Consult with CMS for instructions before completing this item. This field describes the status of a transition process at the point in time of submission. Relevant information in the planning phase will differ from information required to describe attainment of milestones. To the extent that the state has submitted a statewide HCB settings transition plan to CMS, the description in this field may reference that statewide plan. The narrative in this field must include enough information to demonstrate that this waiver complies with federal HCB settings requirements, including the compliance and transition requirements at 42 CFR 441.301(c)(6), and that this submission is consistent with the portions of the statewide HCB settings transition plan that are germane to this waiver. Quote or summarize germane portions of the statewide HCB settings transition plan as required. Note that Appendix C-5 HCB Settings describes settings that do not require transition; the settings listed there meet federal HCB setting requirements as of the date of submission. Do not duplicate that information here. Update this field and Appendix C-5 when submitting a renewal or amendment to this waiver for other purposes. It is not necessary for the state to amend the waiver solely for the purpose of updating this field and Appendix C-5. At the end of the state's HCB settings transition process for this waiver, when all waiver settings meet federal HCB setting requirements, enter "Completed" in this field, and include in Section C-5 the information on all HCB settings in the waiver. Completed. 1. State Line of Authority for Waiver Operation. Specify the state line of authority for the operation of the waiver (select one): The waiver is operated by the State Medicaid agency. Specify the Medicaid agency division/unit that has line authority for the operation of the waiver program (select one): The Medical Assistance Unit (specify the unit name) (Do not complete Item A-2) Another division/unit within the State Medicaid agency that is separate from the Medical
(check each that applies) applies) State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample; Confidence Interval = Other Specify: Annually ASAPs and SCOs Continuously and Ongoing Stratified: Describe Group: Other Specify: Other Specify: Data Aggregation and Analysis Responsible Party for data aggregation and analysis (check each that applies Frequency of data aggregation and analysis: (check each that applies State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify: Performance Measure: #2 EOEA and MassHealth worked collaboratively with ASAPs and SCOs to ensure systematic and continuous data collection and analysis of the ASAP and SCO functions, as evidenced by timely and accurate submission of quality data reports. Numerator: Number of ASAP and SCO quality reports that were accurate, on time, and in the correct format Denominator: Number of ASAP and SCO reports due Data Source (Select one) (Several options are listed in the on-line application): Reports to State Medicaid Agency on delegated Administrative functions If ‘Other’ is selected, specify: ASAP quality reporting to EOEA and SCO reporting to LTSS SCO Unit
Continuously and Ongoing Other Specify: b Sub-assurance: The levels of care of enrolled participants are reevaluated at least annually or as specified in the approved waiver. i. Performance Measures Performance Measure: No longer needed in new QM system. Data Source (Select one) (Several options are listed in the on-line application):Other If ‘Other’ is selected, specify: No longer needed. Responsible Party for data collection/generation (check each that applies) Frequency of data collection/generation: (check each that applies) Sampling Approach (check each that applies) State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample; Confidence Interval = Other Specify: Annually No longer needed. Continuously and Ongoing Stratified: Describe Group: Other Specify: No longer needed. Other Specify: No longer needed. Add another Data Source for this performance measure Data Aggregation and Analysis Responsible Party for data aggregation and analysis (check each that applies Frequency of data aggregation and analysis: (check each that applies State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually
Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample; Confidence Interval = Other Specify: Annually Continuously and Ongoing Stratified: Describe Group: Other Specify: Other Specify: Data Aggregation and Analysis Responsible Party for data aggregation and analysis (check each that applies Frequency of data aggregation and analysis: (check each that applies State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify: ii If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible. b. Methods for Remediation/Fixing Individual Problems i Describe the State’s method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items. The Executive Office of Elder Affairs (EOEA), MassHealth and LTSS are responsible for ensuring effective oversight of the waiver program, including administrative and operational functions performed by the Aging Services Access Points (ASAPs) and Senior Care Organizations (SCOs). In
(check one or both): Qualified individual providers of Alzheimer’s/Dementia Coaching Alzheimer’s/Dementia Coaching agencies Homemaker/Personal Care Agencies Home Health Agencies Provider Qualifications Provider Type: License (specify) Certificate (specify) Other Standard (specify) Qualified individual providers of Alzheimer’s/Dementia Coaching In addition to the certification requirements listed below, Alzheimer’s Dementia Coaching must be performed by a professional with a valid Massachusetts license for any of the following: - Registered Nurse - Licensed Independent Clinical Social Worker - Licensed Certified Social Worker w/one year of experience working with person with dementia/related illness - Occupational Therapist - or other similar professional licensure. Services must be performed by an individual trained in Habilitation Therapy by the Alzheimer’s Association Adherence to Continuous QI Practices: Providers Qualified individuals must have established strategies to prevent, detect, and correct problems in the quality of services provided and to achieve service plan goals with individual consumers by providing effective, efficient services. Availability: Providers must be able to provide contracted service(s) in the geographical areas they designate. Responsiveness: Providers must be able to initiate services with little or no delay. Confidentiality: Individual Providers must maintain confidentiality and privacy of consumer information in accordance with M.G.L. c.66A (Fair Information Practices Act) and EOEA Program Instruction 97-55 (Clarification of Client Privacy and Confidentiality Policies). Alzheimer’s/Dementia Coaching agencies In addition to the certification requirements listed below, Alzheimer’s Dementia Coaching must be performed by a professional with Services must be performed by an individual trained in Habilitation Therapy by the Alzheimer’s Association. Agencies may apply to EOEA for Education, Training, Supervision: Providers must ensure effective training of staff members in all aspects of their job duties, including handling emergency situations, and establish procedures for appraising staff performance and for effectively modifying poor performance where it
Massachusetts license for any of the following: - Registered Nurse - Licensed Independent Clinical Social Worker - Licensed Certified Social Worker w/one year of experience working with person with dementia/related illness - Occupational Therapist - or other similar professional licensure. have an individual who has been trained in Habilitation Therapy by the Alzheimer’s Association conduct training for additional staff. Adherence to Continuous QI Practices: Providers must have established strategies to prevent, detect, and correct problems in the quality of services provided and to achieve service plan goals with individual consumers by providing effective, efficient services. Availability: Providers must be able to provide contracted service(s) in the geographical areas they designate. Responsiveness: Providers must be able to initiate services with little or no delay. Confidentiality: Providers must maintain confidentiality and privacy of consumer information in accordance with M.G.L. c.66A (Fair Information Practices Act) and EOEA Program Instruction 97-55 (Clarification of Client Privacy and Confidentiality Policies). Policies/Procedures: Providers must have policies and procedures that include: Client Not at Home Policy, Client Emergency in the Home Policy; all policies required by 105 CMR 155.00 (Department of Public Health regulations addressing patient and resident abuse prevention, reporting, investigation and registry requirements). Home Health Agencies In addition to the certification requirements listed below, Alzheimer’s Dementia Coaching must be performed by a professional with a valid Massachusetts Services must be performed by an individual trained in Habilitation Therapy by the Alzheimer’s Association. Agencies may apply to EOEA for a waiver in order to have an individual Education, Training, Supervision: Providers must ensure effective training of staff members in all aspects of their job duties, including handling emergency situations, and establish procedures for appraising staff performance and for effectively modifying poor performance where it exists.
license for any of the following: - Registered Nurse - Licensed Independent Clinical Social Worker - Licensed Certified Social Worker w/one year of experience working with person with dementia/related illness - Occupational Therapist - or other similar professional licensure. who has been trained in Habilitation Therapy by the Alzheimer’s Association conduct training for additional staff. Adherence to Continuous QI Practices: Providers must have established strategies to prevent, detect, and correct problems in the quality of services provided and to achieve service plan goals with individual consumers by providing effective, efficient services. Availability: Providers must be able to provide contracted service(s) in the geographical areas they designate. Responsiveness: Providers must be able to initiate services with little or no delay. Confidentiality: Providers must maintain confidentiality and privacy of consumer information in accordance with M.G.L. c.66A (Fair Information Practices Act) and EOEA Program Instruction 97-55 (Clarification of Client Privacy and Confidentiality Policies). Policies/Procedures: Providers must have policies and procedures that include: Client Not at Home Policy, Client Emergency in the Home Policy; all policies required by 105 CMR 155.00 (Department of Public Health regulations addressing patient and resident abuse prevention, reporting, investigation and registry requirements). Verification of Provider Qualifications Provider Type: Entity Responsible for Verification: Frequency of Verification Qualified individual providers of Alzheimer’s/Dementia Coaching ASAPs Every 3 years Alzheimer’s/Dementia Coaching agencies ASAPs Every 3 years
confidentiality; adapt to a variety of situations; and respect and accept different values, nationalities, races, religions, cultures and standards of living. Verification of Provider Qualifications Provider Type: Entity Responsible for Verification: Frequency of Verification Grocery Shopping and Delivery Provider Agencies ASAPs Every 3 years Service Specification Service Type: ☐ Statutory ☐ Extended State Plan Other Service Name: Home Based Wandering Response Systems ☐ Service is included in approved waiver. There is no change in service specifications. Service is included in approved waiver. The service specifications have been modified. ☐ Service is not included in approved waiver. Service Definition (Scope): Home Based Wandering Response Systems are communication alert systems for participants at risk for wandering. Participants are outfitted with a device that transmits signals using technology such as GPS or radio frequency. The service includes 24/7 emergency response and location assistance in the event the participant wanders. Specify applicable (if any) limits on the amount, frequency, or duration of this service: Service Delivery Method (check each that applies): Participant-directed as specified in Appendix E Provider managed Specify whether the service may be provided by (check each that applies): Legally Responsible Person Relative Legal Guardian Provider Specifications Provider Category(s) (check one or both): Individual. List types: Agency. List the types of agencies: Home Based Wandering Response Provider Agencies Provider Qualifications Provider Type: License (specify) Certificate (specify) Other Standard (specify) Home Based Wandering Response Education, Training, Supervision: Providers must ensure effective training of staff members in all aspects of their job
Equipment Provider Service Specification Service Type: ☐ Statutory ☐ Extended State Plan Other Service Name: Orientation and Mobility ☐ Service is included in approved waiver. There is no change in service specifications. ☐ Service is included in approved waiver. The service specifications have been modified. Service is not included in approved waiver. Service Definition (Scope): Orientation and Mobility (O&M) services teach an individual with vision impairment or legal blindness how to move or travel safely and independently in his/her home and community and include (a) O&M assessment; (b) training and education provided to Participants; (c) environmental evaluations; (d) caregiver/direct care staff training on sensitivity to blindness/low vision; and (e) information and resources on community living for persons with vision impairment or legal blindness. O&M Services are tailored to the individual’s need and may extend beyond the home setting to other community settings as well as public transportation systems. Specify applicable (if any) limits on the amount, frequency, or duration of this service: Service Delivery Method (check each that applies): Participant-directed as specified in Appendix E Provider managed Specify whether the service may be provided by (check each that applies): Legally Responsible Person Relative Legal Guardian Provider Specifications Provider Category(s) (check one or both): Individual. List types: Agency. List the types of agencies: Certified Orientation and Mobility Specialists (COMS) Human Service Agencies Provider Qualifications Provider Type: License (specify) Certificate (specify) Other Standard (specify) Certified Orientation and Mobility Specialists (COMS) Individual providers of Orientation and Mobility Services must have a master’s degree in special education with a specialty in orientation and mobility or a bachelor’s degree with a certificate in orientation and mobility from an ACVREP (Academy for Certification of Vision Rehabilitation and Individuals providing services must also have: - Knowledge and experience in the evaluation of the needs of an individual with vision impairment or legal blindness, including functional evaluation of the individual in the individual’s customary environment. - Knowledge and/or experience in educating caregivers or direct care staff, or other individuals who provide services to or are otherwise substantially involved in the major life functions of individuals with vision impairment or legal blindness, in sensitivity to low vision/blindness.
by either a certified occupational therapy assistant or an occupational therapy student under the direct supervision of a licensed Occupational Therapist performance where it exists. Adherence to Continuous QI Practices: Providers must have established strategies to prevent, detect, and correct problems in the quality of services provided and to achieve service plan goals with individual consumers by providing effective, efficient services. Availability: Providers must be able to provide contracted service(s) in the geographical areas they designate. Responsiveness: Providers must be able to initiate services with little or no delay. Confidentiality: Providers must maintain confidentiality and privacy of consumer information in accordance with M.G.L. c.66A (Fair Information Practices Act) and EOEA Program Instruction 97-55 (Clarification of Client Privacy and Confidentiality Policies). Policies/Procedures: Providers must have policies and procedures that include: Client Not at Home Policy, Client Emergency in the Home Policy; all policies required by 105 CMR 155.00 (Department of Public Health regulations addressing patient and resident abuse prevention, reporting, investigation and registry requirements). Health Care Agencies The agency must be licensed as a Group Practice in accordance with 130 CMR 432.404 (MassHealth Therapist Regulations that describe the provider eligibility requirements for therapy providers) or as a Rehabilitation Center in accordance with 130 CMR 430.600 (MassHealth Education, Training, Supervision: Providers must ensure effective training of staff members in all aspects of their job duties, including handling emergency situations, and establish procedures for appraising staff performance and for effectively modifying poor performance where it exists. Adherence to Continuous QI Practices: Providers must have established strategies to prevent, detect, and correct problems in the quality of services provided and to achieve
Rehabilitation Center Regulations that define provider eligibility requirements and program rules). Home Safety/Independence Evaluation services must be performed by an Occupational Therapist with a valid Massachusetts license or by either a certified occupational therapy assistant or an occupational therapy student under the direct supervision of a licensed Occupational Therapist service plan goals with individual consumers by providing effective, efficient services. Availability: Providers must be able to provide contracted service(s) in the geographical areas they designate. Responsiveness: Providers must be able to initiate services with little or no delay. Confidentiality: Providers must maintain confidentiality and privacy of consumer information in accordance with M.G.L. c.66A (Fair Information Practices Act) and EOEA Program Instruction 97-55 (Clarification of Client Privacy and Confidentiality Policies). Policies/Procedures: Providers must have policies and procedures that include: Client Not at Home Policy, Client Emergency in the Home Policy; all policies required by105 CMR 155.00 (Department of Public Health regulations addressing patient and resident abuse prevention, reporting, investigation and registry requirements). Home Health Agencies The agency must be licensed as a Home Health Agency participating in MassHealth under 130 CMR 403.000 (MassHealth Home Health Agency regulations that define provider eligibility requirements and program rules). Home Safety/Independence Evaluation services must be performed by an Occupational Therapist with a valid Education, Training, Supervision: Providers must ensure effective training of staff members in all aspects of their job duties, including handling emergency situations, and establish procedures for appraising staff performance and for effectively modifying poor performance where it exists. Adherence to Continuous QI Practices: Providers must have established strategies to prevent, detect, and correct problems in the quality of services provided and to achieve service plan goals with individual consumers by providing effective, efficient services. Availability: Providers must be able to provide contracted service(s) in the geographical areas they
(Clarification of Client Privacy and Confidentiality Policies). Verification of Provider Qualifications Provider Type: Entity Responsible for Verification: Frequency of Verification Homemaker/Personal Care agencies ASAPs Every 3 years Health Care Agencies ASAPs Every 3 years Home Health Agencies ASAPs Every 3 years Individual Occupational Therapist ASAPs Every 3 years Service Specification Service Type: ☐ Statutory ☐ Extended State Plan Other Service Name: Peer Support Alternative Service Title (if any): ☐ Service is included in approved waiver. There is no change in service specifications. ☐ Service is included in approved waiver. The service specifications have been modified. Service is not included in approved waiver. Service Definition (Scope): Peer Support is designed to provide targeted recovery services to older adults with behavioral health diagnoses. Peer Support assistance includes mentoring participants about self-advocacy and participation in the community, including, but not limited to, such activities as accessing a senior center, getting to medical appointments or a hospital for a medical procedure, assisting with care transitions, and housing paperwork, accompanying for walks to various community locations, and generally engaging to reduce isolation. Peer support may be provided in small groups or peer support may involve one peer providing support to another peer, the waiver participant. Peer support promotes and assists the waiver participant's ability to participate in self-advocacy. The service utilizes trained peers as coaches who have lived experience with mental illness to promote care and attainment of measurable personalized recovery goals. Specify applicable (if any) limits on the amount, frequency, or duration of this service: Not to exceed 16 hours per week. centered
Category(s) (check one or both): Senior Care Organization Provider Qualifications Provider Type: License (specify) Certificate (specify) Other Standard (specify) Senior Care Organization Senior Care Organizations enrolled under contract with MassHealth. A senior care organization is a qualified contractor selected to provide services to MassHealth members aged 65 or older who have chosen to participate in Senior Care Options. Under this program, senior care organizations provide a fully integrated geriatric model of care. Verification of Provider Qualifications Provider Type: Entity Responsible for Verification: Frequency of Verification Senior Care Organization MassHealth Office of Long Term Services and Supports Annually Service Specification Service Type: ☐ Statutory ☐ Extended State Plan Other Service Name: Complex Care Training and Oversight (formerly Skilled Nursing) ☐ Service is included in approved waiver. There is no change in service specifications. Service is included in approved waiver. The service specifications have been modified. ☐ Service is not included in approved waiver. Service Definition (Scope): Complex Care Training and Oversight is a periodic, episodic service that includes medication management (e.g., filling medication cassettes) as well as development and ongoing management and evaluation of the participant’s Home Health Aide Plan of Care, for purposes of monitoring the participant’s underlying conditions or complications to ensure the unskilled care is successfully addressing the participant’s needs. Complex Care Training and Oversight services listed in the service plan that are within the scope of the State's Nurse Practice Act and are provided by a Registered Nurse or a Licensed Practical Nurse with a valid Massachusetts license. Agencies that provide Complex Care Training and Oversight services under the waiver do not need to meet the requirements for participation in Medicare, as provided in 42 CFR §489.28. Specify applicable (if any) limits on the amount, frequency, or duration of this service: Service Delivery Method (check each that applies): Participant-directed as specified in Appendix E Provider managed Specify whether the service may be provided Legally Relative Legal Guardian
data collection/generation (check each that applies) collection/generation: (check each that applies) (check each that applies) State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample; Confidence Interval = Other Specify: Annually ASAPs and Senior Care Organizations (SCO) Continuously and Ongoing Stratified: Describe Group: Other Specify: Other Specify: Data Aggregation and Analysis Responsible Party for data aggregation and analysis (check each that applies Frequency of data aggregation and analysis: (check each that applies State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify: ii If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible. b. Methods for Remediation/Fixing Individual Problems
c. Sub-assurance: Service plans are updated/revised at least annually or when warranted by changes in the waiver participant’s needs. i. Performance Measures Performance Measure: Case Managers documented their review of waiver participants’ service plans within the past year. Numerator: Number of waiver participants with a documented review/update of their service plan within the past year Denominator: Number of waiver participants Data Source (Select one) (Several options are listed in the on-line application):Other If ‘Other’ is selected, specify: SIMS data reports Responsible Party for data collection/generation (check each that applies) Frequency of data collection/generation: (check each that applies) Sampling Approach (check each that applies) State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample; Confidence Interval = Other Specify: Annually Continuously and Ongoing Stratified: Describe Group: Other Specify: Other Specify: Data Source (Select one) (Several options are listed in the on-line application): Reports to State Medicaid Agency on delegated Administrative functions If ‘Other’ is selected, specify: SCO quality reports Responsible Party for data collection/generation (check each that applies) Frequency of data collection/generation: (check each that applies) Sampling Approach (check each that applies)