrence of seizures, a new diagnosis, e. g., diabetes mellitus. Behavioral destabilization, such as an increase in injurious behavior to oneself or others, property destruction, etc. Loss of functional skills such as eating, walking, personal hygiene, etc.

B.

A Health Risk Status is determined using the PSR, items A through V. These rating items are divided into five major categories as follows: 1. Functional Status a. b. c. d. e. Eating Ambulation Transfer Toileting Program days missed

Provider Manual, Appendix E Physical Status Review Guidelines Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

E-3

E
2. Behavioral a. b. c. d. 3. Self abuse Aggression Use of mechanical restraints Use of anti-psychotic medications

Physiological a. b. c. d. e. f. g. Gastrointestinal Seizures Anticonvulsant medications Skin breakdown Bowel function Nutrition Complex treatments

4.

Safety a. b. Injuries Falls

5.

Frequency of Service a. b. c. Physician visits Emergency visits Hospital admissions

Note: Each area is assigned a numerical score between 0 and 4, with the lowest number denoting the lowest risk in the category. The level is determined by the sum of each area. Levels are from 1-6. C. As a result of the persons assessed rating scores in the categories above, a Health Care Risk Level is assigned in one of the following categories: 1. Level 1: Total score of 0-12 This person ordinarily has no body system compromised, but may have deficits in functional skills or minor behavioral issues. The person usually requires the same level of health support as for people without disabilities.

Provider Manual, Appendix E Physical Status Review Guidelines Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

E-4

E
2. Level 2: Total score of 13-25 This person may have a minor chronic condition, but the condition has been stable for an extended period. 3. Level 3: Total score of 26-38 This person usually has two or more chronic health conditions but has been stable for at least one year.

4.

Level 4: Total score of 39-53 This person has two or more unstable chronic health conditions, which require close monitoring and specialized health training for all staff.

5.

Level 5: Total score of 54-68 This person meets all the criteria for level 4 but also has health needs that require licensed nursing intervention one or more times daily.

6.

Level 6: Total score of 69 or greater This person has several health issues that are unstable and require treatment by a licensed nurse more frequently than every 2 hours over a 24-hour period.

D.

Health Care Risk Levels are further divided into three categories: 1. 2. 3. Low Risk-Levels 1 and 2 Moderate Risk-Levels 3 and 4 High Risk-Levels 5 and 6

E.

The PSR tool is completed by the following individuals: 1.In the community, the PSR tool is completed by the appropriately trained and designated provider. and reviewed by a Registered Nurse. for levels 3 and above. Each of these individuals must have completed the required Division PSR training module and demonstrated competency in the completion and scoring of the instrument.

Provider Manual, Appendix E Physical Status Review Guidelines Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

E-5

E
2. For individuals funded for RN oversight, the PSR will be completed and reviewed by the RN providing the oversight. The RN must be trained and demonstrate competency in the completion and scoring of the PSR tool. F. As a result of the assigned Health Care Risk Level, the following health management outcomes will be assured by the Individual Support Team: 1. A Registered Nurse develops recommendations for: a. b. c. Level of health care and nursing supports. Staff training on health issues. The level of health care oversight to be provided.

2.

The Support Team establishes health care service needs and staff health training needs, based on the recommendations of the Registered Nurse.

G.

Oversight and monitoring of staff competency to screen and manage health care concerns is accomplished by a designated and qualified Registered Nurse who reviews the PSR instrument for accuracy and completeness:

1. 2. 3. 4.

For Health Care Levels 1 and 2, five percent (5%) of the nurses caseload per month. For Health Care Levels 3, and 4, quarterly. For Health Care Levels 5 and 6, monthly. For problem-focused situations, oversight and monitoring will be based on the persons specific need(s) and determined by a Registered Nurse.

Provider Manual, Appendix E Physical Status Review Guidelines Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

E-6

F
APPENDIX F USEFUL WEBSITES

American Heart Association www.americanheart.org

American Journal of Health-System Pharmacy www.ashp.org

American Occupational Therapy Association www.aota.org

American Physical Therapy Association www.apta.org

American Red Cross www.redcross.org

Americans With Disabilities Act Home Page www.usdoj.gov/crt/ada/adahom1.htm

American Association on Mental Retardation (AAMR) www.aamr.org

Provider Manual, Appendix F Useful Websites Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

F-1

F
Arc of Tennessee www.thearctn.org

Arc of the United States www.thearc.org

Association for Behavior Analysis www.abainternational.org

Behavior Analyst Certification Board www.bacb.com

Bureau of TennCare www.state.tn.us/tenncare/ Center on Disability and Employment (Formerly UT-TIE) www.uttie.org
www.cde.tennessee.edu

Code of Federal Regulations (CFR) http://www.gpoaccess.gov/cfr/index.html

Department of Health www.state.tn.us/health

Provider Manual, Appendix F Useful Websites Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

F-2

F
Department of Human Services www.state.tn.us/humanserv

Department of Mental Health and Developmental Disabilities www.state.tn.us/mental

Division of Mental Retardation Services http://www.state.tn.us/dmrs

Division of Rehabilitation Services www.state.tn.us/humanserv/VRServices.html

Family Village www.familyvillage.wisc.edu

National Association for the Dually Diagnosed www.thenad.org

thenadd

National Association for Persons in Supported Employment www.apse.org

National Council on Disability www.ncd.gov

Provider Manual, Appendix F Useful Websites Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

F-3

F
National Down Syndrome Congress www.ffcmh.org
www.ndsccenter.org

National Down Syndrome Society www.ndss.org

National Information Center for Children and Youth with Disabilities www.nichcy.org

National Organization on Disability www.nod.org

National Rehabilitation Information Center www.naric.com

Service Provider Registry www.state.tn.us/finance/rds/ocr/sprs.html

TASH (Formerly Association for Persons with Severe Handicaps) www.tash.org

Tennessee Administrative Register www.state.tn.us/sos

Provider Manual, Appendix F Useful Websites Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

F-4

F
Tennessee Association for Behavior Analysis (TABA) www.taba.org/

Tennessee Code Annotated (TCA) http://198.187.128.12/tennessee/lpext.dll?f=templates&fn=fs-main.htm&2.0

Tennessee Council on Developmental Disabilities www.state.tn.us/cdd/

Tennessee Disability Coalition www.tndisability.org

Tennessee Family Pathfinder Resource www.vanderbilt.edu/kennedy/pathfinder/

kc

Tennessee Protection and Advocacy www.tpainc.org

Tennessee Rules & Regulations http://www.state.tn.us/sos/rules/rules2.htm

Tennessee State Government www.state.us.tn

Provider Manual, Appendix F Useful Websites Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

F-5

F
Tennessee Technology Access Program www.state.tn.us/humanserv/ttap_index.htm

The National Coordination Council for Medication Error Reporting and Prevention www.nccmerp.org

The United States Pharmacopoeia www.usp.org

United States Code Annotated (USC) http://assembler.law.cornell.edu/uscode/

Vanderbilt Kennedy Center for Research on Human Development http://kc.vanderbilt.edu/kennedy/

Provider Manual, Appendix F Useful Websites Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

F-6

APPENDIX G SERVICES AVAILABLE THRU DMRS PROGRAMS

The Division of Mental Retardation Services (DMRS) within the State Department of Finance and Administration is responsible for providing services and support to Tennesseans with mental retardation and other developmental disabilities and to their families. The Division provides services, either directly or through contracts with community providers, in a variety of settings. These settings range from institutional care to individual supported living in the community. The Division also provides support to the Council on Developmental Disabilities, which consists of members appointed by the Governor that represents a broad range of disabilities. Additionally, the DMRS has three long-term care facilities; Arlington Developmental Center in Arlington; Clover Bottom Developmental Center in Nashville; and Greene Valley Developmental Center in Greeneville. Regional offices are located in Bartlett, Nashville and Knoxville and work with community agencies to provide support services. The Division has various Sections to assist persons with mental retardation, other developmental disabilities and their families: Administrative Services addresses the workforce requirements of 4,200 employees, coordinates the Divisions budget for operational capital maintenance and expansion, and fiscally manages receivables and payables, including payments to service providers. Additionally, Administrative Services is responsible for the coordination of consistent fiscal policy division wide. Policy and Planning is responsible for the development and maintenance of administrative/operational policies, the development of provider manuals and consumer information materials, the compilation of the DMRS Annual Report and Strategic Plan and the fostering of effective partnerships with other State agencies and departments. Operations supervises program directors of Residential, Day, Early Intervention and Family Support Services. Provides Medicaid waiver management through the development of applications, amendments, policies and procedures, and provides

Provider Manual, Appendix G Services Available Thru DMRS Programs Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-1

G
technical assistance to the DMRS and provider staff on waiver requirements. Operations is responsible for recruitment, enrollment, orientation and technical assistance of providers. Develops provider requirements and develops, maintains, and oversees provider services rate structures. Further, Operations works with and monitors DRMS regional staff on provider management. Complaint Resolution is the mechanism for service recipients and families to express concerns about any aspect of the service system. Incident Management oversees the reporting of incidents, which cause or could cause harm to a service recipient and determines if referral to Investigations is appropriate. Investigations reviews allegations of abuse, neglect, or exploitation and maintains follow-up with providers. Clinical Unit is responsible for clinical issues and proper treatment regarding the DMRS population. The Clinical Unit educates and trains DMRS staff and the community on clinical issues, and provides consultation with persons the Division serves on treatment and care. Support Coordination/Case Management oversees support coordination for persons receiving services in the Statewide or Arlington Waivers. Services include ongoing assessment, development, evaluation and revision of the plan of care, assistance with selection of service providers and the provision of general education regarding the waiver program. Contracted providers who are independent of other service provisions conduct these services. This office also develops and implements case management services for individuals on the waiting list or enrolled in the Self-Determination Waiver. These services are similar to support coordination, but are provided by state employees. Quality Assurance/Protection From Harm is responsible for surveys of contracted Day and Residential Independent Support Coordinators and Clinical Service providers to determine their levels of performance. Data collected from the surveys is used to determine the level of quality across the service system. Protection From Harm is the Divisions safeguard for the persons it serves. It includes three (3) areas, Complaint Resolution, Incident Management, and Investigations. Office of Consumer and Family Services serves as the customer service arm of the Division. This office handles all aspects of customer service such as, responding to public inquiries, conducting monthly focus group conference calls with a random selection of family members and legal representatives of service recipients, conducting satisfaction surveys and conducting an annual series of town hall meetings across the state.

Provider Manual, Appendix G Services Available Thru DMRS Programs Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-2

G
General Counsel assists services recipients in obtaining conservators in compliance with court ordered provisions, represents the Division on civil service and human resource issues, handles all Division hearings before administrative law judges, and maintains and litigates all sanctions appeals cases. The General Counsel also assures compliance with all statutory and regulatory requirements of the Division, advises Division staff on legal matters, provides interpretation of all statutory provisions applicable to the Division and the appropriate legal measures to be taken. Further the General Counsel provides litigation support for inter-agency matters, drafts and reviews all division contracts, provides legislative assistance and serves and legal liaison, as well as, develop, draft, and review policies, procedures and rules. The Compliance Unit through data management and analysis, coordinates the Divisions activities related to the Clover Bottom Settlement Agreement, the Grier Decree and CMS reporting requirements. In this role the Compliance Unit serves as the repository of data and information for DMRS. The unit is the Divisions portal of communications between litigation parties, court monitors, the Department of Justice, CMS and others. The unit is also responsible for the production of key reports such as the Quality Management Report, status updates for litigation parties, counsel and court monitors. Title VI is responsible for compliance of Title VI, which is part of the Civil Rights Act of 1964 and applies to all recipients of federal financial assistance. Title VI charges that no person in the United States shall, on the ground of rate, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance. It is applicable to all of the programs facilities, activities, and operations of the DMRS and all service providers with which DMRS contracts utilizing state and federal funds. Communications handles day to day media relations, stakeholder communications, communications planning, and acts as liaison to and member of the Governors Communications Office. Additionally, Communications provides community outreach, publications management, speechwriting for the Division, and DMRS website design.

The following is a list of services available through DMRS programs: Consumer Directed Support Services Consumer Directed Support Services are available pursuant to recent settlement of the Brown v. People First class action lawsuit. Consumer-directed supports are state-funded and will be available to limited numbers of people who are on the

Provider Manual, Appendix G Services Available Thru DMRS Programs Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-3

G
waiting list for services. Funding for this program became available July 1, 2004. The program provides state funds up to $2,280 per year for each person, up to a total annual state expenditure of $5 million. The money provided to each person may provide for respite, transportation or other services.

Early Intervention The Early Intervention Program, provided pursuant to Part C of the Individuals with Disabilities Education Act (IDEA), which became effective in 1997. IDEA originated from Part H of the Education of the Handicapped Act, enacted in 1986 and amended in 1990 and 1991. Tennessees Early Intervention System (TEIS) is administered through an interagency agreement between the Department of Education and the Division of Mental Retardation Services. The program provides an array of services to infants and toddlers with disabilities and their families, in a variety of settings, such as center based programs, the home, childcare settings, and early head starts. There are currently thirty-six (36) Early Intervention programs throughout Tennessee. Additional Resources: Availability: Early Intervention Manual (under development) DMRS Central Office; or DMRS Website

Family Support The Family Support Program is a community-based, state-funded program assisting families with a family member who has a severe disability. This program is very flexible and additional services may be available based on the needs of the family. Local Family Support Councils oversee the Family Support Programs across the State. Local agencies and providers who receive grant funds and technical assistance from DMRS provide services. Additional Resources: Availability: Tennessee Family Support Guidelines DMRS Central Office Family Supports Coordinator; DMRS Regional Office Family Supports Staff; or DMRS Website

Provider Manual, Appendix G Services Available Thru DMRS Programs Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-4

G
Medicaid Home and Community Based Waiver Services (HCBS) Programs Medicaid HCBS Waiver Programs developed as an alternative to services provided in an institutional setting such as an Intermediate Care Facility for the Mentally Retarded (ICF/MR), have been in existence since 1981. Tennessees first HCBS waiver for people with mental retardation approved was in 1986. Currently, Tennessee has three (3) waiver program for people with mental retardation. The three (3) waivers are: 1. 2. 3. Home and Community Based Services Waiver for Persons with Mental Retardation (Arlington Waiver) Home and Community Based Services Waiver for the Mentally Retarded and the Developmentally Disabled (Statewide Waiver); Tennessee Self- Determination Waiver Program.

Waiver Services available through the Medicaid HCBS Waiver Programs include the following: Statewide Waiver Arlington Waiver Self-Determination (waiver #0128.90.R2A) (waiver #0357.90) Waiver (waiver #0427) Yes Yes Yes Yes No Yes Yes Yes No Yes Yes Yes Yes Yes No

Waiver Service Behavior Services Behavioral Respite Services Day Services Dental Services Adult Dental Services, Enhanced (Adult) Environmental Accessibility Modifications Family Model Residential Support Financial Administration Entity Services Individual Transportation Services

Yes Yes No Yes

Yes Yes No Yes

Yes No Yes Yes

Provider Manual, Appendix G Services Available Thru DMRS Programs Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-5

G
Waiver Service Medical Residential Services Nursing Services Nutrition Services Occupational Therapy Orientation and Mobility Training Personal Assistance Personal Emergency Response System Physical Therapy Residential Habilitation Respite Specialized Medical Equipment, Supplies and Assistive Technology Speech, Language and Hearing Services Support Coordination Supported Living Supports Brokerage Services Vehicle Accessibility Modifications Vision Services Statewide Waiver Arlington Waiver Self-Determination (waiver #0128.90.R2A) (waiver #0357.90) Waiver (waiver #0427) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes No Yes

Yes

Yes

Yes

Yes Yes Yes No Yes No

Yes Yes Yes No Yes Yes

Yes No (uses state-funded case managers) No Yes Yes No

Provider Manual, Appendix G Services Available Thru DMRS Programs Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-6

G
State Funded Services Each year the State legislature appropriates funding which allows the DMRS to provide State-Funded Services to people who are not eligible or are otherwise not getting needed services through the Medicaid waivers or other DMRS programs. The services provided are generally the same as those available through the Medicaid Waiver Programs.

Case Management Funding for Case Management services became available July 1, 2004, because of the recent settlement of the Brown v. People First class action lawsuit. Case Management will be provided with a combination of state and federal funding and will be available to people on the waiting list of Medicaid Waiver or DMRS StateFunded services and the service recipients in the Self Determination Waiver. State-employed staff will provide Case Management services. Case managers will provide information about DMRS programs and services, provide assistance in completing eligibility application forms, gather information to assess service needs, connect people to generic community services, provide ongoing contact and assistance as needed and/or requested, and will refer people to advocacy organizations and support groups as needed and/or requested.

Developmental Center Nursing Developmental center nursing provides a link to the community transition process.

Central Office Clinical Unit The Central Office Clinical Unit focuses on supporting health care, education, and consultation. Directors for medical, nursing, therapeutic and behavior services comprise the unit.

Health Related Training Health related training is available to all interested parties. Each region within the state has a nurse educator who is available to offer technical assistance and training.

Provider Manual, Appendix G Services Available Thru DMRS Programs Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-7

G
The Family Support Grant Program The family support grant program is administered by the Division, through contracts with community agencies across the state. To be eligible, an individual must have a severe disability and must be residing in the community in an unsupported setting. Services include a wide range of care and assistance.

Behavior Services Behavior services are provided in response to an assessed behavior need that is presenting a significant barrier to safe participation in habilitative and preferred activities. These services incorporate the use of behavior analysis to assess, design, implement, and evaluate systematic environmental modifications for producing changes in behavior.

Provider Manual, Appendix G Services Available Thru DMRS Programs Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

G-8

H
APPENDIX H SUMMARY OF LAWSUITS & COURT ORDERS
Lawsuits directed against the Division of Mental Retardation Services have had a major effect on the Divisions operations in recent years. All three developmental centers are currently monitored under the supervision of the federal courts. Arlington In January 1992, the U.S. Department of Justice sued the State of Tennessee for violations of the Civil Rights of Institutionalized Person Act (CRIPA) at the Arlington Developmental Center. Since November 1993, the facility has been under a U.S. District Court order to correct conditions at the facility. A court-appointed monitor ensures that Arlington Developmental Center complies with the terms of the remedial order. The remedial monitors staff reviews treatment programs at Arlington twice a year and performs quarterly reviews of community services in West Tennessee.

Clover Bottom/Greene Valley In 1996, the Department entered into a settlement agreement with the advocacy group People First, which had sued the state, charging violations of CRIPA at Clover Bottom and Greene Valley Developmental Centers. The Department of Justice strongly suggested that the state settle and followed with a suit to become a party in the settlement negations. The 1997 settlement agreement calls for the state to provide adequate community placements for eligible residents of the two developmental centers. A four member Quality Review Panel is required to monitor the developmental centers and community annually. The settlement agreement is still being implemented and there is a motion for partial dismissal of the agreement as it pertains to the Greene Valley Developmental Center.

The Brown Lawsuit In 2000 Tennessee Protection and Advocacy filed a lawsuit on behalf of Medicaid eligible citizens of Tennessee who are on the waiting list for services provided through the DMRS, or

Provider Manual, Appendix I Tuberculin Skin Testing Policy (DOH) Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

H-1

H
who have been denied the opportunity to apply for services. A settlement agreement was signed in December 2003 and approved by the court on June 15, 2004. The settlement agreement required the DMRS to seek approval of a new Self-Determination Waiver, which was approved by CMS in January 2005. Case managers will be assigned to each person on the waiting list to assist them with accessing services through the DMRS, as well as, other generic resources within their communities. Also, the DMRS is required to undertake a public information campaign to inform people about how to apply for services, as well as, what types of services are available. One program instituted is the Consumer Directed Supports Program will provide a small amount of money for individuals and their families to use to purchase a small amount of services and supports while they are waiting for waiver services. Centers for Medicare and Medicaid Services (CMS) Moratoriums The State of Tennessee operates three home- and community-based waiver programs for persons with mental retardation and developmental disabilities. These waivers provide services in community-based settings to individuals who would otherwise require institutionalization in an Intermediate Care Facility for the Mentally Retarded (ICF/MR). The Home- and Community-Based Services (HCBS) Waiver for the Mentally Retarded and Developmentally Disabled (#0128.90.R2A) provides a wide range of services including in-home, residential care, habilitation, special services and therapies, and health care transportation. The HCBS Waiver for Persons With Mental Retardation (#0357.90) who are class members of one of the settlement agreements. On July 17, 2001, CMS imposed a moratorium on new community placements in the HCBS Waiver for the mentally retarded and the developmentally disabled. The moratorium was based on a CMS review, which found that Tennessee had not met its obligations to protect the health and safety of waiver participants. In March 2003 CMS imposed a moratorium on new admissions to the HCBS Waiver for Persons with Mental Retardation. It is anticipated that the moratoriums will be lifted in March 2005.

Provider Manual, Appendix I Tuberculin Skin Testing Policy (DOH) Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

H-2

TUBERCULOSIS ELIMINATION PROGRAM STATE OF TENNESSEE DEPARTMENT OF HEALTH CORDELL HULL BUILDING, FORTH FLOOR 425 5TH AVENUE NORTH NASHVILLE, TN 37247

TUBERCULIN SKIN TESTING POLICY JANUARY 1, 2004

While tuberculosis (TB) remains a serious public health threat, the incidence of TB in the United States and Tennessee has decreased to an all-time low. In addition, the epidemiology of TB has dramatically changed in that TB disease now occurs predominately among groups with certain risk factors. These risk factors include birth or residence in a county where TB is common, HIV infection, homelessness, residence or employment at a correctional facility, residence or employment in a long term care facility, and use of injection drugs. In 2000, the Centers for Disease Control and Prevention (CDC) changed its approach to tuberculosis (TB) screening and testing. The previous TB screen-all strategies have been replaced by targeted tuberculin testing of high-risk persons who would benefit from treatment to prevent this disease. Targeted tuberculin testing of high-risk populations is an effective TB control strategy that focuses TB screening and prevention efforts on groups in greatest need for these services. Under these new CDC guidelines, testing of low-risk occupational groups for administrative purposes (i.e. school teachers and bus drivers, childcare workers, adult day home workers, food handlers) is discouraged. Tuberculin testing of persons without a specified TB risk factor is low yield and may result in a falsely positive test result that could lead to the inappropriate treatment with potentially toxic TB medications.

Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

I-1

Based on the above current CDC recommendations, the Tennessee Department of Health has instituted a policy that targeted tuberculin testing of high-risk persons be performed statewide, and that tuberculin testing of low-risk groups be discouraged. Under this policy, tuberculin testing should only be performed for the following person at higher risk for exposure to or infections with TB: Close contacts of a person known or suspected to have TB Foreign-born persons from areas where TB is common Health care workers who serve high-risk clients Mycobacterial laboratory workers Persons with HIV infections or AIDS Persons with medical conditions that place them at high-risk Person who inject illegal drugs Residents and staff or volunteer workers in high-risk congregate settings (alcohol and drug rehabilitation or methadone maintenance centers, homeless shelters, correctional facilities, mental health facilities, and long-term care facilities) Children under 18 years of age exposed to adults in high risk categories Homeless persons Residence or prolonged travel in a country where TB is common Other high-risk populations as locally defined by the Department of Health

Modified December 7, 2003

Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

I-2

APPENDIX J ADVANCE PSYCHIATRIC DIRECTIVES

If you are concerned that you may be subject to involuntary psychiatric commitment or treatment at some future time, you can prepare a legal document in advance to express your choices about treatment. The document is called an advance directive for mental health decision-making. Templates to prepare such a directive are available at www.bazelon.org. These templates may be used to: Tell a doctor, institution or judge what types of confinement and treatment you do or do not want; and/or Appoint a friend or family member as agent to make mental health care decisions for you if you are incapable of making them yourself. What are the advantages of a psychiatric advance directive? If you expect to need mental health treatment in the future and believe that you might be found incompetent to make your decisions at that time: An advance directive empowers you to make your treatment preferences known. An advance directive will improve communication between you and your physician. It can prevent clashes with professionals over treatment and may prevent forced treatment. Having an advance directive may shorten your hospital stay.

Will a psychiatric advance directive be legally binding? While advance directives for health care have been around a long time, their use for psychiatric care is a very new area of law. We do not yet know how courts will deal with them, especially when safety issues arise. State laws vary and it is possible that part or all of the document will not be effective in Tennessee. However, many mental health consumers who are now using these documents find that an advance directive increases the likelihood that doctors, hospitals, and judges will honor their choices. Please note that the template forms do not constitute legal advice. Before you assume that the advance directive you create using any or all of the forms will be legally valid in Tennessee, you should consult an attorney. Where can I get legal advice about advance directives? Tennessee Protection and Advocacy (www.tpainc.org) may be able to tell you about requirements or refer you to an attorney who can.
Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005 J-1

J
Do I have to appoint an agent? That depends on the law in Tennessee. In some states, you may set up an advance directive without appointing a person to act for you. In most states, however, an advance directive for psychiatric care is only valid if you have named an agent. The Bazelon Centers study of advance directives suggests that these tools are much more likely to be honored by providers when an agent has been appointed. It is strongly advised that consumers name an agency whenever possible. If you appoint an agent, it should be someone you trust. You can direct your agent to present the choices you have expressed in your advance directive. You can also authorize him or her to make other decisions about your care that are not in your directive. Alternatively, you can appoint an agent without giving any written instructions, but if you do this, you should clearly explain what your wishes are so he or she can advocate effectively on your behalf. The templates include a provision that your agents decisions about mental health treatment would prevail even if a court appoints a guardian or conservator for you. Additional Information is available through the Bazelon Centers website. On the website version of this page at www.bazelon.org/issues/advancedirectives/index.htm, you will find links to a number of materials. An analysis of state statutes related to advance directives for mental health care, see Advance Directive for Mental Health Care: An Analysis of State Statutes, an article by Robert D. Fleishner, and a bibliography of cases and materials on advance directives for people with mental illness, both available at www.napas.org. Two articles on Advance Directives on the National Empowerment Center website, www.power2u/selfhelp: Making Advance Directives Work for You by Daniel Fisher, M.D., Ph.D.; and Advance Directives Are What You Make Them by Xenia Williams.

Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

J-2

APPENDIX K THE BEHAVIOR SUPPORT PLAN FORMAT

Considered in the determination and preparation of a Behavior Support Plan are the following: 1) Frequency, intensity, and duration of the target behaviors that present a health or safety risk to the individual or others or that significantly interferes with home or community activities; 2) Level of risk of the target behaviors to self and others; 3) Input from the individual regarding the function of the behaviors and alternative ways to interact with the environment and what interventions may work/not work; 4) Input from the planning team regarding their views on the functions of the behaviors, alternative behaviors, views on interventions that are working/not working, and reaction to proposed interventions; and 5) Input from direct support professionals regarding their views on the functions of the behaviors, alternative behaviors, views on interventions that are working/not working, reactions to the proposed interventions, including their comments on ability to implement the proposed interventions.

The following are specific requirements for all Behavior Support Plans: 1) The plan must be written by a behavior analyst or a behavior analyst in conjunction with a behavior specialist. The behavior analyst retains overall responsibility and clinical oversight for the plan and its implementation. 2) The author must consider input from the planning team and others who have direct experience with the person. The plan should contain a listing of the names of people who had input in the development of the plan, including the individual and direct support professionals. 3) The least intrusive and effective planned behavior intervention that supports the person in decreasing target behaviors and increasing alternative replacement behaviors must be used.

The plan has two sections: 1) Behavior analysis and technical assessment; and 2) What I Do to Carry Out this Plan
Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005 K-1

K
1) Behavior Analysis and Technical Assessment Technical reports used in developing the plan, such as the Behavior Services Assessment Report, functional assessment data, competency checklists to assess staff skills, and other technical documents, shall be in this section. These documents or narratives are separate from the specific document that describes what staff is to do. The behavior analysis and technical assessment section must include at least the following: a) A functional assessment, including the hypothesized functions of the behavior and treatment rationale; b) Behavioral definitions of target and replacement behaviors; c) Specific, measurable, time-limited behavior change objectives, that are used to determine treatment progress, service effectiveness, and criterion for transitioning to a behavior maintenance plan; d) Overview of procedures; e) A description of risk/benefits of the procedures; f) A description of how the plans effectiveness will be assessed and reported; g) A discussion of what, if any impact the plan will have on the persons rights; h) A description of staff training protocols and methods to document, including frequency of checks on correct staff implementation (reliability) of the plan; i) A description of what the indicators are for transitioning to a behavior maintenance plan.

2) What I Do to Carry Out this Plan This section describes what staff should do to implement the plan. This is a separate section. This section should provide information in clear language and avoid technical jargon. It should include a brief reminder/take home sheet for staff to carry and which briefly describes what staff are to do to carry out the plan. The What I Do to Carry Out this Plan section must include at least the following labeled sections: a) Do this to increase behavior (list the replacement behavior, and what to do)
Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005 K-2

K
b) Do this to decrease behavior (list the target behavior, and what to do) c) Do this to respond to a crisis (as applicable, list what to do) d) Do not do this (as applicable, what staff should not do) e) Write this down (what documentation/data recording needs to be done) f) Necessary approvals and consent must be obtained prior to implementation. The implementation of a Behavior Support Plan must occur in a timely fashion. Implementation is defined as direct support professionals are carrying out the procedures required in the behavior support plan.

Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

K-3

APPENDIX L PROTOCOL FOR REQUEST FOR VARIANCE

This protocol is the procedure to be followed when approved behavior analysts are requesting a variance from the current behavior policies given a person's unique needs. 1) A variance shall only be considered as based on an individual's needs. No variance shall be granted for an agency to apply the variance to general agency procedures. 2) The variance must be incorporated into a written intervention plan (Behavior Support Plan) for which an approved behavior analyst has oversight. Justification for the variance should be clearly stated. An associate behavior analyst (behavior specialist) may help to construct the intervention plan, but an approved behavior analyst would be required to be ultimately responsible for the plan. 3) The written intervention plan must be reviewed and approved by the Circle of Support, including the individual and the guardian or conservator, if applicable. 4) The written intervention plan must be reviewed and approved by any properly constituted local behavior support and human rights committees. 5) The written intervention plan must be reviewed and approved by the Regional Behavior Support Committee and the Regional Human Rights Committee. 6) The written intervention plan must be reviewed and approved by the State Behavior Analyst Coordinator. 7) The written intervention plan must receive final authorization from the Deputy Commissioner for Mental Retardation Services or designee.

Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

L-1

APPENDIX M BEHAVIOR ASSESSMENT REPORT

This appendix describes in more detail the information needed to be included in a Behavior Assessment. A Behavior Assessment Report is a Clinical Service Assessment completed by a behavior analyst. It shall include the items required for all Clinical Service Assessments (see Chapter 12) and specific information relevant to a behavior assessment completed by a behavior analyst. The behavior assessment provides the team with a functional assessment of behavior(s) relevant to the reason for referral and recommended behavior interventions, as applicable. The functional assessment shall include an analysis of the possible level of influence or relationship, if any, medical, psychological/psychiatric, sensory, social environment, physical environment, staff behavior, and quality of life issues that might be important in influencing the behaviors of interest. A reinforcer assessment shall also be included. A variety of information sources should be collected/reviewed, including direct observations, staff interview and data, previous and current interventions and treatment, and assessment reports of relevant professionals. A set of recommendations regarding behavior analyst services and behavior specialist services, as determined by the level of behavioral need, and including justification for the scope, amount, duration, and frequency of the recommended services. Recommendations may also include suggestions to the team regarding the importance of considering referrals to other professionals A behavior analyst writes the report in clear language. All Clinical Service Assessment Reports, including the behavior assessment report must include the following information: 1) The reason for referral. 2) Relevant service recipient preferences and outcomes (for behavior assessment, this would include the reinforcer assessment). 3) Pertinent health history and current health status 4) Documentation of information and findings from interviews with the service recipient, family, legal representatives, the support coordinator or case manager, and support staff regarding behavior related issues, concerns, capacity, and other information.
Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005 M-1

5) Documentation of information and findings from review of relevant service recipient records 6) Documentation of assessment/evaluation and findings related to applicable clinical parameters (for behavior assessments this would include direct observation of the behaviors of interest, data collection and evaluation, analysis of staff interviews, functional analysis as appropriate, behavior rating scales as appropriate, and reinforcement assessment). 7) Identification of risk factors or health safety issues that might relate to the behaviors (for behavior assessment this would include an analysis of the benefits derived from the proposed interventions and a determination of the benefits relative to any risks). 8) Evaluation of functional potential (for behavior assessment this would include a review of the factors that will be important in promoting the successful implementation of the proposed plan and what successful implementation will mean for the individuals success in the community). 9) Identification of any equipment needs (for behavior assessments this would include protective equipment). 10) Presentation of the comprehensive clinical analysis of the information compiled to justify the scope, amount, duration, and frequency of the services recommended. 11) Recommendations. 12) Proposed actions, goals, or outcomes to be included in the ISP, if services are recommended 13)The signature of the clinical service practitioner and credentials with the date the assessment was completed.

Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

M-2

APPENDIX N BEHAVIOR PROVIDER QUALIFICATIONS

A DMRS Approved Behavior Analyst is a professional providing behavior services independently who has been approved to provide services through the Operational Administrative Agency. The provider meets the qualifications listed below and has at least one of the credentials listed. QUALIFICATIONS 1) Completion of at least a Masters degree in behavior analysis, psychology, special education, or related field; 2) A minimum of 12 credit hours of graduate level course work in behavior analysis; courses must have focus on teaching of behavior analysis, rather than more generic topics in the discipline for which the graduate degree was awarded. The courses should address the following issues in applied behavior analysis: ethical considerations; definitions, characteristics, principles, processes and concepts; behavioral assessment and the selection of intervention strategies and outcomes; experimental evaluation of interventions; measurement of behavior and displaying/interpreting behavioral data; behavioral change procedures and systems support (Adapted form the Behavior Analyst Certification Board ); and 3) A minimum of six months full-time supervised employment (or internship/practicum) in behavior analysis under the supervision of a behavior analyst. Supervision minimally consists of face to face meetings for the purposes of providing feedback and technical consultation at least once per week. Behavior analysts with the following credentials will be deemed as acceptable supervisors for an applicant who wishes to meet these criteria: Board Certified Behavior Analyst; TN Licensed Practicing Psychologist with practice in behavior analysis and therapy; TN Licensed Senior Psychological Examiner with practice in behavior analysis and therapy; DMRS Approved Behavior Analyst. CREDENTIALS 1) Licensed in the State of Tennessee for the independent practice of psychology; 2) A Qualified Mental Health Professional licensed in the State of Tennessee with a scope of practice to include behavior analysis; or 3) A certified behavior analyst, certified by the Behavior Analyst Certification Board (BCBA)
Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005 N-1

N
A DMRS Approved Behavior Analyst (Provisional/Time-Limited) is a professional providing behavior services independently who does not have one of the above credentials and has been approved to provide services through the Operational Administrative Agency based upon the qualifications below. The approval status shall remain for three years at which time the individual shall have achieved at least one of the above credentials or will no longer retain the status of DMRS Approved Behavior Analyst. The provider must meet the qualifications listed below: 1) Completion of at least a Masters degree in behavior analysis, psychology, special education, or related field; 2) A minimum of 12 credit hours of graduate level course work in behavior analysis; courses must have focus on teaching of behavior analysis, rather than more generic topics in the discipline for which the graduate degree was awarded. The courses should address the following issues in applied behavior analysis: ethical considerations; definitions, characteristics, principles, processes and concepts; behavioral assessment and the selection of intervention strategies and outcomes; experimental evaluation of interventions; measurement of behavior and displaying/interpreting behavioral data; behavioral change procedures and systems support (Adapted form the Behavior Analyst Certification Board ); and 3) A minimum of six months full-time supervised employment (or internship/practicum) in behavior analysis under the supervision of a behavior analyst. Supervision minimally consists of face to face meetings for the purposes of providing feedback and technical consultation at least once per week. Behavior analysts with the following credentials will be deemed as acceptable supervisors for an applicant who wishes to meet these criteria: Board Certified Behavior Analyst; TN Licensed Practicing Psychologist with practice in behavior analysis and therapy; TN Licensed Senior Psychological Examiner with practice in behavior analysis and therapy; DMRS Approved Behavior Analyst. A DMRS Approved Behavior Specialist is a professional providing behavior services with a limited scope of practice that has been approved to provide services through the Operational Administrative Agency, meets the listed qualifications and has the following credential. 1) Completion of a Bachelor's degree in one of the behavioral sciences or in an alternative discipline, and acceptable field work and experience equivalent to one year of full-time behavioral therapy or behavioral modification for the behavioral sciences or two years for those with a degree in an alternative discipline. 2) Certification by the Behavior Analyst Certification Board (BACB) as an Associate Behavior Analyst. A DMRS Approved Behavior Specialist (Provisional/Time Limited) is a professional providing behavior services with a limited scope of practice who has been approved to
Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005 N-2

provide services through the Operational Administrative Agency, and meets the qualifications listed below, but has not achieved the credential of Associate Behavior Analyst. 1) Completion of a Bachelor's degree in one of the behavioral sciences or in an alternative discipline, and acceptable field work and experience equivalent to one year of full-time behavioral therapy or behavioral modification for the behavioral sciences or two years for those with a degree in an alternative discipline.

Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

N-3

APPENDIX O PROCESSING A CRISIS PREVENTION PLAN

Crisis prevention plans for behavioral crises should be integrated with other relevant plans in order to be effective within the existing environment. If a behavior support plan or a behavior maintenance plan is developed, the behavior plans and the crisis plan need to be integrated. The following are specific requirements for crisis prevention plans: 1) Description of the individual behaviors that are components of a behavioral crisis; 2) Behaviors or situations likely to trigger a crisis; 3) What staff should do to prevent a crisis; 4) What staff should do if a crisis does occur; 5) De-escalation strategies; 6) Emergency crisis management procedures that are to be considered for the individual (e.g., escort techniques, manual restraint); 7) Emergency medical services, including psychiatric in-patient facilities that may be available and when to access; 8) Additional information in the plan or in attachments, that may be included: a) b) c) d) e) Psychiatric diagnosis; Other medical diagnosis; Current medications and dosages; Allergies; and Other relevant medical information.

9) An emergency consultation phone sequence for staff to follow to get guidance on situations that are not explained or planned for in the crisis prevention plan. a) The phone sequence should include descriptors that help staff know who to call first and under what circumstances the person should be called. b) The phone sequence should begin with the local on-call administrator and be sequenced so that providers most familiar with the environment and situation are contacted first.
Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005 O-1

c) If the situation is resolved there is no need to move down the list of phone numbers. Roles and responsibilities of the behavior service provider(s) in crisis support should be defined. 1) The defined responsibilities include descriptions of the level of the phone sequence at which the local administrator on-call contacts the local behavior analyst or behavior specialist. 2) It should be clarified under what circumstances the behavior analyst or behavior specialist will make an on-site assessment. 3) It should be clarified under what circumstances will the local on-call administrator contacts the regional on-call administrator for contacting Regional Office behavior staff. 4) If the behavior service provider provides emergency assistance or emergency consultation, a report is completed within 48 hours and forwarded to the ISC. The report describes the circumstances of the consult and any recommendations to help prevent a future crisis. 5) The report should be attached to the next Service Note following the emergency crisis support. The behavior analyst or a behavior analyst in conjunction with a behavior specialist determines the minimum number of staff that need to be trained to adequately implement the crisis prevention plan. 1) A behavior specialist, if available, may be an authorized trainer. 2) If no staff are available to become authorized trainers, the behavior analyst is responsible for training staff to implement the guidelines. If it is necessary to receive an emergency consultation by the behavior service provider to respond to situations not described on the crisis prevention plan, the ISC shall facilitate a team discussion to review the circumstances and to discuss whether there are any adjustments to the crisis prevention plan. The behavior service provider responding to the emergency consultation call should be involved in the discussion.

Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

O-2

APPENDIX P RESTRAINTS AND PROTECTIVE EQUIPMENT

1) Staff should be aware of proactive and reactive strategies for recognizing, preventing, and minimizing the intensity and risk factors presented by an individuals behavior. 2) Staff should be aware of proactive and reactive strategies and other procedures which may be located in the Independent Support Plan, the agency General Crisis Plan, the Crisis Prevention Plan, a Behavior Support Plan, or a Behavior Maintenance Plan as applicable. 3) If specific proactive and reactive strategies are in place, the direct support professionals shall follow these procedures with the intent of preventing a difficult situation that may become a dangerous situation. 4) Emergency procedures may be considered for individuals who are continuously presenting a high risk of danger to self and others and for which the prescribed proactive and reactive strategies are not effectively protecting the person or others. 5) Also, in unusual circumstances, an individual who does not have a pattern of behavior incidents may unexpectedly carry out high risk behaviors that present an imminent danger to self and others. 6) Emergency procedures may be necessary to protect the person or others. 7) If an emergency situation places the individual and/or others in imminent danger of harm and no alternative strategies have been successful in reducing the danger, the provider agency staff may have no other alternative but to apply emergency procedures to immediately manage the situation. These emergency procedures are emergency manual restraint, emergency mechanical restraint, and emergency protective equipment. a. Where possible, the staff should contact the provider agency director, behavior service provider, or designee when behaviors are escalating, to discuss the behavior issues, any alternative measures, and the possible use of emergency procedures. b. If emergency manual restraint, emergency mechanical restraint, or emergency protective equipment is used, the provider agency director or designee, the behavior service provider, and any other staff designated by the agency shall be immediately contacted to:
Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005 P-1

i. Review the current situation; and ii. Authorize the continued use of emergency manual restraint, emergency mechanical restraint, or emergency protective equipment; or iii. To not authorize the continuation of the emergency procedure and to instruct staff to stop the procedure; or iv. To provide alternative instructions to staff. c. Authorization for emergency manual or emergency mechanical restraint shall be required for each emergency use. d. Authorization for protective equipment may be for any specified time period appropriate to the individual circumstance but shall not exceed 24 hours. e. If there is an authorization for the emergency procedures, the provider agency director or designee, with the assistance of other professionals as needed, shall specify the criteria for release from restraint or protective equipment and the maximum duration of continuous application. f. The provider agency director or designee must ensure that staff are capable of correctly applying the emergency manual restraint, emergency mechanical restraint, or the emergency protective equipment. g. Emergency use of manual restraint, mechanical restraint, or protective equipment constitutes a reportable incident, and must comply with procedures detailed in the Provider Manual. h. The independent support coordinator shall be notified of each us of emergency manual restraint, emergency mechanical restraint, or emergency protective equipment within one working day. The independent support coordinator shall coordinate any needed actions. i. The agency Incident Review Committee shall review all uses of restraint or protective equipment according to the procedures detailed in the Provider Manual. Programmatic Use of Restraint or Protective Equipment 1) The behavior analyst assesses the level of behavior need and risk factors, and completes additional assessments to determine the intervention approach to achieve a behavior change objective. a) The behavior analyst consults with the planning team regarding his or her assessments and recommendations. b) If the programmatic use of manual restraint, mechanical restraint, or protective equipment is viewed as a necessary component of the least restrictive, most effective behavioral intervention, and the benefits of incorporating this intervention outweighs the risks, a behavior support plan is developed by the behavior analyst or a behavior analyst in conjunction with a behavior specialist. The behavior analyst shall retain total responsibility for the Behavior Support Plan.

Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

P-2

2) The behavior analyst must include a description of the step-by-step procedures for applying and monitoring restraint or protective equipment (including release criteria and maximum duration) and identification of persons who may authorize the application of restraint or protective equipment in the Behavior Support Plan. The plan must include specific procedures to develop alternative replacement behaviors that will facilitate the phasing out of the manual restraint, mechanical restraint, or protective equipment. 3) The behavior analyst shall present the Behavior Support Plan to the planning team and receive input. 4) The individual, if competent, or the guardian/conservator must give informed consent for the Behavior Support Plan. 5) The behavior analyst must present the plan to a properly constituted Behavior Support Committee and a Human Rights Committee for review and approval prior to implementation. a) Evidence of the planning teams input and acceptance of the plan should accompany the copy of the plan submitted to the Committees. b) A copy of the informed consent should also be attached to the plan submitted to the Committees. 6) Upon receipt of approval by the Committees, the behavior analyst determines the minimal number of staff that need to be trained to adequately carry out the plan and authorizes a trainer who can train staff on the program. a) If a behavior specialist is available, a behavior specialist may be authorized to provide training. b) If no staff is appropriate to be authorized trainers, the behavior analyst will carry out the training of staff to implement the plan. c) Only staff who have been trained to implement the Behavior Support Plan, including the use and application of manual restraint, mechanical restraint, or protective equipment may use these procedures. 7) Programmatic use of restraint or protective equipment constitutes a reportable incident, and must adhere to the current DMRS policies regarding reportable incidents. 8) The independent support coordinator shall be notified of each use of manual restraint, mechanical restraint, or protective equipment within one working day. The independent support coordinator shall coordinate any needed actions. 9) The agency Incident Review Committee shall review all uses of restraint or protective equipment according to the procedures detailed in the Provider Manual.

Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

P-3

10) The behavior analyst shall be responsible for analyzing progress monthly and incorporating that information into the service note. If there are service objectives for a behavior specialist, the behavior specialist shall also complete a service note. a) b) c) The analysis shall include the result of on-site monitoring at least twice a month. The on-site monitoring may be completed by a behavior specialist, if available. This on-site monitoring shall include: i. ii. iii. iv. v. vi. Review of documentation for the plan; Review of the condition of any equipment; Review of the availability of trained staff to implement the Behavior Support Plan; Training of new staff or the retraining of staff, as needed; Information from direct support staff concerning the persons response to the Behavior Support Plan; and Information from the individual about the plan.

d) Copies of the review shall be provided to the ISC and the Regional Office Behavior Analyst Director as part of the service note. The ISC shall share this information with the planning team, the individual, the family, and the guardian/conservator, as applicable. 11) Every 90 days following approval of the plan, the behavior analyst presents information on the progress toward the behavior objectives to the Behavior Support Committee and the Human Rights Committee. Each committee reviews the analysis and makes a determination as to whether the benefits of the manual restraint, mechanical restraint, or protective equipment procedures appears to outweigh the risks and if it is acceptable to continue programmatic use of the procedures.

Application of Restraint 1) Staff applying emergency manual or mechanical restraint shall be trained in the use and application of restraint. a) The agency may designate staff who may carry out this training. b) The provider agency should set up a mechanism for having the training completed, documenting staff competency, and for retraining as needed. c) If needed, technical consultation can be requested from the behavior analyst or behavior specialist. 2) If the manual or mechanical restraint is part of a Behavior Support Plan, the behavior analyst is responsible for authorizing those who can train staff. If a behavior specialist is available, the behavior specialist can be authorized to train other authorized trainers and to train staff as needed. If there is no one who can be authorized to train staff, the behavior analyst will be responsible for the training.
Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005 P-4

P
3) If a mechanical restraint device(s) is used, the person applying such a device(s) must inspect and document that the device is in good repair and is free from tears or protrusions that may cause injury. 4) A person placed in restraint shall be continuously observed for signs and symptoms of adverse effects on his or her health and well being. 5) A designated person, other than the person(s) implementing the restraint procedures (e.g., another direct contact staff member, nurse, supervisor, behavior specialist on site), shall conduct this continuous observation when there are other staff or persons available. The persons condition shall be documented every five (5) minutes that he or she is restrained. 6) If there are no other persons available to provider assistance, the person applying the restraint shall continuously observe and then complete the necessary documentation after the episode has ended. 7) Supervisory and/or nursing/medical personnel shall be promptly notified as needed in the event that there are signs or symptoms of adverse effects resulting from the restraint. 8) Any threats of harm to a persons health or well being shall require immediate release from restraint. 9) The provider agency director or designee must be informed each time restraint is used through the incident reporting process and any other mechanism established by the provider agency. If the restraint is part of the Behavior Support Plan, there may be additional documentation required as part of the Behavior Support Plan. 10) If emergency use, the person shall be released from restraint per the criteria established by the agency director or designee. The agency director may consult with other professionals as appropriate, including the behavior analyst service provider or the behavior specialist service provider, as applicable, regarding release criteria or other actions to take to stabilize the situation. 11) The release criteria established by the agency director or designee must include at least two components: a) A description of the behaviors that should not be occurring at the time of release; and b) The amount of time these behaviors should be absent, not to exceed five (5) minutes of the absence of the behaviors. 12) If the restraint is part of the Behavior Support Plan, the person shall be released from restraint per the criteria established in the Behavior Support Plan.
Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005 P-5

P
13) If the criteria for release from mechanical restraint has not been met within fifty (50) minutes from the time the restraint was first initiated, or if the release criteria from manual restraint has not been met within fifteen (15) minutes, the person must be released from restraint. a) The release ends the specific episode. b) Thus, for emergency restraint use, if it is necessary to use emergency restraint again, that application will have to be authorized. 14) Upon release from manual or mechanical restraint, the person shall be offered the opportunity for motion and exercise, and if appropriate to the situation, the opportunity for food and drink, and attention to personal needs. Application of Protective Equipment 1) Staff applying emergency protective equipment shall be trained in the use and application of the protective equipment. a) The provider agency shall set up a mechanism to have the training completed, documenting staff competency, and for retraining as needed. b) If needed, technical consultation can be requested from the behavior analyst or behavior specialist. 2) If the protective equipment is part of a Behavior Support Plan, the behavior analyst is responsible for authorizing those who can train staff. a) If a behavior specialist is available, the behavior specialist can be authorized to train other authorized trainers and to train staff as needed. b) If there is no one who can be authorized to train staff, the behavior analyst will be responsible for the training. 3) Prior to applying a protective equipment device(s), the person applying such a device(s) must inspect the device to see if it is in good repair and is free from tears or protrusions that may cause injury. a) If the equipment is unsafe, it shall not be used. b) The result of the inspection shall be documented. 4) A person placed in protective equipment shall be monitored for signs and symptoms of adverse effects on his or her health and well being. 5) The persons condition shall be checked and documented at least every fifteen (15) minutes, unless otherwise specified in an approved Behavior Support Plan.

Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

P-6

6) Supervisor and/or nursing/medical personnel shall be promptly notified as needed in the event there are signs or symptoms of adverse effects resulting from the protective equipment. 7) Any threats of harm to a persons health or well being shall require immediate release from the protective equipment. 8) The provider agency director or designee must be informed each time protective equipment is used. 9) Emergency use of protective equipment requires that authorization and release criteria be obtained from the agency director or designee. a) An authorization can be granted for emergency use of protective equipment for up to twenty-four (24) hours. b) The director or designee may consult with other professionals as needed regarding release criteria and alternative strategies. c) The release criteria must include a description of the persons specific behaviors(s) that should not occur before release and/or the conditions that must exist before he or she is released. 10) If the criteria for release from emergency protective equipment has not been met within fifty (50) minutes from the time it was first applied, and there is no risk of imminent danger, then the person must be released to determine if continued application of protective equipment is necessary and to ensure that there are no signs or symptoms of adverse effects resulting from the protective equipment. 11) If the persons behavior, which lead to the application of emergency protective equipment, reoccurs after the initial release, the protective equipment may be reapplied for the authorized time period, not to exceed twenty-four (24) hours if there are no adverse effects resulting from the equipment. 12) If the persons behavior continues to reoccur after the authorized time period, the agency director or designee shall be contacted to consider alternative interventions or to reauthorize application of the emergency protective equipment. 13) Supervisory and/or nursing/medical personnel shall be promptly notified in the event there are signs or symptoms of adverse effects resulting from the protective equipment. 14) A DMRS Reportable Incident Form shall be completed, as well as, any other forms required by the provider agency or the behavior analyst/specialist as described in the Behavior Support Plan. 15) If the use of protective equipment is part of an approved Behavior Support Plan, the person shall be released from protective equipment per the criteria established in the Behavior Support Plan.
Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005 P-7

P
Procedures For Exclusionary Time Out to a Specific Location 1) Exclusionary time out to a specific location is defined as directing an individual to any designated time out location, and requiring the individual to remain in this location without positive reinforcement and other activities for a specified period of time not to exceed fifteen (15) minutes. 2) Rooms specifically designed for time out procedures are prohibited. 3) The time out location shall not include the use of locked doors. 4) Exclusionary time out to a specific location may not be used in emergency situations. 5) The use of exclusionary time out to a specific location must be incorporated into an approved behavior support plan prior to implementation. Variances to the Policy 1) Requests for variances to approved procedures, including use of devices not included in the approved definition list, shall be considered on a case-by-case basis. For instance, a request for a variance may be considered in cases where the requirements of the policy are contraindicated by the behavioral data. 2) A Behavior Support Plan, which incorporates the requested variance, shall be proposed by the behavior analyst. 3) The plan containing the variance must be approved by the planning team and informed consent from the individual or the guardian/conservator must be obtained. 4) The Behavior Support Plan containing the variance must be reviewed and approved by: a) The local Behavior Support Committee and Human Rights Committee (if established); b) The Regional Behavior Support Committee and Human Rights Committee; c) The State Behavior Analyst Coordinator shall submit the plan to the Assistant Deputy Commissioner or designee for final approval; d) The following information shall be included in the proposed plan: i. A description of the variance requested, and the reason for the variance; ii. A description of and data concerning previous interventions attempted; and iii. A time table for how and when the need for a variance will be eliminated.

Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

P-8

5) In exceptional cases, the provider agency director may authorize a one-time, temporary variance during an emergency. The provider agency director shall ensure that: a) The regional director and independent support coordinator are notified within twenty-four (24) hours. b) A Reportable Incident Form is completed. c) Consultation from a behavior analyst is promptly obtained to confer with the planning team concerning needed emergency procedures and crisis prevention strategies.

Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

P-9

APPENDIX Q CLINICAL SERVICE MONTHLY REVIEW FOR BEHAVIOR PROVIDERS

This appendix provides additional information regarding the completion of a Service Note. To be consistent with the terminology in Chapter 12 of the Provider Manual, this will now be referred to as a Clinical Service Monthly Review. Monthly reviews provide a summary of progress toward implementing the clinical service plan of care. A copy is to be submitted to the support coordinator or case manager by the twentieth (20th) calendar day of the month. The Regional Office Behavior Analyst Director or State Director of Behavior Services may request that a behavior provider forward a copy of the Monthly Review to the Regional Office Behavior Analyst Director by the twentieth (20th) calendar day of the month for clinical review and quality assurance. Effective February 17, 2005, the Regional Office requires a copy of the Clinical Service Monthly Review by the twentieth (20th) calendar day of the month. Summarized below is the minimal information to be included in all Clinical Service Monthly Reviews and additions specific to a behavior provider. Item Name of the Service Recipient Dates of Services Provided Identify Behavior Change Objectives or Behavior Maintenance Objectives assessed in the current monthly review. For each objective reviewed indicate progress, no change, achieved. Service Recipients Response to the Service as determined by data and graphical analysis assessed in the current monthly review (include a copy of the graph(s) displaying baseline and current levels of behavior); address behavior change objectives reviewed, and provide clinical interpretations; if applicable, describe possible barriers to effectiveness. Any proposed revisions to behavior plan since previous month Any recommendations for changes to the ISP Number of Visits that were Scheduled/Number of Visits that Occurred
Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

Source Provider Manual 3.14 3.14 Specific to Behavior Services

3.14, with Specific Information for Behavior Services

3.14 3.14 Provider Manual 8.6c

Q-1

Item Number of units approved/ Number of Units Used Explanation: For units of services approved, but not used; Explanation: For scheduled visits missed Statements regarding whether the clinical service plan of care (BSP/BMP) is meeting the service recipients needs Recommendation: continue service, no change; initiate revision, modification, or amendment to the ISP and plan of care Recommendation: continue, reduce, increase service unit or discharge/closure Documentation of staff training planned for the following month Providers signature, credentials, date the review was completed

Source 8.6c

8.6c 8.6c

8.6c 8.6c 8.6c

Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

Q-2

APPENDIX R BEHAVIOR SUPPORT COMMITTEE MINUTES

NAME OF BSC CASE NUMBER CASE DATE RESOLVED MEMBERS PRESENT APPROVAL SIGNATURE(S)

DATE OF MEETING INITIAL MEETING DATE FOR

IDENTIFYING INFORMATION NAME OF THE PERSON ___________________________________________ CASE NUMBER AS APPLICABLE __________________________________________ NAME OF AGENCY ___________________________________________ NAME/TITLE OF PRESENTER ___________________________________________

PURPOSE OF THE REVIEW ___INITIAL REVIEW OF BEHAVIOR SUPPORT PLAN/MAINTENANCE PLAN

___90-DAY REVIEW OF BEHAVIOR SUPPORT PLAN ___ANNUAL REVIEW OF BEHAVIOR SUPPORT PLAN/MAINTENANCE PLAN ___FOLLOW-UP REVIEW TO RESOLVE ISSUES

___OTHER (DESCRIBE) _______________________________________________________________ Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

R-1

Behavior Support Plan Checklist

Acceptable Based Upon Current Professional Practice

R
Follow-up Response Required by Author and Date Needed

Components

Behavior Services Assessment Report, including functional assessment is attached and complete Hypothesized function of behaviors and any details on contributing influences is included(establishing operations) Rationale for selecting the specific, least restrictive interventions is included Objectives of BSP, desired outcomes, criterion for discontinuing the plan are included Baseline graph Proactive (preventative) procedures Replacement behavior procedures Reactive procedures for challenging behaviors Crisis procedures, if applicable, are integrated into the plan Statements describing input (individual; guardian, if applicable; direct support professionals; others) and acceptance of the carrying out the interventions Statements on how the effectiveness of the plan will be measured and that the plan will be adjusted as needed How the consistency of staff intervention or reliability of implementation is to be measured and reported Proposed mechanisms for scheduling implementation training, direct observations, and program monitoring A copy of the material that is given to those who carry out the BSP. It should tell staff what to do, when, and where. If needed, it should tell staff what not to do. It should be written in clear language, and not contain technical terms In the cases of annual or 90-day reviews, there is a description of current assessment of the behavior, graphical data, details on program effectiveness, and recommendations

Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

R-2

R
RESOLUTION ___ APPROVED ___ DISAPPROVED ___ APPROVED CONTINGENT UPON THE LISTED REVISIONS ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ __________________

DESCRIBE ACTIONS NECESSARY FOR RESOLUTION: _____________________________________________________________________________ ________________________________________________________________________ _____ DATE OF FOLLOW-UP (WITHIN THE NEXT 30 DAYS) ________________________________________________________________________ _____

Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

R-3

APPENDIX S HUMAN RIGHTS COMMITTEE MINUTES

NAME OF HRC CASE NUMBER CASE DATE RESOLVED MEMBERS PRESENT APPROVAL SIGNATURE(S) IDENTIFYING INFORMATION NAME OF THE PERSON (CASE NUMBER) __________________________________ NAME OF AGENCY _______________________________________________________ NAME/TITLE OF PRESENTER _____________________________________________ DATE OF MEETING INITIAL MEETING DATE FOR

PURPOSE OF THE REVIEW

___ INITIAL REVIEW OF PSYCHOTROPIC MEDICATION ___ANNUAL REVIEW OF PSYCHOTROPIC MEDICATION ___INITIAL REVIEW OF BEHAVIOR SUPPORT PLAN ___ANNUAL REVIEW OF BEHAVIOR SUPPORT PLAN ___FOLLOW-UP REVIEW TO RESOLVE ISSUE ___RIGHTS ALLEGATION ___RESEARCH PROPOSAL ___OTHER (DESCRIBE)___________________________________________________________________ __________________________________________________________________________________ ________ Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005 S-1

S
RESOLUTION
ISSUES ADEQUATELY ADDRESSED___________________________________________________ ISSUES INADEQUATELY ADDRESSED_________________________________________________ ISSUES ADDRESSED WITH THE FOLLOWING CONDITIONS:_____________________________ DESCRIBE ACTIONS NECESSARY FOR RESOLUTION: __________________________________ DATE OF FOLLOW-UP (WITHIN THE NEXT 30 DAYS) ________________________________

Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

S-2

APPENDIX T SAMPLE UNIVERSAL PRECAUTIONS BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN

OSHA Bloodborne Pathogens Standards. In accordance with the OSHA Bloodborne Pathogens standard, 29 CFR 1910.1030. 1. EXPOSURE DETERMINATION OSHA requires employers to perform an exposure determination concerning which employees may incur occupational exposure to blood or other potentially infectious materials. The exposure determination is made without regard to the use of personal protective equipment (i.e. employees are considered to be exposed even if they wear personal protective equipment). This exposure determination is required to list all job classifications in which all employees may be expected to incur such occupational exposure, regardless of frequency. In addition, OSHA requires a listing of job classifications in which some employees may have occupational exposure. Since not all the employees in these categories would be expected to incur exposure to blood or other potentially infectious materials, tasks or procedures that would cause these employees to have occupational exposure are also required to be listed in order to clearly understand which employees in these categories are considered to have occupational exposure. The job classifications and associated tasks for these categories are as follows: B CLASSIFICATIONS TASK/PROCEDURES Home Manager Changing depends, pads Residential Assistant Assisting the consumer in the bathroom or public Day Services Staff restroom Cleaning home/bathroom Medication Administration Performing CPR & First Aid

2. IMPLEMENTATION SCHEDULE AND METHODOLOGY OSHA also requires that this plan also include a schedule and method of implementation for the various requirements of the standard. The following complies with this requirement:

Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

T-1

COMPLIANCE METHODS Universal precautions will be observed in this program in order to prevent contact with blood or other potentially infectious materials. All blood or other potentially infectious material will be considered infectious regardless of the perceived status of the source individual. Engineering and work practice controls will be utilized to eliminate or minimize exposure to employees at this facility. Where occupational exposure remains after institution of these controls, personal protective equipment shall also be utilized. At this facility the following engineering controls will be utilized: Protective gloves, plastic bags, CPR masks, dust pan or tongs. Program Manager shall ensure that the Supportive Living Home shall always have on hand a supply of protective gloves. Plastic bags shall be available for disposal of potentially infectious materials. Shall have a mouth guard in the home first aid kit. Shall have a dust pan or tongs to pick up bloody or other potentially infectious materials. The above controls will be examined and maintained on a regular schedule. The schedule for reviewing the effectiveness of the controls is as follows: Schedule Inventory supplies monthly Responsible Party Program Manager/House Manager

Hand washing facilities are also available to the employees who incur exposure to blood or other potentially infectious materials. OSHA requires that these facilities be readily accessible after incurring exposure. At this home hand washing facilities for this program site are located: Site bathroom

Alternatives to hand washing facilities are provided: Alternative Sink Location Kitchen

After removal of personal protective gloves, employees shall wash hands and any other potentially contaminated skin area IMMEDIATELY or soon as feasibly possible with soap and water.

Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

T-2

If employees incur exposure to their skin or mucous membranes then those areas shall be washed or flushed with water as appropriate as soon as feasibly possible following contact. NEEDLES Contaminated needles and other contaminated sharps will not be bent, recapped, removed, sheared or purposely broken. OSHA allows an exception to this if the procedure would require that the contaminated needles be recapped or removed and no alternative is feasible and the action is required by the medical procedure. If such action is required then the recapping or removal of the needle must be done by the use of a mechanical device or a one handed technique. At this facility recapping or removal is only permitted for the following procedures: (List the procedure and also list the mechanical device to be used or alternately if a one handed technique will be used. Procedure Not Applicable CONTAINERS FOR USED SHARPS (NEEDLES) Contaminated sharps are not to be re-capped. They are to be placed immediately, or as soon as possible after use into an appropriate sharps container. At this facility the sharps containers are puncture resistant, labeled with a biohazard label, and are leak proof. Sharps containers are located in the places listed below. Individuals responsible for removing sharps from containers and how often the containers will be checked are indicated as well. Location Frequency Checked No sharps in this home. Responsible Party Mechanical Device

WORK AREA RESTRICTIONS In work areas where there is a reasonable likelihood of exposure to blood or other potentially infectious materials, employees are not to eat, drink, apply cosmetics or lip balm, smoke, or handle contact lenses. Food and beverages are not to be kept in refrigerators, freezers, shelves, cabinets or on counter tops or bench tops where blood or other potentially infectious materials are present. All procedures will be conducted in a manner which will minimize splashing, spraying, splattering, and generation of droplets of blood or other potentially infectious materials. Methods which will be employed at this home to accomplish this goal are:
Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005 T-3

T
Depends/Pads Depends and or pads or other potentially infectious materials will be placed in a plastic container lined with a plastic bag which prevents leakage during the collection, handling, processing, storage and transport of the items. The container used for this purpose will be labeled or color coded in accordance with the requirements of the OSHA standard. If outside contamination of the primary container occurs, the primary container shall be placed within a secondary container (clean plastic bag) which prevents leakage during the handling, processing, storage, transport or shipping of the specimen. CONTAMINATED EQUIPMENT Equipment which has become contaminated with blood or other potentially infectious materials shall be visually examined and if need will be decontaminated as necessary unless the decontamination of the equipment is not feasible. PERSONAL PROTECTIVE EQUIPMENT All personal protective equipment used at this home will be provided without cost to employees. Personal protective equipment will be chosen based on the anticipated exposure to blood or other potentially infectious materials. The protective equipment will be considered appropriate only if it does not permit blood or other potentially infectious materials to pass through or reach the employees clothing, skin, eyes, mouth or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used. The protective clothing listed below will be provided to employees for the indicated tasks: PERSONAL PROTECTIVE EQUIPMENT Gloves Mouth Guard Goggles Mask Med Administration Dust pan or tongs TASK Toileting Assistance CPR Eye Protection Respiratory Protection Med cups Picking up materials

Distribution of protective clothing and devices will be coordinated by: Home Manager
Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005 T-4

T
All personal protective equipment will be cleaned, laundered and disposed of by the employer at no cost to the employees. All repairs and replacements will be made by the employer at no cost to employees. All garments which are penetrated by blood shall be removed immediately or as soon as feasibly possible. All personal protective equipment will be removed prior to leaving the work area. Gloves shall be worn where it is reasonably anticipated that employees will have hand contact with blood, other potentially infectious materials, non-intact skin and mucous membranes. Gloves will be available from supply in bathroom, kitchen and consumer rooms. Disposable gloves used are not to be washed or decontaminated for re-use and are to be replaced as soon as practical when they become contaminated or as soon as feasibly possible if they are torn, punctured or when their ability to function as a barrier is compromised. Utility gloves may be decontaminated for re-use provided that the integrity of the glove is not compromised. Utility gloves will be discarded if they are cracked, peeling, torn, punctured or exhibit other signs of deterioration or when their ability to function as a barrier is compromised. Masks in combination with eye protection devices, such as goggles or glasses with solid state shield, or chin length face shields are required to be worn whenever splashes, spray, splatter or droplets of blood or other potentially infectious materials may be generated and eye, nose or mouth contamination can reasonably be anticipated. Situations at this home which would require such protections are as follow: All sites will be equipped with masks and goggles. This OSHA standard also requires appropriate protective clothing to be used such as lab coats, gowns, aprons, clinic jackets or similar outer garments. The following situations require that protective clothing be utilized: Not applicable This site will be cleaned and decontaminated according to the following schedule: When a spill occurs Decontamination will be accomplished by utilizing the following materials: Bleach based cleaning solution, ie Clorox Clean-up All contaminated work surfaces will be decontaminated after completion of procedures and immediately or as soon as feasibly possible after any spillage of blood or other potentially infectious materials, as well as at the end of the work shift if the surface may have become contaminated since the last cleaning. The following special precautions shall be taken when decontaminating work surfaces at this location: Clean immediately with a bleach based cleaning solution

Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

T-5

All bins, pails, cans and similar receptacles shall be inspected and decontaminated on a regularly scheduled basis as detailed below: Items for Routine Inspection & Decontamination Bathrooms will be inspected daily for cleanliness Responsible Party Home Manager Residential Assistant

Any broken glassware which may be contaminated will not be picked up directly with hands. The following procedures will be used: Sweep floor with broom and dust pan and clean with sanitized bleach based solution REGULATED WASTE DISPOSAL All contaminated sharps shall be discarded as soon as feasibly possible in sharps containers which are located in the facility. Sharps containers are located in: Not applicable Regulated waste other than sharps shall be placed in appropriate containers. Such containers are located in: Not applicable

LAUNDRY PROCEDURES Laundry contaminated with blood or other potentially infectious materials will be handled as little as possible. Such laundry will be place in appropriately marked bags at the location where it was used. Such laundry will not be sorted or rinsed in the area of use. All employees who handle contaminated laundry will utilize personal protective equipment to prevent contact with blood or other potentially infectious materials. Laundry for this program will be cleaned in home washing machine. The washing machine drum should be cleaned between uses with Clorox wipes or a bleach based solution such as Clorox Clean-up. HEPATITIS B VACCINE All employees who have been identified as having exposure to blood or other potentially infectious materials will be offered the Hepatitis B vaccine at no cost to the employee. The vaccine will be offered within 10 working days of their initial assignment to work involving the potential for occupational exposure to blood or other potentially infectious materials unless the employee has previously had the vaccine or who wish to submit to antibody testing which shows the employee to have sufficient immunity.

Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

T-6

Employees who decline the Hepatitis B vaccine will sign a waiver specifying that choice. The offer of the Hepatitis B vaccine is made during orientation by the Human Resources representative who informs employees about how to obtain the vaccination. Employees who initially decline the vaccine but who later wish to have it may then have the vaccine provided at no cost. POST-EXPOSURE EVALUATION AND FOLLOW UP When the employee incurs an exposure incident, it should be reported to: Home Manager and Director on a critical incident form. All employees who incur an exposure incident will be offered post-exposure evaluation and follow up in accordance with the OSHA standard. This follow-up will include: Documentation of the route of exposure and the circumstances related to the incident. If possible, the identification of the source individual and if possible, the status of the source individual will be tested (after consent is obtained) for HIV/HBV infectivity. Results of testing of the source individual will be made available to the exposed employee with the exposed employee informed about the applicable laws and regulations concerning disclosure of the identity and infectivity of the source individual. The employee will be offered the option of having their blood collected for testing of the employee HIV/HBV serological status. The blood sample will be preserved for up to 90 days to allow the employee to decide if the blood should be tested for HIV serological status. However, if the employee decides prior to that time that testing will or will not be conducted then the appropriate action can be taken and the blood sample discarded. The employee will be offered post exposure prophylaxis in accordance with recommendations of the U.S. Public Health Service. The employee will be given appropriate counseling concerning precautions to take during the period after the exposure incident. The employee will also be given information on what potential illnesses to be alert for and to report any related experiences to appropriate personnel. The following person has been designated t assure that the policy outlined is effectively carried out as well as to maintain records related to this policy: INTERACTION WITH HEALTH CARE PROFESSIONALS A written opinion shall be obtained from the health care professional who evaluates employees of this facility. Written opinions will be obtained in the following circumstances: 1. When the employee is sent to obtain the Hepatitis B vaccine.
Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005 T-7

2. Whenever the employee is sent to a health care professional following an exposure incident. Health care professionals shall be instructed to limit their opinions to: 1. Whether the Hepatitis B vaccine is indicated and if the employee has received the vaccine or evaluation following an incident. 2. That the employee has been informed of the results of the evaluation and 3. That the employee has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials. (Note that the written opinion to the employer is not to reference any personal information.) TRAINING Training for all employees will be conducted prior to initial assignment to tasks where occupational exposure may occur. Training will be conducted in the following manner: Training for employees will include the following explanation of: 1. The OSHA standard for Bloodborne Pathogens 2. Epidemiology and symptomatology of bloodborne diseases 3. Modes of transmission of bloodborne pathogens 4. This Exposure Control Plan 5. Procedures which might cause exposure to blood or other potentially infectious materials at this facility 6. Control methods which will be used at the facility to control exposure to blood or other potentially infectious materials 7. Personal protective equipment available at this facility and who should be contacted concerning the equipment 8. Post Exposure evaluation and follow-up 9. Signs and Labels used at the facility 10. Hepatitis B vaccine program at the facility RECORD KEEPING: All records required will be maintained by:

DATES: All employees will receive annual refresher training on Universal Precautions/ Bloodborne Pathogens and this Agency Exposure Control Plan.
2. In case of an emergency, such as a fire, do you think you would be able to get out of your house or apartment safely?

Yes 3.

No

In case of an emergency, such as a fire or fall, do you think you could summon help to your home?
T-8

Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

T
Yes Signature of Person Completing Checklist: Copy of Completed Checklist Shared With: No Date:

Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

T-9

APPENDIX U PRINCIPLES OF INFORMED CONSENT IN PSYCHIATRY RESOURCE DOCUMENT

Approved by the Board of Trustees, June 1996 The findings, opinions, and conclusions of this report do not necessarily represent the view of the officers, trustees, or all members of the American Psychiatric Association. Views expressed are those of the authors. --APA Operations Manual. This document was prepared by the APAs council on psychiatry and law. Informed consent has legal, ethical, and clinical dimensions. a) From the legal perspective, it requires physicians to disclose certain classes of information to patients, and to obtain their consent before initiating medical treatment. b) In its ethical dimension informed consent encourages respect for individual autonomy in medical decision making. c) As a clinical process, informed consent offers a mechanism for collaboration between physicians and patients in identifying clinical problems and selecting appropriate treatment. Although legal requirements (which may vary across jurisdictions) define the minimum criteria for an adequate informed consent process, the ways in which they are implemented and the degree to which they are augmented will reflect appropriate concern with ethical and clinical considerations. Of course, psychiatrists should be familiar with the laws in their jurisdiction relevant to informed consent. Legal Principles of Informed Consent The principles governing the law of informed consent can be summarized as follows. 1. In general, informed consent should be obtained from all adult patients prior to the initiation of psychiatric treatment, and from minor patients who are legally authorized to provide consent. For minors who cannot provide consent, it should be obtained from parents or other legal custodians.
Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005 U-1

U
2. Psychiatrists should offer patients or others from whom consent is being obtained information about the nature of their condition, the nature of the proposed treatment, benefits of the proposed treatment, risks of the proposed treatment, and available alternatives to the proposed treatment along with their benefits and risks. 3. Legal standards may require physicians to disclose the information that a reasonable practitioner in a similar situation would disclose (professional standard of disclosure); or the information that a reasonable patient would find material to his or her decision (materiality standard); or may specify exactly which information should be disclosed. 4. Exceptions to disclosure requirements fall into several categories: a. Emergencies: When the time required for disclosure would create a substantial risk of harm to the patient or third parties, full disclosure requirements may not apply. b. Waiver: Patients may waive their rights to receive information. To be meaningful, this should be a knowledgeable waiver, i.e.; patients should be made aware that they have a right to receive the information, to designate a surrogate to receive the information, or to be informed at a later date. c. Therapeutic privilege: Some jurisdictions permit information to be withheld when disclosure per se would be likely to cause harm to patients (e.g., when a patient with an unstable cardiac arrhythmia would have his or her situation exacerbated by the anxiety attendant on full disclosure of the risks of treatment). The harm cannot result from patients decisions not to receive the proposed treatment. This exception must be construed narrowly lest it undermine the general principle of informed consent. d. Incompetence: Incompetent patients may not, as a matter of law, give an effective informed consent. State law generally provides alternative mechanisms by which consent can be obtained, and requires disclosure to a substitute decision-maker. e. Involuntary Treatment: Many states allow psychiatric treatment to occur without patients informed consent when countervailing policy objectives can thereby be achieved. This occurs most commonly when patients refusals of treatment are specifically overridden following clinical, administrative, or judicial review. Some states also make general exceptions in the contest of civil, criminal, or outpatient commitment.
Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005 U-2

U
5. Existence of an exception to disclosure requirements does not necessarily mean that patients do not retain the right to give or withhold consent to treatment. For example, patients retain the right to consent even if they waive their right to disclosure (unless they also waive their right to make a decision and designate an alternative decision-maker) or if therapeutic privilege has been invoked as the basis for limiting disclosure.

Clinical Aspects of Informed Consent Although the law establishes the required dimensions of informed consent, clinical experience suggests the value of augmenting these required practices in several ways, consistent with physicians ethical obligations to respect patients autonomy and to promote their well being. These clinical aspects of informed consent should not be seen as standards to be followed concretely in all situations, but as ideals to be shaped according to the specific circumstances of a patients conditions and treatment. 1. Whatever the governing legal standard of information disclosure, it is desirable for patients to receive that information that they find most relevant to their decisions. This can be accomplished by encouraging patients to ask for additional information after a basic disclosure has taken place. 2. Information disclosure need not occur at a single point in time, but can and often shouldproceed in stages, with additional information provided in an educational manner as patients are able to assimilate it. Ability to assimilate information often improves as patients; symptomsincluding anxious, depressive, and psychotic symptomsbegin to resolve. Periodic re-disclosure should occur when patients conditions, the risks and benefits of treatment, or available alternative treatments change. 3. Even when an exception to requirements for disclosure exists (except in cases of waiver and therapeutic privilege), it is generally desirable for patients to be given as much information as they can assimilate from the usual disclosure. This is true for minors for whom treatment consent is obtained from their parents or guardians, as well as for adults. This practice facilitates physician-patient collaboration in treatment and may permit more knowledgeable participation in and adherence to treatment by the patient. 4. Printed forms may have some value in documenting that disclosure has occurred and that patient consent has been obtained. The information on such forms generally is not a substitute, however, for direct discussion between clinicians and patients. An alternative to the use of forms is for
Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005 U-3

psychiatrists to write a note in patients charts indicating that a consent discussion has occurred and whether consent was obtained. Careful documentation may be valuable in the event of subsequent claims that a valid informed consent was not obtained. Another way in which the law of informed consent can be augmented by clinical experience is when legal principles fail to provide clear guidance from practitioners faced with special problems or issues related to informed consent. Some of these problems may be particularly likely to arise in psychiatric treatment. 5. Incompetence: Some psychiatric patients may lack the capacity to decide about treatment as a result of their disorder. When readily available mechanisms exist for obtaining formal determinations of incompetence and having legally authorized decision-makes appointed, it will usually be desirable that they be pursued. In many instances, however, such mechanisms are not readily available (e.g., no resources exist to initiate legal proceedings for appointment of a substitute decision-maker). This circumstance may leave physicians and patients in a legal gray zone. Patients require care and often acquiesce to proposed treatment. In such cases, psychiatrists might consider pursuing second-best options, including: obtaining consent from patients family members, as typically occurs in general mental practice; involving institutional review committees or patient advocates in authorizing care; obtaining a second physicians opinion prior to proceeding with treatment. Psychiatric facilities, whether inpatient or outpatient, may find it useful to develop defined procedures for responding to these situations, rather than leaving clinicians to devise their own responses. 6. Limited impairments in patients decision-making capacities: Psychiatric patients may exhibit impairments in their decision making that are limited in either extent or duration. a. Extent: Some psychiatric disorders can impair decision-making functions to some extent, but not to the point where patients would be considered legally incompetent. In such cases, clinicians have generally made disclosure in a fashion that takes patients limitations into account. This may include simplifying elements of the disclosure, offering information in smaller amounts stretched out over time, and repeating disclosure several times. The implication of these accommodations to patients impairments is that some patients may be asked to consent to treatment (when it needs to be implemented promptly) before having received a disclosure comparable to that offered to non-impaired persons. This may be the preferred approach when delay in treatment is

Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

U-4

undesirable from the patients perspective and alternative decisionmaking mechanisms are unavailable. Not all disclosures by psychiatrists to patients fall into categories traditionally subsumed under the law of informed consent. This is the case for the issues addressed in Sections 8 and 9 below. 7. Psychotherapy: Informed consent developed in the context of invasive procedures and has since been extended to treatment with medication. There has always been uncertainty as to the extent to which the doctrine of informed consent is applicable to psychotherapy. Although discussions about treatment may fit poorly into some psychotherapeutic approaches, recent changes in practice that emphasize short-term, problem-focused therapies are more accommodating (or even encouraging) of such interactions. Whether or not required by the law, it seems reasonable to encourage psychiatrists to discuss with their patients the nature of psychotherapy, likely benefits and risks (where applicable) and alternative approaches (both psychotherapeutic and non-psychotherapeutic) to their problems. 8. Confidentiality: Psychiatrists have been required by their ethical code to reveal to the patient likely limitations on confidentiality in certain settings. Given the large number of exceptions to the general principle of confidentiality, it does not seem reasonable to ask psychiatrists to disclose them all. Rather, patients should be told at the outset of treatment about risks to confidentiality that are evident to the treating psychiatrist, and should be told in the course of treatment about additional risks as they appear to be relevant to their cases.

The American Psychiatric Association 1400 K Street NW Washington, D.C. 20005 Telephone: (888) 357-7924 Fax: (202) 682-6850 Email: apa@psych.org

Provider Manual, Appendix T Sample Universal Precautions Division of Mental Retardation Services, State of Tennessee Published March 15, 2005

U-5