HCBS Case Management 525-05-30-05

(Revised 02/01/2024 ML #3797)

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Purpose

Case Management is a service that assists individuals in learning about, applying for, accessing and maintaining home and community-based services in the most integrated setting appropriate to their needs.

The purpose of HCBS Case Management is to assist an individual to achieve and maintain independent living, in the living arrangement of their choice, until it is no longer appropriate or reasonably possible to maintain or meet the individual's needs in that setting. In order to facilitate independent living, the HCBS Case Manager leads the person-centered planning process that enables individuals and their natural and formal supports to explore and understand long-term service and support (LTSS) options, identify barriers, set goals, and collaborate with stakeholders to assist the individual in accessing needed community-based services. The HCBS Case Manager also advocates for and promotes individual-focused systems of service delivery, exercises an awareness of the larger target population in need, and exercises prudence in each individual's person-centered plan of care to link individuals with resources and services, utilizing those services and resources effectively.

Standards for HCBS Case Managers

The service shall be performed by a social worker or agency that employs individuals licensed to practice social work in North Dakota and who has met all the requirements to be enrolled as either an Individual or Agency Qualified Service Provider in NDAC 75-03-23 and agreed to comply with policy.

1. Case Managers employed by Aging Services are eligible to receive payment for the service of Case Management and authorize services under the SPED and EXSPED Programs upon receiving a written notice from the HCBS Program Administration that an individual in the SPED or Expanded SPED Program Pool is authorized for services under the SPED or Expanded SPED Program.
   
   
2. Case Managers employed by Aging Services are eligible to receive payment for the service of Case Management under the HCBS Waiver and authorize services if the individual is eligible for services under the Waiver.
   
   
3. Individual Case Managers or an Agency who is enrolled as a QSP for the Service of Case Management are eligible to receive payment for the service of Case Management under the HCBS Waiver and are eligible to authorize services for an individual if the individual is eligible for services under the Wavier.

Case file documentation must be maintained:

1. In a secure setting
   
   
2. On each individual, in separate case files

Quarterly Visit Requirements for Medicaid Waiver

Case Managers are required to monitor during their quarterly face-to-face contacts to ensure an individual’s is being afforded the rights of privacy, dignity and respect, and freedom from coercion and restraint (including the limited use of restraints that are allowable under Adult Residential Services in accordance with NDCC 50-10.2-02 (1)).

• Any violation of an individual's rights must be reported as complaint to the HCBS Program Administrator and/or Vulnerable Adult Protective Services.
  
  
• If a restraint or restriction is identified, the case manager must document the restraint or restriction on the Person-Centered Plan of Care and review the need for the restriction at a minimum of every six (6) months.

Standards for Targeted Case Management (TCM) for persons in need of Long-Term Care

• The service shall be performed by a social worker or agency that employs individuals licensed to practice social work in North Dakota and who has met all the requirements to be enrolled as either an Individual or Agency Qualified Service Provider (QSP) or an Indian Tribe/Indian Tribal Organization who has met State Plan requirements and requirements to be enrolled as a QSP or Developmental Disabilities Program Manager (DDPM) who is a Qualified Developmental Disabilities Professionals (QDDP) or has one year experience as a DDPM with the Department.

The following enrolled provider types are eligible to receive payment for TCM:

• Case Managers employed by Aging Services who have sufficient knowledge and experience relating to the availability of alternative long-term care services for elderly and disabled individuals.
  
  
• Developmental Disabilities Program Manager (DDPM) who is a Qualified Developmental Disabilities Professional (QDDP) or has one year experience as a DDPM with the Department.
  
  
• An Individual Case Manager or Agency Case Manager that has sufficient knowledge and experience relating to the availability of alternative long-term services and supports for elderly and disabled individuals.
  
  
• Indian Tribe or Indian Tribal Organization who has met the provider qualifications outlined in the North Dakota State Plan Amendment.

The following enrolled provider types are eligible to receive payment for TCM and Authorize Service(s):

• Case Managers employed by Aging Services are eligible to approve services under SPED, EXSPED and Medicaid State Plan - Personal Care (MSP-PC), (see Chapter 535-05).
  
  
• DDPMs are eligible to approve MSP-PC services.

• If the individual is a recipient of services funded by the SPED, Expanded SPED Programs, or MSP-PC the one case file will contain documentation of eligibility for TCM as well as for the service(s).

The following enrolled provider types are eligible to receive payment for single event TCM:

• HCBS Case Managers, DDPMs, enrolled Individual or Agency Case Managers and enrolled Indian Tribe or Indian Tribal Organizations.

• If the individual requests a contact more than once every six months, the Case Manager needs to obtain prior approval from a HCBS Program Administrator.

• Indian Tribe or Indian Tribal Organizations are limited to providing TCM Services to enrolled tribal members.

 

Targeted Case Management (TCM)

The individual receiving TCM will meet the following criteria:

1. Medicaid recipient.
   
   
2. Not a recipient of HCBS (1915c Waiver) services.
   
   
3. Not currently being covered under another case management/targeted case management system or payment does not duplicate payments made under other program's authorities for the same purpose.
   
   
4. Lives in the community and desires to remain there; or be ready for discharge from a hospital within 7 days; or resides in a basic care facility; or resides in a nursing facility if it is anticipated that a discharge to alternative care is within six months.
   
   
5. Case management services provided to individuals in Medical institutions transitioning to a community setting. Services will be made available for up to 180 consecutive days of the covered stay in the medical institution. The target group does not include individuals between the age of 22-64 who are served in Institutions for Mental Disease or inmates of public institutions.
   
   
6. Has long-term care need (need anticipated to exceed 30 days). Document the required long-term care need on the Application for Services, SFN 1047. The applicant or legal representative must provide a describable need that would delay or prevent institutionalization.

The applicant or referred individual must agree to a home visit and participate in the assessment and person-centered planning.

Activities of Targeted Case Management

1-Assessment/Reassessment

2-Person Centered Plan Development

3-Referral and Related Activities,

4-Monitoring and Follow-up Activities

(Details outlined in section- HCBS Case Management - Service Activities, Standards of Performance, and Documentation of HCBS Case Management Activities)

• The focus or purpose of TCM is to identify what the individual needs to remain in their home or community and be linked to those services and programs.

• An assessment must be completed, and a person-centered plan developed. The individual’s case file must contain documentation of eligibility for TCM. The HCBS Comprehensive Assessment and narrative must be entered into the web-based data collection system.

• Targeted case management is considered a medical need and thus included as a health care cost. Use of Medicaid funding for targeted case management may result in the recipient paying for/toward the cost of their case management. The individual must be informed of that fact by noting Case Management Service and cost on the Person-Centered Plan of Care. Individuals must also check and sign acknowledgment that if they are on Medicaid they may have a recipient liability. Payments from the Medicaid Program made on behalf of recipients 55 years or older are subject to estate recovery including for Targeted Case Management.

• If the only medical need is Targeted Case Management, then the individual receiving SPED services, need not apply for Medical Assistance.

• The case record must include a HCBS Comprehensive Assessment and narrative (entered into the web-based data collection system) which includes:

• Name of the individual
  
  
• Dates of case management service
  
  
• Name of the case management provider/staff
  
  
• Nature, content, units of case management service received, and whether goals specified in the plan are achieved
  
  
• Whether the individual has declined services in the care plan
  
  
• Coordination with other case managers
  
  
• Timeline of obtaining services
  
  
• Timeline for reevaluation of the plan

Limits:

Case management does not include direct delivery of services such as counseling, companionships, provision of medical care or service, transportation, personal care, homemaker services, meal preparation, shopping (this is not an all-inclusive list).

Case file documentation must be maintained:

1. In a secure setting
   
   
2. On each individual, in separate case files

HCBS Case Management - Service Activities, Standards of Performance, and Documentation of HCBS Case Management Activities

HCBS Case Management Service consists of the service activities or components listed below.

1. Assessment of Needs - This component is completed initially and at least every six months thereafter. At least one home visit is required during the initial assessment of needs process.

• The case manager must schedule an appointment for an initial assessment no later than 5 business days after receiving a request for home and community-based services (HCBS) and must complete an initial comprehensive assessment no later than 10 working days after receiving a request for HCBS. All contacts with an individual must be documented in the case file.

Exception: In cases where the HCBS referral is initiated through ADRL Transition or MFP Transition Services by Money Follows the Person (MFP) and HCBS Case Management, the HCBS Case Manager may follow the established timeline of MFP Transition Coordination.

• MFP Transition Coordination reaches out to the referred individual within 5 working days of the referral and facilitates a Transition Team meeting to initiate the referral within 14 days of the referral. The start date of the referral for HCBS case management is the date that the MFP transition coordinator reaches out to the team to schedule the transition team meeting.

Individuals must sign and be given a “Your Rights and Responsibilities” brochure DN 46 annually and a signed copy of this must be kept in the individual's file.

During the assessment process, when applicable, the information needed for submission to Maximus is obtained. The case management entity must use the existing and established procedures for requesting a level-of-care determination from Maximus.  

For an adult (at least 18 years of age): Complete the HCBS comprehensive assessment and gather input from other knowledgeable persons as authorized by the applicant/individual.

For a child (under 18 years of age): Complete the HCBS Comprehensive assessment AND submit the necessary documents to Maximus for a level-of-care determination.

The following service combinations require approval by the HCBS Program Administrator as indicated in the chart below;

If the individual referred to HCBS appears to potentially meet the criteria for ID/DD waiver, the case manager may contact an HCBS Program Administrator to request an interdisciplinary team staffing to determine the options available to meet the individuals request for services.

2. Person-Centered Planning

Person-Centered Planning (PCP) is a way of thinking about a person as a whole. PCP is a way to develop a plan using both formal and natural supports to address all areas that are important to the individual. PCP is a process, not a procedure or document. HCBS case management has been utilizing PCP with the current assessment and care planning process. Utilizing the Charting the LifeCourse (CtLC) framework allows HCBS to enhance our PCP practices by really focusing on what matters to the individuals, what the individuals need to live the life they want and how they can be supported to meet their needs. PCP encourages community integration and recognizes the individual’s preferred role in the community. The case manager assists the individual to overcome barriers that prevent them from living their best lives in the most integrated setting appropriate.

 

The purpose of person-centered planning is to identify, arrange, and maintain the supports and services necessary to meet the individual's needs in the most integrated setting, consistent with the member's informed choice as appropriate to the individual’s needs.

 

Person centered plans will be developed with input at a minimum from:

1. The individual to the fullest extent possible, including when the member has a legal guardian, consistent with state law N.D.C.C. 30-1-28-12. The individual will have the primary role in developing the person-centered plan when possible.
   
   
2. The individual's family and/or friends with permissions and desire of the individual; and
   
   
3. The individual's legal guardian, where applicable, to the extent the guardianship order confers residential and/or medical decision-making upon the guardian per N.D.C.C 30.1-28-04(5).

Any decision(s) made by the guardian about where the member will receive services should reflect the member’s preferences, as documented in the person-centered plan, to the fullest extent possible. See N.D.C.C. 30.1-26-01(3).

 

Case managers should facilitate a process to resolve conflicts that arise during the person-centered planning process if the individual and their family/natural supports or guardians do not agree on where the individual should live and receive services.

 

Role of Case Manager in Person-Centered Planning

The role of the case manager in the PCP process is to lead and facilitate conversations with the individual requesting or receiving home and community-based services. Person-centered planning is a way of developing a care plan that takes all aspects of what is important to an individual into consideration. The role of the case manager has four components.

 

1. Request for an assessment/reaching out for services.

The role of the case manager during this phase is to gather information. Identify who is most important to the person and who they would like to be on their team. Discuss with the individual what your role is as a case manager and what you will be discussing at the home visit. Invite them to ask friends, family or other supports to be present at the assessment if they would like. An individual may wish to invite their QSP to the assessment planning process to ensure an understanding of what services are needed and the preferences of the individual. Remind the individual of the sensitive information that you will be discussing at the visit.

2. Assessment

The case manager will engage in facilitated discussion with the individual requesting services. The case manager utilizes the HCBS Comprehensive Assessment, the Vision Tool and the Risk Assessment and Health and Safety Plan with every individual initially, annually, at six-months and when there are significant changes. When a case manager is completing the assessments and vision tool the individual may be asked to provide information about themselves, such as what is important to the individual, are there community supports or other formal supports that they are involved in? What roles does the individual have in life, such as do they identify as a friend, mother, grandmother, employee, friend, church member, quilter, wood carver, card player, veteran? How can the case manager support the individual to continue in their role? Through these conversations you will be discussing the life domains that are identified in the Charting the LifeCourse Vision tool. Additionally, the financial assessment and caregiver assessment may need to be completed.

 

The case manager must document in the assessments and vision tool the exchange of information between the individual and the case manager. Additionally, collateral information from the individuals care team may be included. If an individual does not wish to discuss information or questions in the assessment or vision tool, the case manager must document in that area the individuals wish to not answer the questions or discuss the topic.

 

For each functional impairment identified the functional assessment note must include:

• the reason the individual is unable to complete the task and/or why the individual is impaired,
  
  
• who is completing the task, how this need is met.
  
  

If the need is met through HCBS, the functional assessment must also include the following information:

• Who assists with the task,
  
  
• What service the task falls under
  
  
• The overall number of units authorized for this service type
  
  
• The anticipated outcome or goal.
  
  

3. Developing the plan

Case managers will use the information gathered through the assessment process to coordinate with the individual and team members on an action plan that meets the needs of the individual and reflects their preferences. The plan will be reviewed and updated at least every 6 months, upon individual request, or as situations arise. The PCP of care is based off of the facilitated discussion. Components of the person-centered plan of care includes the Charting the LifeCourse, (CtLC) Vision tool, formal and natural supports, strengths, barriers, unmet needs, services offered and declined, timelines and strategies to meet the individual’s goals. Additionally, the Risk Assessment and Health and Safety Plan must be completed.

 

• For Basic Care ONLY, the Personal Care Services Plan of Care and Authorization of Services in a Basic Care Setting, SFN 662, must be completed annually. DO NOT complete the Vision Tool, Person-Centered Plan of Care or the Risk Assessment and Health and Safety Plan for Basic Care. The SFN 662 must be submitted to Aging Services via the HCBS Submission Fax Line.

For Medicaid Waiver, Service Payments for the Elderly and Disabled, Expanded Services Payments for the Elderly and Disabled and Medicaid State Plan – Personal Care Services the following procedures for the person-centered plan of care applies:

 

The person-centered plan of care (PCP) includes the Vision Tool, Person-Centered Plan of Care, the preauth in Therap and the Risk Assessment and Health and Safety Plan. Additionally, the plan may include the caregiver assessment, transition plan, and/or the Individual Program Plan.

When completing the person-centered plan of care the case manager will refer to the functional assessment section of the HCBS Comprehensive Assessment to review and discuss with the individual the services and scope of the tasks (limits to the tasks) that can be provided through HCBS. The discussions on services may require gathering additional information as follows:

• In order to authorize the task of vital signs, the case manager must have on file: a written, signed recommendation (provided by a nurse or higher credentialed medical provider) outlining the requirements and frequency of monitoring. For the task/activity of exercise, a written recommendation and an outlined plan by a therapist for exercise must be on file.
  
  

The HCBS Case Manager must review with the individual or the individual's representative the following information about qualified service providers (QSP) available to provide the service and endorsements required by the individual:

1. Name, address and telephone number of QSP.
   
   
2. Whether QSP is an agency or individual.
   
   
3. The unit rate per QSP.
   
   
4. If applicable, limitations of the QSP available.
   
   
5. If applicable, endorsements for specialized cares:
   
   
6. Global Endorsements (Only a QSP who carries a global endorsement may provide these activities and tasks. Refer to the QSP list to determine which global endorsements the provider is approved to provide.) Global Endorsements include: Cognitive/Supervision, Exercises, Hoyer Lift/Mechanized Bath Chair, Indwelling Bladder Catheter, Medical Gases, Prosthesis/Orthotics/Adaptive Devices, Suppository, TED Socks, and Temperature/Blood Pressure/Pulse/Respiration Rate.

• On the Preauth document the name of the agency or person who is to be contacted to provide the results of the individual’s blood pressure, pulse, rate of respiration, or temperature.

• Client Specific Endorsements: These activities and tasks may be provided only by a provider who has demonstrated competency and a Request for Client Specific Endorsement, SFN 830, is on file in the individual's file. The provider must obtain documentation that a health care professional has verified the provider's training and competency specific to the individual's need and provide a copy to the Case Management Entity. The Case Management Entity must forward a copy of the SFN 830 to HCBS Program Administration. Client Specific Endorsements include:  Apnea Monitoring, JOBST Stockings, Ostomy Care, Postural/Bronchial Drainage or Nebulizer Treatment, RIK Bed Care (Specialty Beds).

Qualified Service Providers who can provide the required care and whom the individual has selected will be listed on the HCBS Care Plan and PreAuth.

• When a change in service provider occurs between case management contacts – the individual or legal representative may contact the case manager requesting the change in provider. The contact and approval for the change in provider must be verified in the case manager's documentation and noted on the person-centered plan of care.
  
  
• A copy of the updated care plan must be sent to the individual or legal representative. However, changes in services or the amount of service must be signed by the individual or legal representative and approved.
  
  

The service, amount of each service to be provided, the costs of providing the selected services, the specific time-period, and the source(s) of payment are recorded on the HCBS Care Plan and PreAuth.

• Individuals must be made aware of funding caps and documentation must verify that the individual has been informed of the service limits when developing the care plan at a minimum of every 6 months. If an individual's needs exceed the service limit, they would be issued a denial notice and would have the right to appeal. Or contact the HCBS Program Administration to request an exception or reasonable modification to meet the individual need if the individual is at risk of institutional placement.
  
  

Contingency plans

6. Contingency planning must occur in all person-centered plans of care. The backup provider or plan must be listed on the HCBS Care Plan.

The case manager must review with all individuals and/or the individual's representative the individual stated goal. The goal must be recorded as part of the Person-Centered Plan of Care. The individual goals must be reviewed and updated annually, every 6 months and as significant changes in the individual's needs occur or if the individual requests an update.

The final step in Care Planning is to review the completed HCBS Care Plan, with the individual/legally responsible party and obtain required agreements/acknowledgments and signatures.

When services are reduced, you must provide the individual or their legal representative.

 

In situations where the individual has requested the reduction in services, they may sign a statement requesting the services be reduced. This request must be kept the individual’s record, and the reduction in service citation is not required.

Interim Care Plans

Interim care plans are limited to individuals who receive services though the HCBS Medicaid Waiver and require services immediately, or who are affected by a natural disaster or other emergency.  An interim care plan may be developed for an individual who is on Medicaid, has an approved Level of Care (LOC) Determination that was completed within the previous 90 days, and the case manager is unable to complete an immediate visit. When services are needed immediately the case manager will need to complete a face-to-face visit and complete an assessment within 10 working days of the request. During natural disasters or other emergencies, a face- to- face visit must be made within 60 days of the request. Prior approval from the Department is required.

• Example 1: An individual who is currently in a Nursing Home, has a LOC in place, and is on Medicaid, plans to return home and the Case manager is unable to see the individual on the day of transfer home. An interim care plan could be written, and services could begin, however, a face-to-face visit would need to be completed within 10 days.
  
  
• Example 2: A current individual has a LOC in place, is on Medicaid but because of flooding their residence is not accessible, an interim care plan could be written so services could continue for up to 60 days before a face-to-face visit is required.

Medicaid eligibility redetermination is completed by Economic Assistance. An individual who is receiving service through the HCBS Waiver is required to be receiving Medicaid. If, in the redetermination process, it is determined the individual is not eligible for Medicaid, payment for services stops the day Medicaid terminates. If the individual has an established HCBS Care Plan and PreAuth and the termination is overturned, waiver services could be paid during that period of time.

4. Implementation/Review

The case manager's role during implementation is to educate others in the team about the possibilities of long-term services and supports, facilitating planning now and into the future, problem solving, coordinating integrated services and supports, conflict resolution and advocacy (CtLC, 2020). The case manager is responsible for assessing and authorizing services offered under Aging Services in addition to working collaboratively other formal and natural supports. It is important to understand the role of the case manager in relation to the other team members involved in the individual’s care. Open discussion surrounding the roles of the team members should be included in the care planning meeting and implementation planning process. It is helpful to clearly define the roles of each member and write a list of tasks that team members are responsible for in the implementation of the plan. The case manager is responsible for monitoring the plan for progress and any changes in the individual's care needs.

Release of Information (ROI) Guidance for Implementation and Review of Person-Centered Planning

It is best practice is to have a ROI signed by the individual and/or their legal representative whenever releasing information. A ROI provides proof that the individual agrees and understands what information is being released and the purpose of releasing the information. As a professional, with a professional license or certification, having an ROI on file, also provides guidance and assurance to the professional on the individual wishes to how and what information they have agreed to release to another entity.

Governing Policy; DHHS Confidentiality Manual

01-20. Disclosure of Client-Identifying Information (Revised 03/18 ML #3516)

01-20-01. Use Within the Department (Revised 03/18 ML #3516)

01-20-10. Disclosure Outside the Department (Revised 03/18 ML #3516)

01-25-45.01. Treatment, Payment, Health Care Operations (Revised 03/18 ML #3516)

Treatment: Treatment means the provision, coordination, or management of health care and related services by one or more health care providers, including the coordination or management of health care by a health care provider with a third party; consultation between health care providers relating to a patient; or the referral of a patient for health care from one health care provider to another.

Treatment involves health services provided by a health care provider and tailored to the specific needs of an individual patient (not entire populations).

Activities are considered treatment only if delivered by a health care provider or a health care provider working with another party.

Activities of health plans are not considered to be treatment.

01-25-45-25. Disclosure of PHI to Business Associates (Revised 03/18 ML #3516)

Continuity of Care

In order to coordinate services for an individual, case managers may need to make referrals and gather other collateral information. Not all communication requires a release of information.

 

Examples, Questions and Answers

 

Case Managers can share individual information with health care professionals working in these following settings: Home Health Care, Hospitals, Clinics, PACE, and LTC facilities as this communication is part of the continuum of care guidelines under HIPAA. Case Managers can also share information with other case management entities (i.e. DD, VR, Behavioral Health) within the Department of Health and Human Services, as well as Eligibility Workers under the Medical Services Division. Information shared without a release of information must be on a need-to-know basis to coordinate care for the individual, disclosing only the minimum necessary amount of information pursuant to 45 CFR 164.502(b). Disclosure of information related to Psychological or Substance Abuse Treatment requires that the individual sign a Release of Information.

 

Question: Are there program federal and state rules and regulations that dictate what information can be disclosed?

Answer: HIPAA permits health care providers to disclose to other health providers any protected health information (PHI) contained in the medical record about an individual for treatment, case management, and coordination of care and, (with few exceptions), treats mental health information the same as other health information. Some examples of the types of mental health information that may be found in the medical record and are subject to the same HIPAA standards as other protected health information include:

• medication prescription and monitoring

• counseling session start and stop times

• the modalities and frequencies of treatment furnished

• results of clinical tests

• summaries of: diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date.

HIPAA generally does not limit disclosures of PHI between health care providers for treatment, case management, and care coordination, except that covered entities must obtain individuals’ authorization to disclose separately maintained psychotherapy session notes for such purposes. Covered entities should determine whether other rules, such as state law or professional practice standards place additional limitations on disclosures of PHI related to mental health.

Requests for records made by a covered entity to be delivered to another covered entity for care purposes are called “Continuity of Care” requests. Records necessary for care of the patient fall under the “treatment” provision on the HIPAA Privacy Rule and do not require an authorization from the patient.

 

Question: Are case managers able to release third party records (medical records that the CM may have on file from medical providers) to perspective providers such as AFC, ARS, or skilled nursing facilities?

When an HCBS client asks for assistance with admission into a nursing home or into an agency AFC, ARS, etc., the admitting agency may want medical records to review in order to make a determination for accepting the individual.

Example: An HCBS client is requesting SNF placement. The family isn’t much help as they do not understand the paperwork and can’t send the records needed. The individual family wants the CM to help with getting this individual admitted ASAP and the individual is in agreement. We are searching for nursing homes across the state, but each NH wants a history and physical, med list, therapy notes, all the medical information they can get to review the case and see if they can meet the individual needs. With an ROI signed, can HCBS send the requested third-party records to the potential provider?

Answer: Case Managers are able to release (provide) third party records to perspective providers, AFC, ARS or SNF to provide “Continuity of Care” to the individual served. This would include records such as the history and physical, medication list, physical or occupational therapy notes and other medical diagnosis or needs.

 

Case Manager are NOT able to release psychotherapy notes as they are protected information.

 

Further Guidance referenced from DHS Confidentiality Manual 01-25-35. Information Obtained from Sources Outside the Department (Revised 03/18 ML #3516) Information obtained from sources outside the Department, also known as "third party information" or "collateral information," does not enjoy any special status with regard to its use or transfer within the Department or disclosure outside the Department unless different treatment is specifically required by federal or state law, federal regulations, or state administrative rules.

 

Information, which does enjoy special status, includes Social Security records, Vocational Rehabilitation records, substance use disorder treatment information, adoption information, and the identity of a reporter of suspected child abuse or neglect.

 

The workforce member responsible for responding to requests for information (e.g., counselor, case worker, records custodian) has the duty to be aware of laws and regulations mandating different treatment, and to seek assistance if he or she has questions.

 

Question: For entities that we have contracts with who are not employed by the DHHS, do we need a release to coordinate services in addition to the contract that permits the disclosure of PHI? (This would include the Alzheimer’s Association, CILS, MFP after a case close with MFP, the Senior Centers, etc.)

Answer: This depends.

1. Are there program federal and state rules and regulations that dictate when and how information can be disclosed?

2. Is there a business associate agreement in addition to the contract that permits the disclosure of PHI?

3. Is the disclosure for treatment purposes? Under the “Continuity of Care” law, it talks about info related to “care of the person” so we know we do not releases for HHC or the hospital, but these other entities are more of a gray area.

Due to this being a gray area, a ROI would be needed in most to release information to outside entities such as The Alzheimer’s Association, CILS, MFP after a case closes with MFP, the Senior Centers, etc.

 

Collaboration and PHI Disclosure between LTC Ombudsman and Vulnerable Adult Protective Services (VAPS)

• Case manager disclosing the PHI of a LTC resident for the purpose of filing a complaint about a LTC facility with the LTC Ombudsman. Case managers are health care providers and are subject to HIPAA. HIPAA permits this disclosure.

• Case Manager disclosing the PHI of a LTC resident for the purpose of reporting abuse/neglect of a vulnerable adult to VAPS. Case managers are health care providers and are subject to HIPAA. HIPAA permits this disclosure and NDCC 50-25.2-03 requires the disclosure.

• Disclosure by VAPS of information of a LTC resident pursuant to an abuse/neglect report, to the LTC Ombudsman. Neither VAPS nor the LTC Ombudsman are subject to HIPAA. They may receive PHI from a case manager, but once they receive it, it is no longer PHI and is subject to the confidentiality of the VAPS and LTC Ombudsman state confidentiality laws. This disclosure of information from VAPS to the LTC Ombudsman is required under NDCC 50-25.2-04.

3. Implementing the Person-Centered Plan of Care - The Case Manager assures that services are implemented, and existing services continued as identified in the person-centered plan of care. This activity includes contacting the QSP and issuance of a Preauth.
   
   
4. Monitoring - Service monitoring is an important aspect of case management and involves the case manager's periodic review of the quality and the quantity of services provided to service recipients. The Case Manager monitors the individual's progress/condition and the services provided to the individual. As monitoring reveals new information to the Case Manager regarding formal and informal supports, the care plan may need to be reassessed and appropriate changes implemented. The case management entity is responsible to monitor the service plan and individual's health and welfare. If the individual’s care needs cannot be met by the care plan and health, welfare, and safety requirements cannot be assured, case management must initiate applicable changes or request a team staff meeting through the HCBS Program Administrator to discuss possible terminate termination of services. If the case is closed, the individual is made aware of their appeal rights (see Closures, Denials, Terminations, and Reductions in Services 525-05). The case manager shall document all service monitoring activities and findings in the individual's case file.

1. The HCBS Case Manager must contact the individual after the first 30 days from the initial care plan implementation. This may be via phone or face-to-face. (If the individual is unable to communicate via telephone, a face-to-face visit is required.) The purpose of this contact is to follow up on the implementation of the person-centered plan of care (PCP), ensure the individual’s needs are met and ensure the scope and amount of services authorized are provided.
   
   
2. The HCBS case manager shall monitor the services provided under the PCP on an as needed basis but not less than direct individual contact at least once every three months for Medicaid Waiver, MSP level B and MSP level C.

3. Residents of basic care facilities under Basic Care Assistance Program must have an initial and annual HCBS Comprehensive Assessment and completion of the SFN 662.
   
   
4. Monitoring contacts and reassessments may be required if there is a change in the individual’s condition or critical incident report (CIR) that requires a follow up to ensure health and safety of the individual.
   
   
5. Monitoring for Abuse, Neglect, or Exploitation: When completing monitoring tasks, if the case manager suspects a Qualified Service Provider or other individual is abusing, neglecting, or exploiting a recipient of HCBS, the following protocol is to be followed by the HCBS Case Manager:

In all situations:

1. Initiate a formal VAPS (Vulnerable Adult Protective Services) referral according to ND Century Code 50-25.2-03(4).
   
   REPORTING OPTIONS

• Online https://bit.ly/3vbYbEj
  
  
• Reporting Form, SFN 1607 sfn01607.pdf (nd.gov) can be emailed to: dhsvaps@nd.gov or faxed to: 701-328-8744

2. Notify the HCBS Program Administrator responsible for complaint resolution in writing of all actions taken to follow up on a suspected case of abuse, neglect, or exploitation of an HCBS recipient.
   
   
3. The Risk Assessment and Health and Safety Plan may need to be updated and reviewed in the following circumstances.

• When there is a risk identified during assessment, reassessment or monitoring visits.
  
  
• Critical incident report (CIR) has identified a risk to the individual served by HCBS.

• The Program Administrator responsible for monitoring and review of all CIR’s will contact the case manager in the event there is an event reported that requires an update to the Risk Assessment and Health and Safety Plan.

• QSP complaint has identified a risk to the individual served by HCBS.

• The Program Administrator for monitoring and review of all QSP Complaints will contact the case manager in the event that there is a complaint that requires an update to the Risk Assessment and Health and Safety Plan.

• VAPS report has identified a risk to the individual served by HCBS.

• VAPS and HCBS case manager will work together to update or revise the Risk Assessment and Health and Safety Plan to address any identified risk or health and safety concerns identified in the VAPS report.

Documentation for an event involving abuse, neglect, exploitation, CIR, QSP complaint or VAPS must be included in the case note and include the following:

• Identify and document in writing the name of the qualified service provider or other individual provider.
  
  
• Document in writing a complete description of the problem or complaint.

Process:

• Immediately report suspected physical abuse or criminal activity to law enforcement.
  
  
• If you have reasonable grounds to believe the recipient’s health or safety is at immediate risk of harm, make a home visit to further assess the situation and take whatever action is appropriate to protect the recipient.
  
  
• If you can document that no immediate risk exists, but a problem requires further action, work with the recipient and other interested parties to resolve the matter as soon as possible.
  
  
• If the HCBS Case Manager and Nurse Educator determine that an incident is indicative of abuse, neglect, or exploitation, the HCBS Case Manager must immediately report the critical incident to the Department.
  
  
• Comply with North Dakota State law Chapter 50-25.1, CHILD ABUSE AND NEGLECT.
  
  
• When the service is provided on Reservation Lands, the Tribal Laws that govern abuse and neglect on that reservation must be followed.

Process specific to the individual's living arrangements, individuals implicated, or the Provider type (all incidents/actions must be reported to the Aging Services Program Administrator):

4. Individual lives in his or her own home and the qualified service provider is an Individual or Agency enrolled QSP:

If you can document that no immediate risk exists, but a problem requires further action, work with the recipient and other interested parties to resolve the matter as soon as possible.

• If the provider is a Basic Care Facility or Residential Care Facility that is licensed as a Basic Care Facility:

Notify the Ombudsman Program Administrator, Aging Services Division

And

The North Dakota Department of Health Facilities.

• If the qualified service provider is an Assisted Living Facility:

Notify the Ombudsman Program Administrator, Aging Services Division

And

The DHS Program Administrator responsible for Assisted Living Licensing.

• If the complaint involves the provision of home delivered meals, contact the HCBS Program Administrator.
  

• Individual lives in his or her own home and is being abused, exploited, or neglected by an individual other than the QSP:

File a report with law enforcement and/or Adult Protective Services as indicated by the seriousness of the allegation.

• If the individual is living in an AFC Home:

Contact the HCBS Case Manager responsible for AFC licensing,

And

Contact the Aging Services Division Program Administrator.  

• If the case involves a Licensed Child Foster Care Home, the regional representative responsible for the children's foster care licensing must be contacted.
  
  
• If the case involves an individual who is receiving DD Services, contact the individual's DD Program Manager or the Regional Program Administrator.

The Department of Human Services may remove a Qualified Service Provider from the list of approved providers if the seriousness and nature of the complaint warrants such action. The Department will terminate the provider agreement with a Qualified Service Provider who performs substandard care, fraudulent billing practices, abuse, neglect, or exploitation of a recipient. North Dakota Administrative Code section 75-03-23-08 lists reasons why the Department may terminate a Qualified Service Provider.

5. Reassessing - The case manager reassesses the individual, care plan, and services on an ongoing basis, but must do a reassessment at six-month intervals and the comprehensive assessment annually. At the six month and annual visit, the individual stated goal must be reviewed, and progress or continuation of the goal must be noted in the narrative of the vision tool.
   
   
6. Termination of Service - When documenting that service(s) on the Individual Care Plan or the Person-Centered Plan of Care were terminated, and indicating the reason(s) for termination, refer to Closures, Denials, Terminations, and Reductions in Services (525-05-40) unless the individual is requesting services to be reduced. In situations where the individual has requested the reduction in services, they may sign a statement requesting the services be reduced.

Contacts with Individuals

Virtual Supports -

A visit by virtual means can be conducted when individual cannot have an in-person face to face due to extenuating circumstances. The individual may be afforded the option to use the phone or other telehealth technology to engage in the development and/or monitoring of person-centered plans when there are extenuating circumstances impeding the ability to conduct the visit in person.

• Extenuating circumstances may include instances where the in-person visit poses a health or safety risk to the individual or case manager; public emergency as determined by local, state and federal government.

  • Examples of extenuating circumstances may include but are not limited to the following instances:

    • The individual cannot be seen due to having a medical condition, ie., contagious disease, treatments that weaken the immune system,

    • Natural disasters and or threats,

    • Weather related road closures, no- travel advisories.

• The participant’s services may not be delivered via virtual support 100% of the time.

• The participant must always have the option to request in-person services.

• Instances of visit by virtual mean must be approved by the HCBS CM Supervisor or HCBS Program Administration as a safeguard to ensure virtual supports can help meet the needs of the participant in a way that protects the right to privacy, dignity, respect, and freedom from coercion.

• Virtual supports are not a system to provide surveillance or for staff convenience.

• Any issues will be addressed prior to the implementation of remote supports and documented in the individual’s case record.

• In virtual supports, the use of cameras in bathrooms or bedrooms impacting the participant’s dignity and privacy is not permitted. Provider must use a HIPAA compliant service delivery method.

  • (e.g. Microsoft Teams, Zoom for Healthcare). HIPAA rules apply to all covered entities regarding HIPAA Privacy and Security. Participant will be given education and support on the use of virtual supports by their chosen provider.

Once the extenuating circumstance no longer limits the ability to complete the home visit, the case manager must follow-up with a face-to-face visit for monitoring as outlined in policy.

• The face to face must be scheduled as soon as possible, not waiting until the next required visit.

• The required face to face visits provides assurance that the individual is receiving services within the scope and amount authorized.

• The face to face also assures a view of possible health, welfare and safety concerns that may not be relayed through the phone or virtual contact.

For SPED and EXSPED -

• An Initial HCBS Comprehensive Assessment is required to establish eligibility for services and following implementation of the service a contact shall be made with a NEW individual within the first 30 days of implementation of services. The initial, annual assessment and six-month assessment are required to be face-to-face visits in the individual’s home. During the annual and six-month assessments a quality review questionnaire is completed with the individual as part of the assessment process.

Waiver:

• HCBS Waiver Services: An Initial HCBS Comprehensive Assessment is required to establish eligibility for services. Following implementation of the service, a contact (either in person or via telephone) must be made with a NEW individual within the first 30 days of implementation of services. Quarterly contacts with the individual are required, including an annual assessment, six-month reassessment and two quarter contacts. During the annual and six-month assessments, a quality review questionnaire is completed with the individual. All four contacts must be face to face and take place in the individual residence.

• Case Management coordinates an annual interdisciplinary team conference and invites the legal representative and others as requested by the individual.

All required contacts must include responses to the following questions:

• Date
  
  
• Reason for contact. (initial, annual, six month, quarterly, collateral, returned call, received call, etc.)
  
  
• Location of visit (home visit, care conference, hospital visit, office visit, telephone contact, letter sent, etc.)
  
  
• A description of the exchange between yourself and the individual or the collateral contact. If this is a face to face visit- describe the environment, individual's appearance, and communication style
  
  
• Review the Individual Service Plan developed by the Adult Residential Provider (who provides services primarily to individual with TBI) or the Transitional Care Provider at the annual and semi-annual interdisciplinary team meeting and document the results of the Individual Program Plan
  
  
• Individual satisfaction
  
  
• Follow-up plan
  
  

Reimbursement/Payment for Service

The Case Management Entity may bill for case management if the individual meets the eligibility criteria of the programs as identified in HCBS Case Management - Service Activities, Standards of Performance, and Documentation of HCBS Case Management Activities.

Request for reimbursement must be supported by documentation in the individual’s case file and/or web-based case management system that case management service activities were completed.

When a change in funding source occurs, initial Case Management can be claimed under the new funding source the month of transfer (opening under new funding). The annual case management cycle starts with this action. No claim for case management can be made to the funding source being closed. Initial case management is allowed to establish the case under the new funding source.  

A higher rate is used for higher-level case management for individuals eligible for Medicaid Waiver for Home and Community Based Services.

Administrative Tasks (Non-billable)

Any task or activity that is not directly related to the following cannot be billed as case management; person-centered planning and coordination; assessment or reassessment of an individual; development, implementation, or monitoring of a care plan. Administrative tasks such as those listed below are examples of non-billable activities:

1. Assisting a provider with billing issues or enrollment; participating in appeal hearings; attending training or staff meetings; supervising/scheduling of In-home Care Specialists, etc.  

Level of Care Determination (LOC)

It is the responsibility of the HCBS case manager to initiate the screening either by submitting information to Maximus.

A LOC determination/screening must be completed for an individual who is requesting services through a waiver program, or an individual who under the age of 18 and requesting SPED services, and MSP-PC Level B or C. LOC determinations must be updated as significant changes occur that would impact the LOC determination outcome and at minimum on an annual basis. Following are the screen types listed on the LOC Determination Form.

• HCBS Waiver
  
  
• MSP-PC (Level B or C)
  
  
• SPED under age 18
  
  
• MSP-PC/SPED under age 18 (Check only if eligible for both)
  
  

For the purposes of opening/re-opening or prematurely closing a HCBS screening, see the instruction for the SFN 474.

No screening will be needed if Waiver Services are re-implemented within 90 days of the individual's discharge from the nursing home or swing bed and prior to end date of the LOC of the current HCBS screening.

• The reopening date of the LOC for HCBS Waiver must be indicated on the SFN 474.

Upon completion of LOC determination, Maximus will submit to the Aging Services Division a list of the recipients, with the approval or effective date of eligibility, ID Number, and date of birth. This information will then be entered on the Nursing Home Eligibility file in the payment system. DDM will also send written confirmation of HCBS (NF) determination to the HCBS case manager for filing in the individual's record.

When an HCBS individual screened for Medicaid Waiver services appears to no longer meet nursing facility (NF) care (Screen Type: HCBS), a re-screening should occur. A significant improvement in the recipient's medical/physical status or a decrease or cessation of services provided are examples that could trigger a re-screening. Maximus needs to be informed of the reason for the screening and intended outcome to "other". If Maximus concurs the recipient no longer needs NF care, an ending date of services needs to be given to Aging Services by using the SFN 474, to Aging Services/HCBS. The ending date is the responsibility of the case manager and needs to allow sufficient time in which to give the individual a ten-day (calendar days) notice of service termination under the Medicaid Waiver funding source. Maximus will report screening terminations with closing dates to Aging Services. Aging Services will input the ending date of services on the computerized screening.

Nursing Facility (HCBS) Level of Care Determination But The Individual Is Not Receiving Waiver Services

The stop date on the screening is important for Medicaid recipients having a spouse in the household who qualify for spousal impoverishment. The recipient is treated, for Medicaid budgeting purposes, as if living in the nursing facility only when RECEIVING services paid by the Waiver. If an individual is residing in their home, receiving spousal impoverishment under Medicaid, they must receive a Medicaid Waiver service each month to remain eligible under the spousal impoverishment guidelines. If Waiver funded services are NOT provided, the screening must be "closed" so that the correct budgeting method is reflected in the Medicaid data system. Submit SFN 474, HCBS Case Closure/Transfer Notice, so a closing date is entered in the Medicaid data system.

Case File Contents

1. For all programs, all case files, or in the web-based case management system should have (at a minimum):

1. Application for Service SFN 1047
   
   
2. A signed copy of Your Rights and Responsibilities brochure (DN 46)
   
   
3. Preauth for Medicaid Waiver, SPED/Ex-SPED, and MSP (updated every six months)
   
   
4. Monthly Rate Worksheet (if applicable)(SFN 1012 updated annually)
   
   
5. HCBS Notice of Denial or Termination SFN 1647 (if applicable)
   
   
6. HCBS Case Closure/Transfer Notice SFN 474 (if applicable)
   
   
7. An end dated or deleted Preauth (if applicable)
   
   

2. The case file for each Medicaid Waiver individual must contain:

1. Documentation of verification the person is a Medicaid recipient
   
   
2. Medical information (if applicable)
   
   
3. Record of current level-of-care determination(s) (updated annually)
   
   

3. The case file for each Expanded SPED individual must contain:

1. Expanded SPED Program Pool Data SFN 56
   
   
2. Add New Record to MMIS Eligibility File, SPED and ExSPED, SFN 676
   
   

4. The case file for each SPED individual must contain the:

1. SPED Program Pool Data SFN 1820
   
   
2. Add New Record to MMIS Eligibility, SPED and ExSPED, SFN 676
   
   
3. SPED Income and Asset SFN 820, (updated annually)