(DD) Waiver Service Standards - New Mexico Department of Health

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BL. BM. BN. BO. BP. BQ. BR. BS. SUPPORT CONSULTANT. means a licensed professional approved by DDSD/OBS to provide Behavioral Support Consultation services. SUPPORTED LIVING SERVICES. means a Community Living Support service provided in a single residence setting to four (4) or fewer individuals. SUPPORT SERVICES. means activities and assistance (clinical, physical and social) provided to the individual that lead to achievement of his or her vision, and that address individual needs to activities of daily living and safety. STAFF TO INDIVIDUAL RATIO. means the number of individuals an employed staff member or subcontractor is responsible for in terms of caseload, stated as a full-time equivalent in relation to number of individuals. TIMELY IMPLEMENTATION OF HEALTHCARE ORDERS. means immediately for emergency medications or orders, eight (8) hours for initiation of urgent care medication and orders, initiation of prescription pain medication or first antibiotic dose, and twenty-four (24) hours for initiation of routine medications and orders. TIMELY MEDICAL ASSESSMENT. means the amount of time taken to perform assessment so that a good healthcare outcome is achieved for an individual. Emergency situations require that an individual be assessed immediately either by calling 911 or by transport to an emergency room. Urgent situations require that a nurse, physician, or other appropriate healthcare practitioner assess an individual within eight (8) hours. Routine situations require that a nurse, physician or other appropriate healthcare practitioner see the individual as soon as an appointment can be scheduled. UR (ALSO LISTED AS NMMUR). means the utilization review agent of the Human Services Department who may perform such functions as authorizing budgets and Levels of Care; a contract entity with the authority to determine medical necessity and approve Individualized Service Plans (ISPs). VOLUNTEER. means an unpaid individual who carries out service or support activities under the direction of a DD Waiver provider agency. ix
CHAPTER 1 INTRODUCTION These standards apply to all services provided through the Medicaid Home and Community Based Services Waiver programs for individuals with developmental disabilities. These standards interpret, and further enforce the New Mexico Human Services Department (HSD), Medicaid Policy Manual for Developmental Disabilities Home and Community Based Services Waiver (8.314.5) and the Centers for Medicare and Medicaid Services (CMS) requirements for Home and Community Based Services Waivers. Under no circumstances may a parent (or guardian) receive payment for services delivered to their minor child under age eighteen (18). Also, under no circumstances may any individual receive payment for services delivered to their spouse. These standards are effective April 1, 2007, and address each service covered by the Developmental Disabilities (DD) Waiver as renewed in 2006, as well as personnel requirements for people employed by or subcontracting with agencies providing services, known herein as the Provider Agency. The Developmental Disabilities Support Division (DDSD) of the Department of Health (DOH) has established these standards to guide service delivery and promote the health and safety of individuals served by DD Medicaid Waiver Provider Agencies. All Provider Agencies that enter into a contractual relationship with DOH to provide Developmental Disabilities Waiver Services shall comply with all applicable standards herein set forth. These standards acknowledge that many individuals and the families of children served on the DD Waiver programs have the ability to direct his or her own services and supports. However, planning is required to occur through an Interdisciplinary Team (IDT) process, in accordance with the Service Plans for Individuals with Developmental Disabilities Living in the Community (7.26.5 NMAC). Within the IDT process, these standards promote self-determination through flexibility regarding types and amounts of service provided. In addition, new service options to promote community integration for adults with developmental disabilities and services designed specifically for children and their families are available to address each individual’s unique Individual Service Plan (ISP) requirements. I. PROVIDER AGENCY ENROLLMENT PROCESS. A. Applications. All Provider Agency applications, for initial renewal to provide services, shall be made using a Developmental Disabilities Medicaid Waiver Provider enrollment application packet issued by the DOH. The DOH and the Medical Assistance Division of the Human Services Department provide all of the forms. The application shall be dated and signed by an individual authorized to represent the Provider Agency. Provider Agencies requesting to amend their existing provider agreement must submit an amendment form issued by DOH with required supporting documentation. B. Issuance. The DOH will not issue an agreement unless and until the applicant has supplied all information requested by the DOH. C. Types of Provider Agency Agreements. The DOH may authorize any one of the following agreements: (1) A Provider Agency agreement issued for a single fiscal year period that has met all requirements for the provision of a specific service or services; 1
Page 1 and 2: Developmental Disabilities (DD) Wai
Page 3 and 4: Developmental Disabilities (DD) Wai
Page 5 and 6: TABLE OF CONTENTS C. Adult Habilita
Page 7 and 8: TABLE OF CONTENTS V. REQUIREMENTS U
Page 9 and 10: TABLE OF CONTENTS A. Provider Agenc
Page 11 and 12: TABLE OF CONTENTS D. Consultation w
Page 13 and 14: TABLE OF CONTENTS D. Non-Medical Tr
Page 15 and 16: DOH/DDSD (Appendix A) Individual Tr
Page 17 and 18: (b) Emotional, psychological, and p
Page 19 and 20: AD. AE. IDEA. means Individuals wit
Page 21: includes a functional assessment of
Page 25 and 26: (2) On the day a Provider Agency is
Page 27 and 28: provided to the receiving agency wh
Page 29 and 30: G. Transportation. Provider agencie
Page 31 and 32: equires delivery by licensed or cer
Page 33 and 34: F. Sanitation. When services are pr
Page 35 and 36: (6) Report required personnel train
Page 37 and 38: implemented, and return the plan to
Page 39 and 40: (g) Reduction in term of the agency
Page 41 and 42: (10) Non-Medical Transportation; (1
Page 43 and 44: (4) Physical Therapy (limited and w
Page 45 and 46: (l) Non-Medical Transportation; (m)
Page 47 and 48: (3) Service Options in Addition to
Page 49 and 50: age 22 or older who are receiving D
Page 51 and 52: CHAPTER 3 BEHAVIORAL SUPPORT CONSUL
Page 53 and 54: (2) Guide the IDT members in assess
Page 55 and 56: B. Behavioral Support Consultation
Page 57 and 58: (4) All Behavioral Support Consulta
Page 59 and 60: (d) Functional evaluations/assessme
Page 61 and 62: the training is not offered by DDSD
Page 63 and 64: K. Inform the individual of his or
Page 65 and 66: (2) A new history and physical; (3)
Page 67 and 68: of the Case Manager and all IDT mem
Page 69 and 70: (b) A change from a less restrictiv
Page 71 and 72: (b) Case Management Provider Agenci
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for at least 30 hours per week of p
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(c) Bachelor’s or Master’s degr
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its designee and will include the n
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(2) Services furnished to an indivi
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(6) Identification of barriers to i
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(4) Volunteer time in the community
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conservator, physician’s name(s)
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(2) Whenever possible, direct suppo
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(9) Job coaching; (10) Situational
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(6) Individuals are not excluded fr
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Individual Supported Employment, a
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E. Reimbursement. (g) Assess barrie
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service are determined by the indiv
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(6) Community Access Coaching is al
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(10) The individual is provided opp
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(p) Implement recommendations from
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The Adult Habilitation Service Prov
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(25) Development of increased indep
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XV. PROVIDER AGENCY STAFF QUALIFICA
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CHAPTER 6 COMMUNITY LIVING SERVICES
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(4) Internal service coordination.
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(a) Documentation of determination
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(b) That each individual with a sco
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individual’s home and an updated
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G. IDT Coordination. (1) Appropriat
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J. Qualification for Agency Supervi
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(a) At a maximum of two (2) individ
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(2) Up to 1000 hours of substitute
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(15) Handrails, grab-bars, door han
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(5) Written verification that the c
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Funding for adaptations is availabl
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of a work uniform for an employed i
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CHAPTER 9 OUTLIER SERVICES I. OUTLI
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Necessity Outlier services, the ind
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(b) The billable unit for Outlier A
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III. PERSONAL PLAN FACILITATION REQ
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CHAPTER 11 PERSONAL SUPPORT SERVICE
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(4) Personal Support Services may n
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CHAPTER 12 RESPITE SERVICES I. RESP
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(c) Direct Support Staff are requir
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B. Eligibility for Medicaid DD Waiv
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(b) Therapy Provider Agencies shall
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D. Integrating Therapy Strategies i
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(f) An Occupational Therapy Aide/Te
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(3) Designing, building or preparin
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(12) Providing other non-administra
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(2) Collaborative therapy services
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F. Training Family/Support Staff. (
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(b) Relevant background information
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listed in the ISP. The therapy inte
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L. Discontinuation of Services Repo
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(c) Caregiver training and consulta
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(3) In the first year of service or
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G. Attend IDT meetings. H. The Tier
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E. Reimbursement. (e) Required DDSD
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R. Skin care; S. Weight management;
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CHAPTER 16 NUTRITIONAL COUNSELING S
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CHAPTER 17 NON-MEDICAL TRANSPORTATI
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support the planning process. This
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CHAPTER 18 SUPPLEMENTAL DENTAL CARE
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(DD) Waiver Service Standards - New Mexico Department of Health

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