Other Specify: Other Specify: 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 X State Medicaid Agency Weekly X Operating Agency Monthly Sub-State Entity Quarterly Other Specify: X Annually Continuously and Ongoing Other Specify: Performance Measure: Number and percentage of reported critical incidents and events in which DSPD notified the SMA and appropriate remediation was completed. The numerator in this PM would capture all incidents where compliance was achieved; the denominator is capturing all incidents, reported or unreported as well as cases in which remediation was insufficient, or explicit follow-up requests were not completed. Data Source (Select one) (Several options are listed in the on-line application):Other If ‘Other’ is selected, specify: Critical Incident/Event Findings Operating Agency report to SMA 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) X State Medicaid Agency Weekly X 100% Review X Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample; Confidence Interval = Other Specify: Annually X Continuously and Ongoing Stratified: Describe Group: Other
% A percentage of the FBR, which is less than 300% Specify the percentage: $ A dollar amount which is less than 300%. Specify dollar amount: % A percentage of the Federal poverty level Specify percentage: Other standard included under the State Plan Specify: The following dollar amount Specify dollar amount: $ If this amount changes, this item will be revised. The following formula is used to determine the needs allowance: Specify: Other Specify: ii. Allowance for the spouse only (select one): Not Applicable The State provides an allowance for a spouse who does not meet the definition of a community spouse in §1924 of the Act. Describe the circumstances under which this allowance is provided: Specify: Specify the amount of the allowance (select one): The following standard under 42 CFR §435.121: Specify: Optional State supplement standard Medically needy income standard The following dollar amount: Specify dollar amount: $ If this amount changes, this item will be revised. The amount is determined using the following formula: Specify: iii. Allowance for the family (select one): Not Applicable (see instructions)
Other Specify: 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 X State Medicaid Agency Weekly X Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Xs Annually Continuously and Ongoing Other Specify: Performance Measure: Number and percentage of events when a level of care is re-evaluated at the time a substantial change in health status occurs to determine if the individual continues to meet nursing facility level of care, when the screening dictates one was required. The numerator is the number of events in compliance; the denominator is the total number of events that occurred during the review period. Data Source (Select one) (Several options are listed in the on-line application):Other If ‘Other’ is selected, specify: Participant records, CBIA and Participant interviews 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) X State Medicaid Agency Weekly 100% Review X Operating Agency Monthly X Less than 100% Review Sub-State Entity Quarterly X Representative Sample; Confidence Interval = 95% Confidence Level, 5% Margin of Error Other Specify: X Annually Continuously and Ongoing Stratified: Describe Group: Other
X Other Specify: Every two years Other Specify: 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 X Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing X Other Specify: Every two years Performance Measure: Number and percentage of Level of Care is determinations documented in USTEPS. The numerator is the number of Level of Care determinations reviewed and which have been documented in USTEPS; the denominator is the total number of Level of Care determinations made by the OA which were reviewed. Data Source (Select one) (Several options are listed in the on-line application):Other If ‘Other’ is selected, specify: Participant records/USTEPS 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) X State Medicaid Agency Weekly 100% Review X Operating Agency Monthly X Less than 100% Review Sub-State Entity Quarterly X Representative Sample; Confidence Interval = 95% Confidence Level, 5% Margin of Error Other Specify: X Annually
Division of Child and Family Services. This service is not for ongoing daycare nor is this service intended to supplant resources otherwise available for child-care. Respite care may not be offered at the same time as the person is receiving any other service, either contained within this Home and Community-Based Services waiver or from other sources including the Medicaid State Plan that will afford the person with care and supervision. Respite care may not be offered for relief or substitution of staff paid to provide care and supervision to persons as part of the residential or day habilitation services they receive in this Home and Community-Based Services waiver. Service Delivery Method (check each that applies): X Participant-directed as specified in Appendix E X Provider managed Specify whether the service may be provided by (check each that applies): Legally Responsible Person X Relative Legal Guardian Provider Specifications Provider Category(s) (check one or both): X Individual. List types: X Agency. List the types of agencies: Self-directed Respite Agency based--Respite Provider Qualifications Provider Type: License (specify) Certificate (specify) Other Standard (specify) Agency Licensed by the State of Utah as a specific category of facility/agency as follows: Licensed Residential Treatment Programs R501-19, UAC Licensed Residential Support Programs R501-22, UAC Nursing Facility: R432-150, UAC Assisted Living Facility: R432-270, UAC Certified by DSPD as an authorized provider of services and supports to people with disabilities in accordance with UCA. Under state contract with DSPD as an authorized provider of services and supports to people with disabilities in accordance with 62A-5-103, UCA. Enrolled as a Medicaid provider Self-directed Respite Certified by DSPD as an authorized provider of services and Under state contract with DSPD as an authorized provider of services and supports to people with disabilities in
Category 3: Sub-Category 3: Category 4: Sub-Category 4: Service Definition (Scope): Consumer Preparation Services ensure that waiver recipients are prepared to supervise and direct their services providers. Consumer Preparation Services includes: (a) instruction in methods of identifying need and effectively communicating those needs to service providers; (b) instruction in management of provider(s) including interviewing, selecting, scheduling, termination, time sheeting, evaluating performance, back up coverage; (c) instruction in addressing problems such as changing levels of personal needs, grievance procedures, emergency coverage, exploitation and abuse. Consumer Preparation Services do not include educational, vocational or prevocational components. Specify applicable (if any) limits on the amount, frequency, or duration of this service: Limitations: Limits on the amount, frequency and/or duration are specified on the individualÂ’s plan of care and based on assessed need. Service Delivery Method (check each that applies): Participant-directed as specified in Appendix E X 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: X Agency. List the types of agencies: Agency-based Consumer Preparation Services Provider Provider Qualifications Provider Type: License (specify) Certificate (specify) Other Standard (specify) Agency-based Consumer Preparation Services Provider Current business license Certified by DSPD as an authorized provider of services and supports to people with disabilities in accordance with UCA. Under state contract with DSPD as an authorized provider of services and supports to people with disabilities in accordance with 62A-5-103, UCA. Enrolled as a Medicaid provider Verification of Provider Qualifications Provider Type: Entity Responsible for Verification: Frequency of Verification administered
supports to people with disabilities in accordance with UCA. accordance with 62A-5-103, UCA Training and experience in the field of acquired brain injuries of at least one year’s length; completion of a training course in positive behavioral supports prescribed by DSPD and approved by the SMA and the successful completion of a learning assessment at the conclusion of the course. Enrolled as a Medicaid provider Agency-based Behavior Consultation Service I Current business license Certified by DSPD as an authorized provider of services and supports to people with disabilities in accordance with UCA. Under state contract with DSPD as an authorized provider of services and supports to people with disabilities in accordance with 62A-5-103, UCA Training and experience in the field of acquired brain injuries of at least one year’s length; completion of a training course in positive behavioral supports prescribed by DSPD and approved by the SMA and the successful completion of a learning assessment at the conclusion of the course. Enrolled as a Medicaid provider Verification of Provider Qualifications Provider Type: Entity Responsible for Verification: Frequency of Verification Behaviorist Division of Services for People with Disabilities Annually Agency-based Behavior Consultation Service I Division of Services for People with Disabilities Annually Behavior Consultation II HCBS Taxonomy Category 1: Sub-Category 1: Category 2: Sub-Category 2: Category 3: Sub-Category 3:
both): Provider Qualifications Provider Type: License (specify) Certificate (specify) Other Standard (specify) Services Provider Certified by DSPD as an authorized provider of services and supports to people with disabilities in accordance with UCA. Under state contract with DSPD as an authorized provider of services and supports to people with disabilities in accordance with 62A-5-103, UCA and R539-5. Completed Provider Agreement Agency-based Companion Services Provider Current business license Certified by DSPD as an authorized provider of services and supports to people with disabilities in accordance with UCA. Under state contract with DSPD as an authorized provider of services and supports to people with disabilities in accordance with 62A-5-103, UCA Enrolled as a Medicaid provider Verification of Provider Qualifications Provider Type: Entity Responsible for Verification: Frequency of Verification Services Provider Division of Services for People with Disabilities Annually Agency-based Companion Services Provider Division of Services for People with Disabilities Annually Environmental Adaptations - Home HCBS Taxonomy Category 1: Sub-Category 1: Category 2: Sub-Category 2: Category 3: Sub-Category 3: Category 4: Sub-Category 4: Service Definition (Scope):
Service Delivery Method (check each that applies): Participant-directed as specified in Appendix E X 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: X Agency. List the types of agencies: Living Start-up Costs Provider Provider Qualifications Provider Type: License (specify) Certificate (specify) Other Standard (specify) Living Start-up Costs Provider Under state contract with DSPD as an authorized provider of services and supports to people with disabilities in accordance with 62A-5-103, UCA. Enrolled as a Medicaid provider Verification of Provider Qualifications Provider Type: Entity Responsible for Verification: Frequency of Verification Living Start-up Costs Provider Division of Services for People with Disabilities Annually Personal Budget Assistance HCBS Taxonomy Category 1: Sub-Category 1: Category 2: Sub-Category 2: Category 3: Sub-Category 3: Category 4: Sub-Category 4:
Service Definition (Scope): Personal Budget Assistance provides assistance with financial matters, fiscal training, supervision of financial resources, savings, retirement, earnings and funds monitoring, monthly check writing, bank reconciliation, budget management, tax and fiscal record keeping and filing, and fiscal interaction on behalf of the individual. 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 X 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: X Agency. List the types of agencies: Agency-based - Personal Budget Assistance Provider Provider Qualifications Provider Type: License (specify) Certificate (specify) Other Standard (specify) Agency-based - Personal Budget Assistance Provider Current business license Certified by DSPD as an authorized provider of services and supports to people with disabilities in accordance with UCA. Under state contract with DSPD as an authorized provider of services and supports to people with disabilities in accordance with 62A-5-103, UCA. Enrolled as a Medicaid provider Verification of Provider Qualifications Provider Type: Entity Responsible for Verification: Frequency of Verification Agency-based - Personal Budget Assistance Provider Division of Services for People with Disabilities Annually Personal Emergency Response System HCBS Taxonomy Category 1: Sub-Category 1:
providing naturals supports and to avoid unwanted out of home placement. Supported living activities are prioritized based upon the individualÃ‚Â’s assessed needs, but may include maintenance of individual health and safety, personal care services, homemaker, chore, attendant care, medication observation and recording, advocacy, communication, assistance with activities of daily living, instrumental activities of daily living, transportation to access community activities, shopping and attending doctor appointments, keeping track of money and bills and using the telephone; and indirect services such as socialization, self-help, and adaptive/compensatory skills development necessary to reside successfully in the community. This service may also include behavioral plan implementation by direct care staff. Specify applicable (if any) limits on the amount, frequency, or duration of this service: Limitations: Individuals receiving Supported Living are not eligible to receive separate individual waiver services in addition to Supported Living if the separate services are essentially duplicative of the tasks defined in Supported Living. Individuals receiving Supported Living may not receive Residential Habilitation; however, they may receive Day Support Services as long as these services are not provided nor billed for times when the individual is receiving Supported Living services Service Delivery Method (check each that applies): X Participant-directed as specified in Appendix E X Provider managed Specify whether the service may be provided by (check each that applies): Legally Responsible Person X Relative Legal Guardian Provider Specifications Provider Category(s) (check one or both): X Individual. List types: X Agency. List the types of agencies: Self-directed Supported Living Agency-based Supported Living Provider Qualifications Provider Type: License (specify) Certificate (specify) Other Standard (specify) Self-directed Supported Living Certified by DSPD as an authorized provider of services and supports to people with disabilities in accordance with UCA. Under state contract with DSPD as an authorized provider of services and supports to people with disabilities in accordance with 62A-5-103, UCA and R539-5. Agency-based Supported Living Current business license Certified by DSPD as an authorized provider of services and supports to people with disabilities in accordance with UCA. Under state contract with DSPD as an authorized provider of services and supports to people with disabilities in accordance with 62A-5-103, UCA. Enrolled as a Medicaid provider
Additionally, this service is not available to children in the custody of the State of Utah: Department of Human Services, Division of Child and Family Services for the purposes of visitation to a family home. Service Delivery Method (check each that applies): X Participant-directed as specified in Appendix E X Provider managed Specify whether the service may be provided by (check each that applies): Legally Responsible Person X Relative Legal Guardian Provider Specifications Provider Category(s) (check one or both): X Individual. List types: X Agency. List the types of agencies: Self-directed--Non-Medical Transportation Agency-based Non-Medical Transportation Provider Qualifications Provider Type: License (specify) Certificate (specify) Other Standard (specify) Transportation Individual with driver’s license and registered vehicle, per 53-3-202, UCA and 41-12a-301 through 412, UCA Certified by DSPD as an authorized provider of services and supports to people with disabilities in accordance with UCA. • Under state contract with DSPD as an authorized provider of services and supports to people with disabilities in accordance with 62A-5-103, UCA and R539-5. • Driver must possess a current Utah Driver License and proof of auto liability insurance in amounts required by state law. Agency-based Non-Medical Transportation Licensed public transportation carrier OR Individual with driver’s license and registered vehicle, per 53-3-202, UCA and 41-12a-301 through 412, UCA Current business license Certified by DSPD as an authorized provider of services and supports to people with disabilities in accordance with UCA. • Under state contract with DSPD as an authorized provider of services and supports to people with disabilities in accordance with 62A-5-103, UCA. • Driver must possess a current Utah Driver License and proof of auto liability insurance in amounts required by state law. • Enrolled as a Medicaid provider Verification of Provider Qualifications Provider Type: Entity Responsible for Verification: Frequency of Verification Transportation Division of Services for People with Disabilities Annually Agency-based Division of Services for People with Disabilities Annually
Performance Measure: Number and percentage of providers who have an adequate quality management plan and human rights plan. The numerator is the number of providers in the review having both a quality management and human rights plan in place and for which a review ensures the minimum required standards are being met in both plans; the denominator is the total number of providers reviewed. Data Source (Select one) (Several options are listed in the on-line application):Other If ‘Other’ is selected, specify: Provider Quality Management plan, Provider Human Rights plan and Provider records 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 X Operating Agency Monthly X Less than 100% Review Sub-State Entity Quarterly X Representative Sample; Confidence Interval = 95% Confidence Level, 5% Margin of Error Other Specify: X Annually Continuously and Ongoing Stratified: Describe Group: Other Specify: Other Specify: 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 X Operating Agency Monthly Sub-State Entity Quarterly Other Specify: X Annually Continuously and Ongoing Other
in their care; the denominator is the total number of sampled employees from all provider staff reviewed. Data Source (Select one) (Several options are listed in the on-line application):Other If ‘Other’ is selected, specify: Provider interviews and Behavior Support plans 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 X Operating Agency Monthly X Less than 100% Review Sub-State Entity Quarterly Representative Sample; Confidence Interval = Other Specify: X Annually Continuously and Ongoing Stratified: Describe Group: Other Specify: Other Specify: 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 X State Medicaid Agency Weekly X Operating Agency Monthly Sub-State Entity Quarterly Other Specify: X Annually Continuously and Ongoing Other Specify: Performance Measure: Number and percentage of ABI Support Coordinators who completed DSPD core curriculum. The numerator is the number of ABI Support Coordinators reviewed who complete the full curriculum as contractually required; the denominator is the total number of ABI Support Coordinators reviewed.
Specify: Every two years Other Specify: 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 X State Medicaid Agency Weekly X Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing X Other Specify: Every two years Performance Measure: Number and percentage of waiver participant deaths for which the Department of Human Services’ Fatality Review Committee process was followed. The numerator is the total number of waiver participant deaths for which the Department of Human Services’ Fatality Review Committee process was followed; the denominator is the total number of waiver participant deaths. Data Source (Select one) (Several options are listed in the on-line application):Other If ‘Other’ is selected, specify: Participant records and Annual report 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 X 100% Review X Operating Agency Monthly Less than 100% Review Sub-State Entity X Quarterly Representative Sample; Confidence Interval = Other Specify: Annually Continuously and Ongoing Stratified: Describe Group:
that required the development/implementation of prevention strategies. Data Source (Select one) (Several options are listed in the on-line application):Other If ‘Other’ is selected, specify: Participant records, Participant Service plans, Participant interviews and Provider interviews 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) X State Medicaid Agency Weekly 100% Review X Operating Agency Monthly X Less than 100% Review Sub-State Entity Quarterly X Representative Sample; Confidence Interval = 95% Confidence Level, 5% Margin of Error Other Specify: Annually Continuously and Ongoing Stratified: Describe Group: X Other Specify: Every two years Other Specify: 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 X State Medicaid Agency Weekly X Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing X Other Specify: Every two years
X Other Specify: Every two years Performance Measure: Number and percentage of providers in a representative sample receive and retain 100% of amounts claimed for Wavier services. The numerator is the total number of providers in the review sample which receive and retain 100% of amounts claimed for waiver services; the denominator is the total number of providers in the review sample. Data Source (Select one) (Several options are listed in the on-line application):Other If ‘Other’ is selected, specify: CAPS claims payment history report; MMIS claims payment history report; Provider Claims 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) X State Medicaid Agency Weekly 100% Review X Operating Agency Monthly X Less than 100% Review Sub-State Entity Quarterly X Representative Sample; Confidence Interval = 95% Confidence Level, 5% Margin of Error Other Specify: X Annually Continuously and Ongoing Stratified: Describe Group: Other Specify: Other Specify: 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 X State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and
Recoupment of Funds: • When payments are made for services not identified on the PCSP: The Medicaid State Agency will require a recoupment of unauthorized paid claims based upon the Federal Medical Assistance Percentage (FMAP). • When the amount of payments made exceed the amount identified on the annual budget: The Medicaid State Agency will require a recoupment of unauthorized paid claims based upon the Federal Medical Assistance Percentage (FMAP). • When payments are made for services based on a coding error: The coding error will be corrected by withdrawing the submission of the claim and submitting the correct code for payment. The recoupment of funds will proceed as follows: 1. The State Medicaid Agency will complete a Recoupment of Funds Form that indicates the amount of the recoupment and send it to the Operating Agency. 2. The Operating Agency will review the Recoupment of Funds Form and return the signed form to the State Medicaid Agency. 3. Upon receipt of the Recoupment of Funds Form, the State Medicaid Agency will submit the recoupment to Medicaid Operations. 4. Medicaid Operations will reprocess the MMIS claims to reflect the recoupment. 5. Overpayments are returned to the federal government within 60 days of discovery. ii. Remediation Data Aggregation Remediation-related Data Aggregation and Analysis (including trend identification) Responsible Party (check each that applies) Frequency of data aggregation and analysis: (check each that applies) X State Medicaid Agency Weekly X Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing X Other Specify: OA: At a minimum every two years. SMA: At a minimum every five years. c. Timelines When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design methods for discovery and remediation related to the assurance of Financial Accountability that are currently non-operational.
ii. Estimate of Factor D – Concurrent §1915(b)/§1915(c) Waivers, or other authorities utilizing capitated arrangements (i.e., 1915(a), 1932(a), Section 1937). Complete the following table for each waiver year. Enter data into the Unit, # Users, Avg. Units Per User, and Avg. Cost/Unit fields for all the Waiver Service/Component items. If applicable, check the capitation box next to that service. Select Save and Calculate to automatically calculate and populate the Component Costs and Total Costs fields. All fields in this table must be completed in order to populate the Factor D fields in the J-1 Composite Overview table. Waiver Year: Year 1 Waiver Service / Component Col. 1 Col. 2 Col. 3 Col. 4 Col. 5 Col. 6 Check if included in capitation Unit # Users Avg. Units Per User Avg. Cost/ Unit Total Cost GRAND TOTAL: Total: Services included in capitation Total: Services not included in capitation TOTAL ESTIMATED UNDUPLICATED PARTICIPANTS (from Table J-2-a) FACTOR D (Divide grand total by number of participants) Services included in capitation Services not included in capitation AVERAGE LENGTH OF STAY ON THE WAIVER Waiver Year: Year 2