Aging and Disability Services Council Sharon Swift Butterworth ...

deletion] does not meet the medical necessity criteria (MN) for nursing facility care.
(5) [begin addition] HCSSAs [end addition] [begin deletion] Home and community
support services providers [end deletion] have refused to serve the [begin addition] individual
[end addition] [begin deletion] participant [end deletion] on the basis of a reasonable expectation
that the [begin addition] individual's [end addition] [begin deletion] participant's [end deletion]
medical and nursing needs cannot be met adequately in the [begin addition] individual's home
[end addition] [begin deletion] participant's residence [end deletion].
(6) The [begin addition] individual [end addition] [begin deletion] participant [end
deletion] or someone in the individual's [end addition] [begin deletion] participant's [end
deletion] home refuses to comply with mandatory program requirements, including the
determination of eligibility [begin addition] or [end addition] [and/or] the monitoring of service
delivery.
(7) The [begin addition] individual [end addition] [begin deletion] participant [end
deletion] fails to pay [his] room and board expenses or copayment in the adult foster care (AFC)
or assisted living/residential care (AL/RC) setting.
(8) The [begin addition] individual [end addition] [begin deletion] participant [end
deletion] fails to pay [begin addition] the required [end addition] [begin deletion] his [end
deletion] qualified income trust copayment.
(9) The situation, [begin addition] individual [end addition] [begin deletion] participant
[end deletion], or someone in the [begin addition] individual's [end addition] [begin deletion]
participant's [end deletion] home is hazardous to the health and safety of the service provider, but
there is no immediate threat to the health or safety of the [begin addition] service [end addition]
provider.
(10) The [begin addition] individual [end addition] [begin deletion] participant [end
deletion] or someone in the individual's [end addition] [begin deletion] participant's [end
deletion] home openly uses illegal drugs or has illegal drugs readily available within sight of the
service provider.
(b) The supporting documentation [begin addition] submitted by the CBA provider [end
addition] must include a [begin addition] detailed [end addition] description of the interventions
[begin addition] attempted by the CBA provider [end addition] [begin deletion] that have
occurred [end deletion] prior to [begin addition] deciding [begin deletion] the decision [end
deletion] to recommend the [begin addition] termination [end addition] [begin deletion] denial
[end deletion] of [begin addition] CBA [end addition] services. The documentation must justify
the reasons for [begin addition] termination [end addition] [begin addition] denial [end deletion]
and describe the strategies, outcomes, and negotiations with the [begin addition] individual [end
addition] [begin deletion] participant [end deletion] in accordance with [begin addition] CBA
[end addition] [begin deletion] the [end deletion] program policies [begin addition], rules, and
[end addition] [in] the provider manual.
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