HCBS Case Management 525-05-30-05

(Revised 11/1/21 ML #3640)

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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 a functionally impaired 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 individuals 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 or TD Waiver and authorize services if the individual is eligible for services under either 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 or TD Waiver and are eligible to authorize services for an individual, if the individual is eligible for services under either 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 a individuals 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 Professionals (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 approved 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 client 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's 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 Individual Care Plan. 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.

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 Dual Diagnosis Management (DDM) is obtained. The case management entity must use the existing and established procedures for requesting a level-of-care determination from (DDM).  

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 DDM for a level-of-care determination.

The following service combinations require approval by the HCBS Program Administrator and re-approved annually:

• Homemaker services when individual lives with capable person or provider
• If an individual lives with a prospective respite care provider

The combination of HCBS services and hospice service requires documentation in the case note that the individual continues to meet eligibility for the service and there is no duplication of services.

The hospice service must also be noted on the "other services" section of the person-centered plan.

All other service combinations or exceptions require one-time approval or when the individual’s needs change.

Individuals who may be eligible for services under the ID/DD Waiver are referred to the Regional Development Disability Program Administrator. Case Manager must issue a formal denial if comprehensive assessment has been completed prior to referral.

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 preventing 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 individuals needs in the most integrated setting, consistent with the members 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 family and/or friends with permissions and desire of the individual; and
3. The individuals 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. When a case manager is gathering information you will be gathering information about the individuals story. 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 functional assessment, financial assessment, risk assessment and caregiver assessment may need to be completed.

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 individuals 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. If a risk is identified a remediation plan must be completed.

The vision tool must be completed for all HCBS funding sources with the exception of Basic Care.

The person-centered plan of care (PCP) includes the signed individual care plan, authorization (Preauth in Therap) and the completed vision tool. PCP requirements per funding source are as follows.

• For Basic Care, the SFN 662 and 663 are completed. DO NOT complete the Vision Tool for Basic Care. The SFN 662 and 663 must be submitted together to Aging Services, HCBS Submission Fax Line.
  
  
• For Medicaid State Plan Personal Cares, the individual needs are included on the SFN 662 and authorized using the Therap Preauth. The SFN 662 must be submitted together to Aging Services, HCBS Submission Fax Line.
  
  
• For HCBS Medicaid Waiver, the individual needs are included on the SFN 404 and authorized using the Therap Preauth. The SFN 404 must be submitted together to Aging Services, HCBS Submission Fax Line.
  
  
• For SPED and EXSPED, the individual needs are included on the SFN 1467 and authorized using the Therap Preauth. The SFN 1467 must be submitted together to Aging Services, HCBS Submission Fax Line

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 HCB services, the functional assessment must also include the following information:

• number of units,
• time per week allocated for the task, and
• the anticipated outcome or goal.
  
  

Refer to the functional 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.

• 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 and provided 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 ICP, SFN 1467 or the SFN 404.

• 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 managers documentation and noted on the ICP which is sent to the Aging Services/HCBS.
  
  
• 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 ICP, SFN 1467, or SFN 404 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.
  
  

Contingency plans

6. Contingency planning must occur in all person-centered plans of care. The backup provider or plan must be listed on the SFN 1467 or SFN 404.

The case manager must review with all individuals and/or the individual's representative the individual stated goal. The goal must be recorded on the Vision tool 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.

For Medicaid Waiver Only:  Complete SFN 1597, Explanation of Individual Choice and submit to Aging Services/HCBS.

The final step in Care Planning is to review the completed SFN 1467, or SFN 404 with the individual/legally responsible party and obtain required agreements/acknowledgments and signatures. See the instructions for completing the SFN 1467 or SFN 404.

When services are reduced, you must provide the individual or their legal representative with a completed SFN 1647 (see Closures, Denials, Terminations, and Reductions in Services 525-05-40).

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 a 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 Economic Assistance sends the termination notice. If the individual has an established ICP and Authorization and the termination is overturned, waiver services could be paid during that period of time.

4. Implementation/Review

The case managers 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 part of the 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 individuals care needs.

Continuum 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. For example, 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 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.

3. Implementing the Person-Centered Plan of Care - The Case Manager assures that services are implemented and existing services continued, as identified in the Individual Care Plan or the Person Centered Plan of Care. This activity includes contacting the QSP and issuance of an Authorization for Service(s) SFN 1699 or SFN 410 to be delivered. Refer to instructions for completing the SFN 1699 or SFN 410.
   
   
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 participant 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 shall monitor the services provided under the Person-Centered Plan of Care on an as needed basis but not less than direct individual contact at least once every three months.

• For Medicaid Waiver Only: 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. Face-to-face contacts are required at least quarterly thereafter.

2. Monitoring for Targeted Case Management (TCM) - The same case management monitoring schedule followed for SPED and Expanded SPED recipients applies even when TCM covers the cost of case management.
3. Residents of basic care facilities under Basic Care Assistance Program must have two face-to-face visits per year (annual and 6-month review), no other contacts are required.
4. 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).

• To file a VAPS report, visit: https://fw2.harmonyis.net/NDLiveIntake/ or
• Complete the SFN 1607 (Report of Vulnerable Adult, Abuse, Neglect, or Exploitation). The SFN 1607 fillable form may be found at: https://www.nd.gov/eforms/Doc/sfn01607.pdf

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. A risk assessment must be completed 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 a CIR that requires a risk assessment.

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

• The Program Administrator responsible for monitoring and review of all QSP complaints will contact the case manager in the event there is a complaint that requires a risk assessment.

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

• VAPS and HCBS case manager will work together to ensure a risk assessment is completed and included in the person-centered plan of care.

Documentation must include:

• Identify and document in writing the name of the recipient.
• Identify and document in writing the name of the qualified service provider or other individual.
• 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 Manager/Trainer determine that an incident is indicative of abuse, neglect, or exploitation, the HCBS Case Manager must immediately report the 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 a AFC Home:

Contact the CSSB 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).

Contacts with Individuals

For SPED and EXSPED -

• An Initial 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. Quarterly contacts with the client are required. Of the four, two must be home visits; one is at the time of the annual assessment and the other at the time of the six month assessment. The other two contacts may be by telephone (if the individual can communicate over the phone) or office visit.

Waiver:

• HCBS and TD Wavier Services: An Initial 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, 6 month reassessment and two quarter contacts. All four contacts must be face to face and take place in the individual residence. During the first quarterly visit, the Medicaid Waiver Quality review, (SFN 1154) must be completed at the first quarterly review of each year (this visit should not occur during the annual or 6-month contact), and a copy of this review must be sent to the Department.

• Services under the HCBS Waiver that are specific to Adult Residential and Transitional Care Services provided to individual as a result of the need for independent living skills training, support and training provided to promote and develop relationships, participate in the social life of the community, or develop workplace task skills including behavioral skill building requires all four contacts to be face to face. The annual and six month contact need to occur in the individual’s residence. The other contacts must be face to face but can occur at other locations. 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
  
  
• A listing of identified needs, which includes the services the individual is currently receiving
  
  
• Service delivery options which includes, discussion about service caps, and potential service available, needed, or requested
  
  
• Summary of care plan, which includes the outcome of the discussion of the agreed upon services requested, including other agencies or individuals providing care
  
  
• Identify individual stated goals, progress, change in goals, etc at the initial, annual and six month contact in this narrative note or in question #1.H.1. Describe the individual's stated goals and results or progress
  
  
• 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
• Do the amount, duration and frequency of services meet the individual’s needs?
  
• Does the provider, provide the services outlined on the care plan and authorization in the amount, duration and frequency expected.
  
  
• 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 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 may be 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 telephoning Dual Diagnosis Management (DDM) or by submitting information to DDM (the web based method is the preferred method to submit information to DDM).  

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. 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.

• Tech Dependent Waiver
• HCBS Waiver
• HCBS Waiver/MSP-PC (Check only if eligible for both)
• SPED under age 18
• MSP-PC/SPED under age 18 (Check only if eligible for both)
• MFP-Final and if the individual is receiving a HCBS Waiver service, complete a referral to a HCBS Program Administrator to assist with the eligibility determination process

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.

Upon completion of LOC determination, DDM 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. DDM needs to be informed of the reason for the screening and intended outcome to "other." If DDM 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. DDM 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. The recipient is treated, for Medicaid budgeting purposes, as if living in the nursing facility only when RECEIVING services paid by the Waiver. At such time as Waiver funded services are NOT provided, the screening must be "closed" so that the correct budgeting method is reflected in TECS. Submit SFN 474, HCBS Case Closure/Transfer Notice or Request for HCBS NF Determination, so a closing date is entered on the Nursing Home Eligibility File.

Case File Contents

1. For all programs, all case files should have (at a minimum):

1. Application for Service SFN 1047
2. A signed copy of Your Rights and Responsibilities brochure (DN 46)
3. Completed/Signed SPED/ExSPED Individual Care Plan SFN 1467 (updated every six months) or a completed/signed Medicaid Waiver Person Plan of Care SFN 404
4. Preauth for Medicaid Waiver, SPED/Ex-SPED (updated every six months)
5. Monthly Rate Worksheet (if daily rate individual) (SFN 1012 updated annually)
6. HCBS Notice of Denial or Termination SFN 1647 (if applicable)
7. HCBS Case Closure/Transfer Notice SFN 474 (if applicable)
8. A cancelled Preauth

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

1. Verification the person is a Medicaid recipient
2. Medical information (if applicable)
3. Record of current level-of-care determination(s) (updated annually)
4. Completed/Signed Explanation of Client Choice SFN 1597
5. CCSB Request for HCBS NF Determination SFN 1288 (if applicable)

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, HCBS Income and Asset Assessment (updated annually)