Community Support Services 525-05-30-21

(Revised 06/01/2025 ML #3921)

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Definition

Community supports is formalized training and supports provided to eligible individuals who require some level of ongoing daily support. This service is designed to assist with and develop self-help, socialization, and adaptive skills that improve the participant’s ability to independently reside and participate in an integrated community. Community Supports may be provided in community residential settings leased, owned, or controlled by the provider agency, or in a private residence owned or leased by a participant.

The participant must be able to benefit from one or more of the following care coordination, community integration/inclusion, adaptive skill development, assistance with activities of daily living, instrumental activities of daily living, social and leisure skill development, medication administration, homemaking, protective oversight supervision, and transportation.

This service may be most beneficial to individuals with physical disability or complex medical needs who require ongoing custodial and/or maintenance care.

Purpose

Community Support Services provides all-inclusive service provided up to 24 hours a day to individuals who otherwise would be in an institutional setting.

Service Eligibility

The individual receiving Community Support Services will meet the following criteria:

1. Must be eligible for Medicaid Waiver for Home and Community Services.
2. Requires some level of on-going daily support.
3. The individual is capable of directing their own care or has a legally responsible party to act on the recipient’s behalf.
4. Pre-approval from the Department of Human Services is required before this service can be authorized.

Service Tasks/Activities

Care coordination is the primary responsibility of the QSP Agency Program coordinator. Authorized task includes:

1. Individual program Plan (IPP) Development, Coordination, Implementation and Evaluation.

1. Complete tasks such as individual plan development, monitoring the plan and observing to assure that the agency staff are trained, and the program is implemented, assisting with the development of behavior support techniques, assuring appropriate permission and approval is received from the individual and/or the legal decision maker.
2. Professional services are included in the "care coordination" hours and are not to be included in determination of direct support service hours.

Care coordination functions provided by the QSP agency include:

1. Management of an individual's property and resources including household budgeting, money management, communicating with creditors and landlords, etc.,
2. Application for generic services, monitoring status of those services, and maintaining communication with families, guardians, and other involved persons and agencies,
3. Coordinating medical needs,
4. Designing and implementing programs to enhance self-direction, independent living skills, community integration, social, recreational, and leisure skills and opportunities, and behavior management,
5. Facilitating the IPP planning process,
6. Assessing effectiveness of personal independence development strategies and other support services through analysis of information, consultation with the individual and/or guardian and family members, and observation of the person's programs and service settings,
7. Asserting and safeguarding the individual's human and civil rights, and
8. Attending to psychosocial needs of the individual.

Hours for direct staff time for personal supports include:

1. General supervision for safety and health monitoring and maintenance,

   1. If the individual is authorized for 24 hour 1:1 support, the QSP agency must ensure staff are present at all times. If the individual is able to be left alone for brief periods of time, this information must be specified in the person-centered service plan and the IPP.

2. Homemaking which may include home maintenance,
3. Assistance with activities of daily living and instrumental activities of daily living

1. bathing
2. communication
3. dressing/undress
4. eyecare
5. feeding/eating
6. haircare/shaving
7. housework
8. incontinence
9. laundry
10. meal preparation
11. mobility (inside/outside)
12. Money Management
13. nailcare (fingernails)
14. shopping
15. skincare
16. teeth/mouth care
17. toileting
18. transferring/turning/positioning

4. Global Endorsements tasks

1. exercises
2. hoyer lift/mechanized bath chairs
3. indwelling catheter
4. medical gases
5. prothesis, orthotics
6. suppository, bowel program
7. TED socks
8. vitals

5. Client specific endorsements

1. apnea monitor
2. JOBST stockings
3. ostomy care
4. postural/bronchial drainage
5. RIK bed care

6. Medication administration

1. Under this chapter employees of an enrolled community support services QSP agency who have received Department approved training may administer routine medications to recipients even if they are unable to self-direct their care. The QSP agency must employ or contract with a licensed registered nurse who provides supervision to the employees who are administering routine medications. The licensed nurse determines competency in medication administration by the employee’s successful completion of the Department approved medication practicum. This does not include medications administered through a parenteral route (e.g. intravenous or intramuscular injections). The licensed nurse is responsible for ensuring that medications have been administered correctly according to the six rights of medication administration (individual, dose, time, route, medication, documentation), and that documentation is completed accurately.
2. The QSP agency must have a training protocol and policy established for the administration of all medications, including PRN medications. The registered nurse is responsible for the training and oversite of all medication administration.
3. The licensed registered nurse employed by the QSP agency may perform medication set-up.

7. Transportation to support medical, social, and essential community services.
   
   
8. Accompanying individual to medical appointments.

Hours for direct staff time for personal independence development:

1. Development of natural supports,
2. Activities and strategies to promote community inclusion/integration, leisure skill development, including activities to facilitate socialization and recreation that are tied to a therapeutic goal, and
3. Support and adaptive strategies to enhance the person's control and independence over environment, resources, activities, and self-care.

Authorization for Services

1. The service tasks/activities within the scope of this service chapter must be identified in the assessment and on the Preauth.
2. An Individual Program Plan (IPP) as outlined in the Community Supports provider standards must be developed by the authorized QSP agency and maintained in the individual’s file. An IPP is an individualized plan that describes the goals, wants, needs, and strengths of the person. It describes in detail how the QSP agency is supporting the individual.

1. Service task and activities must be tied to an individual's goals as determined through the person-centered planning process.
2. The IPP must correlate with the person-centered plan and services authorization that is completed by the HCBS Case Manager.
3. The IPP must be developed by the QSP Agency Program Coordinator within the first 30 days of service provision and forwarded to the case manager and every 6 months thereafter.
4. The IPP must be approved by the state program administrator.
5. The IPP must include:

   1. A plan for promotion of the individual’s independence in ADLs and IADLs, social, behavioral, and adaptive skills,

   2. Tasks being provided which should match the authorization provided by the HCBS case manager,

   3. A medication list if medication administration is authorized and description of how medications are being managed;

   4. Medical diagnoses;

   5. A therapeutic goal for community integration activities which would include companionship and socialization activities. The individual should be involved in goal setting and ideas for these activities;

   6. Temporary absences and requests for retainer payments. Including any requests for retainer payments and dates of absences submitted to HCBS Program Administration for retainer payment authorization.

      • Note: Retainer payments cannot exceed 30 days per calendar year.

   7. Signature of the agency care coordinator and date.

Reasonable Modification:

To comply with Title II of the ADA, a public entity shall make reasonable modifications in policies, practices, or procedures when the modifications are necessary to avoid discrimination based on disability, unless the public entity can demonstrate that making the modifications would fundamentally alter the nature of the service, program, or activity. Refer to: Requests for Reasonable Modification 525-05-55.

This service may include nursing care to the extent permitted by state law under NDCC 43-12.1 and NDAC 54-05, which will maintain the health and well-being of the individual and allow the individual to remain in the community. Approval of tasks medical in nature under Community Support services are services that an individual without a functional disability would customarily and personally perform without the assistance of a licensed health care provider, such as administration of medications, or wound care.

If a modification is approved under the Community Support Program to complete tasks that are medical in nature and that are specific to the needs of an eligible individual, a Registered Nurse (RN) must complete an assessment to determine if the tasks will be completed by the RN or trained to the QSP agency staff. If a necessary medical task is too complex to be taught to the QSP agency staff, the nurse may provide the service directly to the individual.

The QSP agency must submit:

1. Agency policy specific to the medical task being completed

2. Evidence of training of the QSP agency staff by the RN using the SFN 585.

3. Example of how they will document these tasks

   1. Nursing task documentation should align with the professional nursing documentation requirements/standards to ensure accuracy and consistency.

4. A copy of the IPP to include an explanation of tasks that will be delegated, tasks performed by the nurse, and how the nurse will provide an oversight of these tasks. The SFN 585 along with the IPP is required initially within the first 48 hours of services beginning, every 6 months, and annually. If there are medical tasks being performed, the RN must sign and date the IPP along with the Care Coordinator.

Allowable Service Combinations

Chore, ERS, Environmental Modification, Adult Day Care, Supported Employment, Extended Personal Care includes Nurse Education, Home Delivered Meals, Transition Coordination, and/or Specialized Equipment.

Limits

Community Support Services may not be authorized with Respite Care, Homemaker, Adult Foster Care, Family Home Care, Personal Care, Family Personal Care, Adult Residential, Transitional Living, Attendant Care, Supervision, Companionship, Community Support Services and Non-Medical Transportation. For unusual or unique circumstances, contact the Aging Services Program Administrator for approval consideration.

1. This service shall not be used solely for the purpose of supervision or emergency assistance on a 24-hour basis.
2. Supervision may not be authorized in excess of what is necessary for health and safety.

1. For example, the family is requesting that someone stay with their relative 24 hours a day when there is not a safety or health risk other than the possibility that something might happen.
2. Supervision may not be used to restrict an individual from alcohol or substance use.

3. Twenty-four hour supervision in a shared living environment- Continuous supervision by paid staff on a one to one basis is not available unless shared staffing arrangements would create a safety threat to the individual or others. This level of service may only be provided as a last resort. All possible strategies for shared or reduced levels of supervision must be ruled out first.

1. A 'safety threat' means the individual is so aggressive, self-destructive, or requires such close supervision that any attempt to share one on one staff at any time will place the individual at immediate risk.
2. Shared tasks will be considered in a shared living environment, and may affect the daily rate for these services (e.g. housekeeping of common areas, shared meals preparation, and overnight supervision).

4. This service does not include payment for non-medical transportation costs.
5. Payment for Community Support Services does not include room and board, or the cost of facility maintenance and upkeep.
6. Rate for this service and any additional waiver services cannot exceed the current highest daily rate for skilled nursing facility care.
7. Access of services or goods outside of the local area if the same service and goods are available in their local community.

1. For example, a grocery store is available in the local community, but the consumer wants to drive to a larger community because they prefer that location, even though the product and cost is the same at both locations.

8. Travel and direct support outside of the individual's community of residence for vacations, family events and socialization unless approval from an HCBS Program Administrator is received.
9. Direct support time is not available for any time which coincides with the recipients using adult day or other authorized services.

10. A personal assistance retainer payment is allowed for reimbursement during a participant’s temporary absence from the setting. The personal assistance retainer allows for continued payment while a participant is hospitalized (acute hospital stay) or otherwise away from the setting in order to ensure stability and continuity of staffing up to thirty calendar days per year per participant.

    • Absences do not include absences due to the individual receiving care in a skilled nursing facility (SNF) or Swingbed facility.

11. When there is a need for two QSP staff to provide assistance and the QSP agency is authorized the maximum 24 hour care rate, personal care services may be requested for consideration and approval. A request must be submitted to the program administrator including:

    1. an assessment by an Occupational Therapist (OT) or a Physical Therapist (PT) documenting the required need,

    2. the frequency of the task requiring the second staff person,

    3. and the total units needed for the task.

    4. The program administrator will review the request and determine if personal cares may be authorized for the second staff person.

    5. If there is an emergent need for 2 staff, the HCBS case manager will contact the program administrator for review and approval.

Program Administration enters the Preauth upon request from the provider verifying the dates the individual is temporarily absent from the integrated setting.

The provider must review the retainer payments in the IPP that is completed every 6 months.

This process is handled administratively through the approval of Residential Habilitation and Community Supports.

Providers

Community Support Services may NOT be provided by the following employees of a QSP agency:

• Legal spouse

Standards for Providers

Service must be provided by an enrolled Medicaid Agency. Individual QSP are not eligible to provide this service.

Community Support Service providers must be:

Agency QSPs enrolled under NDAC 75-03-23 may include Licensed community support services DD Providers- Licensed according to NDAC 75-04-01 who meet additional enrolment requirements and meet the following:

1. Provider must ensure that staff are adequately trained and qualified as evidenced by:

1. Written job descriptions for employees that include plans for participation in training and include requirements for education, experience, and skills,
2. Documentation of competency or employed by a Licensed DD provider according to NDAC 75-04-01,
3. Department approved training on Traumatic Brain Injury (TBI) and dementia,

1. In-service training to direct contact staff by the program coordinator on implementation of individual's programs and observation of implementation in the service setting.
2. To assure staff meet minimum training requirements, TBI and dementia training must be completed within 30 days of providing care to an individual under community supports.
3. Staff must complete TBI and dementia training every 2 years.

4. Completion of Minot State University medication modules, testing and practicum. Written test is proctored and completed in person. Practicum is administered by a licensed registered nurse employed or contracted through the Agency Provider.

1. Staff must complete department-approved training on the administration of routine medications before administering routine medications. This includes cueing/reminding the individual to take medication.
2. Staff must demonstrate continued competency in medication administration by completing medication practicum with agency RN once yearly and as needed. Staff must complete the practicum checklist specific to the type of medication administration they will be completing (example: if administering an enema, staff must complete the practicum checklist for the administration of an enema prior to administration and yearly).

5. Agency must name a Program coordinator. Program coordinator requirements:

1. Must have at least one year of experience working directly with persons with physical disability; and
2. Is one of the following:

1. A doctor of medicine osteopathy,
2. a registered nurse, or
3. an individual who holds at least a bachelor’s degree and who is licensed, certified, or registered as applicable, to provide professional services by the State in which he or she practices (e.g. social worker, occupational therapist, psychologist, physical therapist, etc.).
   
   An individual with a “bachelor’s degree in a human service field” means an individual who has received: at least a bachelor’s degree form a college or university (master and doctorate degree are also acceptable) and has received academic credit for a major or minor coursework concentration in a human service field (including, but not limited to: sociology, special education, rehabilitation counseling and psychology)
4. Other:

1. An individual who has a bachelor’s degree; and
2. completes the department approved TBI and Dementia training; and
3. has one year of experience working with individuals with a physical disability.
   

3. Ensures quality programs/services for the people supported in the employing agency.
4. Responsible for development of the IPP.

Community Support Service agency providers may employ legally responsible individuals to provide Community Support Service. The following criteria applies when an agency employs a legally responsible person or family member as a staff to provide Community Support Service.

• Community Support Service cannot be provided by spouses,

• Community Support providers or staff cannot live with the care recipient.

• The legal guardian or family member must meet all the required qualifications of a Community Support Service staff member.

• If the legally responsible person wants to provide services as an employee of the provider and has decision making authority over the recipient, the case manager must pre-approve the arrangement with the HCBS Program Administrator for Community Support Service.

• The case manager is responsible to forward a copy of the narrative that explains why the legally responsible person providing the services is in the best interest of the client to the State Medicaid Agency.

The narrative must also be attached to the client's individual care plan when it is submitted to the State.

2. Council on Quality & Leadership (CQL) Accredited

1. Provider must become CQL accredited. Refer to Council on Quality and Leadership (CQL) Accreditation Policy, see 525-05-47.

Involuntary Discharge of an Individual under Community Support Services:

Involuntary discharge occurs when a Community Support Services provider has decided to discontinue services and terminate supports even though the individual has not requested the termination of services. Any opportunities to prevent an involuntary discharge should be explored prior to the discharge by the provider. Community Support Services providers must have written policies and procedures that define the conditions of termination and transfer of an individual’s services. Individuals and/or legal decision makers should receive a copy of the provider’s policy at the time of admission to the provider agency and again when a discharge is being considered.

In the case of an involuntary discharge, the Community Support Services provider is required to give a thirty (30) day written discharge notice to the individual, unless the individual chooses to discontinue the services earlier, schedule a team meeting with the individual and HCBS case manager, and complete a written discharge summary. The timing of the thirty (30) day notice begins the date that the team meeting occurs. The written discharge notice must include the reason for discharge and why the provider cannot continue to serve the individual. A copy of the thirty (30) day notice and the written discharge notice must be forwarded to the HCBS Case Manager. The Community Support Services provider must also file a Critical Incident Report. Any opportunities to prevent discharge should be explored prior to discharge by the provider.

Settings where service can be provided

This service may be provided in a private family dwelling or in a licensed adult foster care home N.D.A.C. 75-03-21.1 that is approved to provide this service. The HCBS settings rule applies to all agency foster homes and the setting must be fully compliant before services can begin.

Services will be administered in the most integrated setting consistent with the Person-Centered Plan of Care, including (checked if allowable):

ü The individual's home

ü Workplace

ü Other community service settings

Maximum Room and Board Rate effective 7-1-2024

The current maximum monthly room and board rate that providers may charge community support services recipients is $1005.00. The maximum room and board rate is equal to the current Medicaid medically needy income level for a one person household less a $125 personal needs allowance. The rate is reviewed annually.

Providers are not required to charge a room and board rate and may choose to charge less than the maximum rate.