DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Virginia’s ID Waiver Transition Plan
in Response to the CMS HCBS
Final Rule
August 2014
Dawn Traver
Waiver Operations Director
DBHDS Division of Developmental Services
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Final Rule CMS 2249-F
and CMS 2296-F
Published in the Federal Register on January
16, 2014.
Text and further CMS guidance is available at:
http://www.medicaid.gov/HCBS
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Intent of the Final Rule
• To ensure that individuals receiving long-term
services and supports through home and
community based service (HCBS) programs . . .
have full access to benefits of community living
and the opportunity to receive services in the
most integrated setting appropriate
• To enhance the quality of HCBS and provide
protections to participants
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Highlights of the Final Rule
• Defines, describes, and aligns home and
community-based setting requirements
• Defines person-centered planning
requirements for persons in HCBS settings
• Provides CMS with additional compliance
options for waiver programs
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Home & Community-Based
Setting Requirements
• Establish an outcome-oriented definition
that focuses on the nature and quality of
individuals’ experiences
• Maximize opportunities for individuals to
have access to the benefits of community
living and the opportunity to receive
services in the most integrated setting
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
HCB Settings Requirements
• Be integrated in and support access to the
greater community
• Provide opportunities to seek employment and
work in competitive integrated settings, engage
in community life, and control personal
resources
• Ensure the individual receives services in the
community to the same degree of access as
individuals not receiving Medicaid home and
community-based services
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
HCBS Requirements
• Is selected by the individual from among
setting options, including
– non-disability specific settings
– an option for a private unit in a residential
setting
• Person-centered service plans document
the options based on the individual’s
needs, preferences; and for residential
settings, the individual’s resources
Page 7
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
HCBS Requirements (cont’d)
• Ensures an individual’s rights of privacy,
dignity, respect, and freedom from
coercion and restraint
• Optimizes individual initiative, autonomy,
and independence in making life choices
• Facilitates individual choice regarding
services & supports and who provides
them
Page 8
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
HCBS Requirements
for Provider-Owned or Controlled
Residential Settings
• Specific unit/dwelling is owned, rented, or
occupied under legally enforceable agreement
• Same responsibilities/protections from eviction
as all tenants under landlord tenant law of state,
county, city or other designated entity
• If tenant laws do not apply, state ensures lease,
residency agreement or other written agreement
is in place providing protections to address
eviction processes and appeals comparable to
those provided under the jurisdiction’s landlord
tenant law
Page 9
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
HCBS Requirements
for Provider-Owned or Controlled
Residential Settings (cont’d)
• Each individual has privacy in their sleeping or
living unit
• Units have lockable entrance doors, with the
individual and appropriate staff having keys to
doors as needed
• Individuals sharing units have a choice of
roommates
• Individuals have the freedom to furnish and
decorate their sleeping or living units within the
lease or other agreement
Page 10
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
HCBS Requirements
for Provider-Owned or Controlled
Residential Settings (cont’d)
• Individuals have freedom and support to control
their schedules and activities and have access
to food any time
• Individuals may have visitors at any time
• Setting is physically accessible to the individual
Page 11
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
HCBS Requirements
for Provider-Owned or Controlled
Residential Settings (cont’d)
• Modifications to the additional
requirements must be:
– Supported by specific assessed need
– Justified in the person-centered service plan
– Documented in the person-centered service
plan
Page 12
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
HCBS Requirements
for Provider-Owned or Controlled
Residential Settings (cont’d)
• Documentation in the PCP of modifications to the
additional requirements includes:
– Specific individualized assessed need
– Prior interventions and supports including less intrusive
methods
– Description of condition proportionate to assessed need
– Ongoing data measuring effectiveness of modification
– Established time limits for periodic review of
modifications
– Individual’s informed consent
– Assurance that interventions and supports will not cause
harm
Page 13
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Settings that are NOT HCB
• Nursing facility
• Institution for mental diseases (IMD)
• Intermediate care facility for individuals
with intellectual disabilities (ICF/IID)
• Hospital
Page 14
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Settings Presumed Not to Be
HCB
• Settings in a publicly or privately-owned
facility providing inpatient treatment
• Settings on grounds of, or adjacent to, a
public institution
• Settings with the effect of isolating
individuals from the broader community of
individuals not receiving Medicaid HCBS
Page 15
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Settings that Have the Effect of
Isolating Individuals
• Settings that might, but will not
necessarily, meet the criteria for isolating
– The setting is designed specifically for people
with disabilities, and often even for people
with a certain type of disability.
– The individuals in the setting are primarily or
exclusively people with disabilities and on-site
staff provides many services to them.
Page 16
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Settings that Have the Effect of
Isolating Individuals (cont’d)
• May have any of the following characteristics:
– Designed to provide people with disabilities multiple types
of services and activities on-site, including housing, day
services, medical, behavioral and therapeutic services,
and/or social and recreational activities
– People in the setting have limited, if any, interaction with
the broader community
– Uses/authorizes interventions/restrictions that are used in
institutional settings or are deemed unacceptable in
Medicaid institutional settings (e.g., seclusion)
Page 17
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Settings that Have the Effect of
Isolating Individuals (cont’d)
• Examples of settings that isolate:
– Farmstead or disability-specific farm community
– Gate/secured “community” for people with
disabilities
– Residential schools
– Multiple settings co-located and operationally
related (i.e., numerous group homes co-located on
a single site or multiple units on the same street)
Page 18
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Required Transition Plan
• For renewals and amendments to existing
HCBS 1915(c) waivers submitted within
one year of the effective date of final rule:
– The state submits a plan in the renewal or
amendment request detailing any actions necessary
to achieve or document compliance with setting
requirements for the specific waiver or amendment
– Renewal or amendment approval will be contingent
upon inclusion of an approved transition plan
Page 19
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Virginia’s DRAFT ID Waiver
Transition Plan
• The full text is available at:
http://www.dbhds.virginia.gov/ODS-default.htm
Page 20
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Elements of VA’s ID Waiver
Transition Plan
•DBHDS to review and propose changes to
its Licensing regulations
•Additions/changes regarding:
–settings expectations, particularly providerowned or controlled residential settings
–person-centered planning provisions of the
Final Rule
Page 21
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Elements of VA’s ID Waiver
Transition Plan (cont’d)
Timeline for DBHDS Licensing Regulations Revisions
Internal review:
Identify Office of Licensing (OL) review team
8/1/14 – 8/15/14
OL review and recommendations for changes
8/18/14 – 10/17/14
Identify DBHDS review team
10/6/14 – 10/17/14
DBHDS review and recommendations for
changes
Stakeholder review:
10/20/14 – 1/30/15
Identify work group members
1/5/15 – 1/23/15
Review and recommendations for changes
2/2/15 – 7/31/15
DBHDS final revisions and approval
8/3/15 – 9/30/15
Review by Office of Attorney General
10/1/15 – 2/29/16
Submission for Virginia Standard Regulatory
Review & Approval process
Promulgation and training of providers
3/1/16 – 2/28/17
Total Time
3/1/17 – 9/1/17
Approx. 36 months
Page 22
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Elements of VA’s ID Waiver
Transition Plan (cont’d)
By 10/01/14:
• DBHDS to distribute a self-assessment
tool to providers affected by the settings
rule to help each determine:
– Areas in which their setting meets Final Rule
settings provisions
– Areas in which their setting requires
improvements
• Participation is mandatory
Page 23
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Elements of VA’s ID Waiver
Transition Plan (cont’d)
January 2015:
•Providers give feedback to DBHDS/DMAS regarding
their self-assessment results via Survey Monkey
–Provider believes licensed site meets the intent of the rule
–Adjustments will be required in order to comply
–TA from DBHDS is needed
–Date provider will be in full compliance (no later than
03/2019)
–Provider plans to stop providing waiver services by
03/2019
Page 24
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Elements of VA’s ID Waiver
Transition Plan (cont’d)
Early 2016:
•DBHDS Office of Licensing staff visit each
provider entity to assure Final Rule
compliance using same checklist
–Those not in full compliance, given 24 mos. to
comply
•DBHDS CRCs available to provide consultation to
those struggling with implementation
–DMAS QMR/PI notified of those substantially
lacking compliance
Page 25
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Elements of VA’s ID Waiver
Transition Plan (cont’d)
December 2018:
• Those not in compliance notified that they will
forfeit waiver provider status by 03/2019
• Support coordinators/case managers for
individuals receiving supports in those settings
will work to provide choice of providers to those
persons should they wish to continue to receive
waiver services.
Page 26
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
VA’s ID Waiver Response to
PCP Elements of the Final Rule
• The ID Waiver is already in compliance
with most of the PCP requirements.
• A multi-agency committee met earlier this
year to make some changes to the PCP
ISP which will make it even more
compliant.
Page 27
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
VA’s ID Waiver Response to PCP
Elements of the Final Rule (cont’d)
• Additional elements to be introduced over
the next 12 months to ensure full PCP
compliance:
– A copy of the ISP must be provided to the individual
and his/her representative.
– The ISP should exclude unnecessary or inappropriate
services and supports.
– The ISP reflects that the setting is chosen by the
individual and is integrated in, and supports full
access to the greater community.
Page 28
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
VA’s ID Waiver Response to PCP
Elements of the Final Rule (cont’d)
• Additional elements (cont’d):
– The ISP and ongoing documentation reflects
individual’s opportunity
• to engage in community life,
• control personal resources, and
• receive services in the community to the same
degree of access as individuals not receiving
Medicaid HCBS.
Page 29
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
VA’s ID Waiver Response to PCP
Elements of the Final Rule (cont’d)
• Additional elements (cont’d):
– The PCP ISP documents any safety needs
warranted restriction is supported by a
specific assessed need and is appropriately
justified.
• There must be a plan to review continued need for
restriction and to provide services to allow the
person to no longer need the restriction.
Page 30
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
VA’s ID Waiver Response to PCP
Elements of the Final Rule (cont’d)
• Additional elements (cont’d):
– Expectations will be clarified regarding the definition
and implementation of informed choice and consent
processes.
– An enhanced focus on achieving the desired
outcomes the individual has chosen
• Verifiable means of documenting that chosen outcomes are
being accomplished in the proposed time frames
• Must be a process in place for individuals to revisit their
outcome choices, inclusive of who is providing supports and
services.
Page 31
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Final Elements of VA’s ID
Waiver Transition Plan
• Update for CMS on VA’s current status of:
– Assessment of quality management practices
– Assessment of information systems
– Guidance and training for providers regarding
Final Rule implementation
• DBHDS staff (OL, OHR, CRCs, CIMs), CSB
support coordinators, and DMAS staff (QMR) will
use site visits and other forums to educate
providers regarding Final Rule components,
completion of the self-assessment tool, and
suggestion ways to remedy deficiencies.
Page 32
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Public Comment
• CMS requires at least a 30 day public
comment period for the state’s Transition
Plan
• Virginia is collecting comments through
this and two additional webinars (8/26 AM
& PM) and written comments through
MyLifeMyCommunity@dbhds.virginia.gov
Through September 6th
Page 33
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Time for Your Comments
Page 34