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2014-2016
Home & Community Based Services
Provider Manual
5240 Fountain Drive
Crown Point, IN 46307
www.nwica.com
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Contents
Home and Community Based Services Manual..........................................................................................1
Funding Sources and Eligibility .................................................................................................................1
Community and Home Options to Institutional Care for the Elderly and Disabled (CHOICE) ............................. 1
Social Services Block Grant-Title XX..................................................................................................................... 2
Title III: Funding Requirements (OAA) ................................................................................................................. 3
Older Hoosier Account Funding Requirements.................................................................................................... 3
HCBS Service Definitions ..........................................................................................................................4
Adult Day Services (AD1, AD2, AD3, ADST) ......................................................................................................... 4
Attendant Care Services (ATTC)........................................................................................................................... 7
Home Delivered Meals (HDM)........................................................................................................................... 10
Home Health Aide Services (HOHE) ................................................................................................................... 13
Home Health Supplies and Assistive Devices (ATCH, ATCM, SUPP)................................................................... 15
Home Repair/Maintenance Services (HCP) ....................................................................................................... 18
Homemaker Services (HMK) .............................................................................................................................. 20
Personal Emergency Response System (PRSI, PRSM) ........................................................................................ 22
Respite (RNUR, RHHA, RATT, RHMK)................................................................................................................. 24
Skilled Nursing (SKNU)....................................................................................................................................... 26
Transportation Services (TRAN)......................................................................................................................... 27
Standard Operating Procedures for HCBS ...............................................................................................29
Service Provision....................................................................................................................................33
Reimbursement to Providers..................................................................................................................42
HCBS Forms ...........................................................................................................................................45
CHOICE Invoice .................................................................................................................................................. 46
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SSBG Invoice………… ........................................................................................................................................... 47
Title IIIE Family Caregiver Invoice ...................................................................................................................... 48
Title IIIB In-Home Services Invoice ..................................................................................................................... 49
Transportation Invoice....................................................................................................................................... 50
HCBS Billing ...........................................................................................................................................51
Appendix A 455 IAC 2: Home & Community Based Services Rule...................................................................... 54
Appendix B: Indiana Division of Aging Incident Reporting Policy ..................................................................... 81
Appendix C: IHCP Bulletin BT200371 – Documentation Standards for HCBS .................................................... 91
Appendix D: Older Americans Act Title III C..................................................................................................... 106
Appendix E: CHOICE Guidelines ...................................................................................................................... 112
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Home and Community Based Services Manual
Funding Sources and Eligibility
Community and Home Options to Institutional Care for the Elderly and Disabled (CHOICE)
The Community and Home Options to Institutional Care for the Elderly and Disabled Program (CHOICE) is
designed to change the way the state provides and delivers long-term care for older adults and persons with
disabilities.
Above all, the purpose of CHOICE is to enable older adults or persons with disabilities to live independently
in their own homes or in community-integrated settings. It is further intended to allow older adults ready
access to community resources in order to improve the quality of life of families and children, with an
emphasis on seniors and persons with disabilities.
The program is also intended to encourage more coordinated planning; to give increased attention to
CHOICE participant views; to provide greater respect for participant preferences; and to value participant
selection of providers as well as services.
Choice Funding Requirements
CHOICE funds are exclusively state dollars used to provide services for older adults and persons with
disabilities enabling these individuals to maintain independence in their own homes and communities.
Eligibility Requirements for Choice Funding
To be eligible for CHOICE funding, the older adult or person with disabilities must:
be a resident of Indiana;
be at least 60 years of age or disabled;
make complete and proper application for Medicaid;
qualify under criteria developed by the CHOICE board as having an impairment that places the person at risk
of losing independence; and
have no assets or have assets that do not exceed the worth of five hundred thousand ($500,000) as
determined by the FSSA DA.
apply for Indiana Medicaid and receive and eligibility determination from the Division of Family Resources
A person is at risk of losing independence if the person is unable to perform two or more activities of daily
living as measured on the long-term care services eligibility screen.
The use by or on behalf of the person of any of the following services or devices do not make the client
ineligible for services under CHOICE:
skilled nursing assistance;
supervised community and home care services, including skilled nursing supervision;
adaptive medical equipment and devices; and
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adaptive non-medical equipment and devices.
Financial Eligibility and Cost Share Requirements for Choice Funding
CHOICE services are offered to all persons regardless of their income. Although there are no income
restrictions on eligibility, there is a method of cost reimbursement applicable to individuals who can pay all
or a portion of the cost of CHOICE services rendered.
The cost share requirement: The client's cost share of the payment for services rendered shall be calculated
by using the CHOICE Cost Share Worksheet, which includes the United States Department of Health and
Human Services Poverty Income Guidelines. (For more information, consult the Community and Home
Options to Institutional Care for the Elderly and Persons with Disabilities (CHOICE)).
CHOICE is the funding of last resort for in-home and community-based services. If funding for a consumer’s
services is available from any other source, that source must be used before CHOICE funding can be used.
* A copy of the complete CHOICE Guidelines manual is included as Appendix E of this Service Provider
Manual.
Social Services Block Grant-Title XX
The Social Services Block Grant (SSBG) was created for the purpose of consolidating federal assistance to
states for social services into a single grant. States are given much flexibility in using social services grants
and are encouraged to furnish services directed at particular objectives. The FSSA DA uses SSBG money to
fund a compilation of in-home, community-based, and facility-oriented services targeted for low-income
older adults and persons with disabilities.
Eligibility Requirements for SSBG Funding
To be eligible for SSBG funding, the older adult or person with disabilities client must meet the following
requirements:
The client must be a resident of Indiana.
The client must have a documented determination of service need. A service need exists when the case
management provider determines and documents that the client's functional status may be enhanced
through the provision of appropriate services.
The client must meet program income guidelines. If the client fails to meet the income guidelines but has a
documented need for service due to abuse, neglect, exploitation, risk of institutionalization, and/or pending
discharge from the hospital or nursing facility, the client may qualify for SSBG funded services as a no
means-test client. Otherwise, the client must be determined to be in financial need by the case
management provider.
Financial need exists when the client's and the family's incomes fall below 300% of the poverty level listed in
the current Department of Health and Human Services Poverty Guidelines. The client must meet program
income guidelines through a declaration of income (the verbal indication of the source and amount of gross
income).
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Title III: Funding Requirements (OAA)
Title III funds are federal dollars that are provided to the FSSA DA for allocation to AAAs and service
providers to develop and implement services necessary to allow older adults to remain in their homes as
long as possible, while enhancing their sense of dignity and worth.
Eligibility Requirements for Title III Funding
To be eligible for Title III funding, the client must be at least 60 years of age.
Priority is given to serving those older adults who are in greatest economic need, social need, or both, with
particular attention to low-income minority older adults, and to serving older adults residing in rural areas.
Although there are no financial eligibility requirements for Title III, specific programs funded partially or fully
with Title III dollars may have special financial eligibility requirements.
For additional eligibility requirements, refer to Section 4 - Service Definitions.
Older Hoosier Account Funding Requirements
The Indiana legislature appropriates state dollars to the FSSA DA to assist with meeting the match
requirements of various funding sources that support programs and activities for older adults. Programs
under Title III, Title V, and Title VII of the OAA require that federal funds be matched by state and local
funds.
Eligibility Requirements for Older Hoosier Account Funding
Eligibility requirements are the same as those of the funding source the Older Hoosier account dollars are
used to match.
Financial Eligibility
Financial eligibility requirements are the same as those of the funding source the Older Hoosier account
dollars are used to match.
Older Hoosier accounts match a percentage of dollars provided by a particular funding source. Services
provided would depend upon the funding source the Older Hoosier account dollars are used to match.
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HCBS Service Definitions
Adult Day Services (AD1, AD2, AD3, ADST)
Applicable Rules and Regulations
455 IAC 1 & 2 – Home and Community Based Services rule; State of Indiana Medicaid Waiver Standards and
Guidelines for Adult Day Services; Section 4003 of the Indiana Division on Aging Operations Manual; Section
7 of the Indiana Division of Aging Waiver Provider Manual ; Section 10038 of the Indiana FSSA CHOICE
Manual; and NWICA all define service as:
Service Description
Adult Day Services are structured community based programs that provide a variety of health, social,
recreational, and related supportive services for older adults and persons with disabilities in a protective
setting during daytime and early evening hours.
This service is designed to meet the needs of eligible persons through an individualized service plan
including personal care and supervision, medical care, transportation to and from the site, and therapeutic
and recreational activities. Adult Day Services also includes the provision of meals and snacks, as
appropriate.
Adult Day Services assess the needs of participating individuals and offer services to meet those needs.
Adult Day Services are provided at 3 different, designated levels of services.
The 3 levels of Adult Day Services include:
Basic Adult Day Services (Level 1) which include the following:
monitoring and/or supervision of all Activities of Daily Living (ADL’s) which are defined as dressing, bathing,
grooming, eating, walking, and toileting with hands on assistance provided as needed;
comprehensive, therapeutic activities;
assurance health assessment and intermittent monitoring of health status;
monitoring of medication/or medication administration; and
the ability to provide appropriate structure and supervision for those with mild cognitive impairment.
Enhanced Adult Day Services (Level 2) which include the following:
assuring that Basic (Level 1) service requirements are met;
providing hands-on assistance with 2 or more ADL’s or hands-on assistance with bathing or other personal
care;
health assessment with regular monitoring or intervention with health status;
dispensing or supervision of the dispensing of medications to participants;
psychosocial needs assessment and addressing needs including counseling for participants and caregivers;
and
provision of appropriate therapeutic structure, supervision and intervention for those with mild to moderate
cognitive impairments.
Intensive (Level 3) which includes the following:
meeting Basic (Level 1) and Enhanced (Level 2) service requirements;
hands on assistance or supervision with all ADL’s and personal care;
one or more direct health intervention(s) as required;
rehabilitation and restorative services including Physical Therapy, Speech Therapy, Occupational Therapies,
coordinated or available;
providing therapeutic intervention to address dynamic psychosocial needs such as depression or family
issues effecting care; and
providing therapeutic interventions for those participants with moderate to severe cognitive impairments.
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Allowable Activities
Supervision and assistance, when needed, with Activities of Daily Living and supervision of personal hygiene
and personal care as determined in level of service assessment.
Provision of individual and group social, health related, and recreational activities provided at the Adult Day
Service site. Recreational activities should be activities that are included in a place of treatment related to
specific therapeutic goals which can include a group exercise program and preventative health screening
such as blood pressure checks and discussion groups.
Activities that may be provided outside the program site, during service hours, if accompanied by a staff
member, Those activities may include:
2 shopping trips per month (per client), when taken in a group;
Medically related trips, when necessary, as documented in the care plan;
a maximum of 4 specialized field trips each per month designed for client groups, such as attendance at
concerts, plays, films, museums, or special events; and
1 nutritionally balanced meal per day (and a nutritional snack if the client is present for more than 3 hours).
Activities Not Allowed
Funding sources for adult day services will cover only those activities described as Allowable Activities.
Provider Requirements
Adult Day Service providers must be approved by the Indiana Division on Aging. The provider must be in
compliance with the following requirements of the Indiana Medicaid Adult Day Services Standards and
Guidelines:
administrative structure requirements
administrative responsibilities
staff requirements
facility and grounds requirements
service requirements
emergency preparedness documentation requirements
service file documentation requirements
activities requirements
food service requirements
meal requirements
nutrition component requirements
vehicle requirements
Unit of Service
¼ hour = 1 unit
Service Authorization
Services must be provided in accordance with the Vendor Authorization issued by the NWICA Case Manager.
Documentation Requirements
Documentation as required by the Indiana Medicaid Adult Day Service Standards and Guidelines
Documentation compliant with the Indiana Health Coverage Programs Provider Bulletin BT200371,
Documentation Standards for Home and Community-Based Services Waiver Programs
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NWICA monthly service progress report.
Funding Source(s)
Funding sources include SSBG, CHOICE, Older Hoosier Funds, Title III, Program income.
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Attendant Care Services (ATTC)
Applicable Rules and Regulations
455 IAC 1 & 2 – Home and Community Based Services Rule; IC 16-27-4 Licensure of Personal Service
Agencies; Section 4007 of the Indiana Division on Aging Operations Manual; Section 7 of the Indiana Division
of Aging Waiver Provider Manual; Section 10039 of the Indiana FSSA CHOICE Manual; and NWICA all define
service as:
Service Description
Attendant Care Services are defined by law as services that could be performed by an impaired individual
for whom the services are provided if the individual were not impaired; and that enable the impaired
individual to live in the individual's home and community rather than in an institution; and to carry out
functions of daily living, self-care, and mobility. The term includes the following:
Assistance in getting in and out of beds, wheelchairs, and motor vehicles
Assistance with routine bodily functions, including:
bathing and personal hygiene;
using the toilet;
dressing and grooming; and
feeding, including preparation and cleanup.
The provision of assistance:
through providing reminders or cues to take medication, the opening of preset medication containers, and
providing assistance in the handling or ingesting of non-controlled substance medications, including eye
drops, herbs, supplements, and over-the-counter medications; and
to an individual who is unable to accomplish the task due to an impairment and who is:
competent and has directed the services; or
incompetent and has the services directed by a competent individual who may consent to health care for
the impaired individual.
Allowable Activities
Attendant Care Services may include:
Assistance, as specified in the plan of care, which may include the following:
Personal Care and Grooming activities including bathing, oral hygiene, hair care, shaving, dressing,
application of cosmetics, etc. under the following circumstances:
Client does not require skilled transfer, skilled skin care or skilled assistance with dressing.
Client’s skin is not broken or open
There are no active chronic skin problems
May include preventive care only such as massage of reddened areas, application of skin moisturizers, nonmedicated OTC lotions or solutions, reporting changes to supervisor, application of preventive spray to
unbroken skin areas, which may be susceptible to breakdown.
Mobility
Transfer under the following circumstances:
Client needs only standby assistance or assistance with adaptive equipment (such as gait belt, wheelchairs,
tub seats, grab bars)
Client is able to direct the transfer and assist with transfer to some extent
Client DOES NOT require a mechanical lift such as a Hoyer lift.
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Client has good balance, is NOT in a weakened state and has a low risk for falls
Client is fully trained in use of adaptive/assistive devices as well as transfer in and out of a motor vehicle.
Attendant Care does NOT transport Clients. May accompany Client to medical appointments and to other
service ONLY if assigned on care plan and when all care provided in relation to the trip is non-skilled
Assistance with ambulation under the following circumstances:
Client is fully trained with adaptive equipment
Skilled transfer is NOT required
Client does NOT have any cast or need for special skin care
Client generally independent and needs only stand-by assistance or assistance with a gait belt
Nutrition
Meal planning, preparation, and clean up
Elimination
Assisting with bedpan, bedside commode, toilet
Incontinent or involuntary care
Emptying urine collection and colostomy bags
Safety
Use of the principles of health and safety in relation to self and client
Identify and eliminate safety hazards
Practice health protection and cleanliness by appropriate techniques of hand washing, waste disposal, and
household tasks
Other
Reminding client to self-administer medication
Realty orientation and sensory stimulation
Escorting client to medical appointments.
Attendant Care shall NOT transport Clients. May accompany Client to medical appointments and to other
service ONLY if assigned on care plan and when all care provided in relation to the trip is non-skilled
Assistance with correspondence and bill paying.
Incidental homemaker activities, which are not furnished in the absence of other attendant care services
that are essential to the client’s health care needs to prevent or postpone institutionalization. Activities
directly related to a client’s medical needs, furnished in conjunction with but subordinate to direct Client
care, are described in the Homemaker Service – Section 4013
Activities Not Allowed
occupied bed changes;
bearing full weight of client during transfer;
supervision of dispensing of medication by client or dispensing of medication for client;
skin care on broken skin;
passive range of motion exercises;
assistance with crutch ambulation;
bed baths;
other activities that must be performed by a licensed health care professional; and
nail care of diabetic clients.
Attendant Care Services will not be provided to medically unstable clients as a substitute for care provided
by a registered nurse, licensed practical nurse, licensed physician, or other health professional.
Provider Requirements
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Pursuant to state law, NWICA requires its providers of Attendant Care to be licensed either as a Home
Health Agency or a Personal Service Agency. To provide services under CHOICE funding, the provider must
also be certified as a Medicaid Waiver provider.
Unit of Service
¼ hour = 1 unit
Service Authorization
Services must be provided in accordance with the Vendor Authorization issued by the NWICA Case
Manager.
Documentation Requirements
Documentation required by the Indiana State Department of Health
Documentation compliant with the Indiana Health Coverage Programs Provider Bulletin BT200371,
Documentation Standards for Home and Community-Based Services Waiver Programs
NWICA monthly service progress report.
Funding Source(s)
Funding sources include SSBG, Title III, CHOICE, and local funds.
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Home Delivered Meals (HDM)
Applicable Rules and Regulations
Title IIIC of the Older Americans Act; 455 IAC 1 & 2 Home and Community Based Services Rule; Section
10043 of the Indiana FSSA CHOICE Manual; Section 8000 of the Indiana Division of Aging Operations
Manual; Section 7 of the Indiana Division of Aging Waiver Provider Manual ; and NWICA all define services
as:
Service Description
A Home delivered meal is a meal provided to a qualified individual at his/her place of residence. The meal is
served as part of a program administered by the AAA and meets all the requirements of the Older
Americans Act and State/Local laws.
Home Delivered Meal Program Requirements
The Home Delivered Meals provider shall deliver the meal that has been prepared by a NWICA contracted
Meal Preparation/Catering vendor, to the eligible participant’s home.
There shall be no more than a four-hour lapse of time between preparation time and meal delivery at the
clients home.
The Home Delivered Meals provider shall maintain the proper temperatures for the hot food at 135° F.; and
cold foods at 40° F.; and shall maintain adequate sanitary practices for handling the food transit.
The Home Delivered Meals provider shall be compliant with any and all pertinent rules and regulations as
set forth by the Local Board of Health having jurisdiction in the area that the provider operates.
The Home Delivered Meals provider must maintain appropriate insurance pertaining to the preparation and
distribution of meals.
The Home Delivered Meals provider must provide meals in accordance with the menu approved by the
NWICA contracted Registered Dietician.
Participant Contributions
The Home Delivered Meals providers shall offer the opportunity for each client to contribute financially
toward the cost of a meal. The Home Delivered Meals provider shall ensure a method to solicit and collect
contributions that maintains client confidentiality. The contribution is considered program income. Program
income records must be available upon request and reported to NWICA on a monthly basis.
The Home Delivered Meals providers will ensure that all contributions are counted and recorded daily by
two (2) people. All contribution records must be documented on the required client signature sheet. The
client signature sheet and proof of deposit must be submitted to NWICA on a monthly basis.
The Home Delivered Meals provider must have written fiscal policies and procedures regarding control of
program income. The fiscal policies and procedures regarding program income must provide reasonable
assurance that program income is correctly earned, recorded, and used to expand Home Delivered Meals
services. In accordance with OMB Circular A-110, use of program income is limited to increasing meal
service, providing supportive services related to improving nutritional status, and facilitating access to
nutrition services. Program income must be verifiable in the provider’s general ledger.
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Emergency Plans
Emergency plans must be in place for all home delivered meal programs. The plan must include at least the
following information:
1) Written procedures are in place:
To contact staff, volunteers, caterers, etc. (e.g., telephone and cell numbers, phone tree)
For weather-related emergencies.
To determine program closings.
To notify participants of program closings (e.g., radio, telephone).
For facility and equipment breakdowns.
When individuals are hurt or become ill.
Identifying emergency service agencies to assist in meal delivery, rescue, or other matters.
When key personnel are absent.
2) Staff is trained to assist older adults in an emergency situation:
Participant files include emergency contact or caregiver designee information.
Participants are provided printed information about the types of foods and other necessities to have on
hand for emergencies.
Home Delivered Meal Supplies for Service:
In order to provide a home delivered nutritious meal to eligible participants some necessary supplies will be
needed.
These supplies will be provided by the NWICA contracted Meal Preparation/Catering vendor. Below are
items that may be required for service;
Condiment
Approved Food Carry-out Containers
Insulated Food Carrier
Emergency Supply Pack
Shelf stable meal packages will be available in the month (s) of December and January. The Nutrition
Coordinator will organize a shelf stable meal request letter that will be sent out to all Home Delivered Meals
vendors for amount submission. Once ordered, the supplier will deliver to all vendors in the six county
region. Shelf stable meals are non-refrigerated and require minimal to no preparation and they are
nutritionally packaged to meet the regulated one-third RDA. The shelf stable meals will supply clients with
an emergency meal replacement due to state of an emergency and nutrition program closures.
Allowable Activities
Delivery of meals supplied by the NWICA contracted Meal Preparation/Catering vendor to the eligible
participant’s home.
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Activities Not Allowed
Activities not covered under allowable activities. Meals provided to individuals not eligible for Older
American’s Act funding.
Eligibility/Target Population
In order to receive home delivered meals the following criteria must be met:
An individual must be 60 years of age or older
Must be homebound or
Must be isolated.
Registered congregate meal participants who request a home delivered meal (s) due to a short-term illness
or health condition
Unit of Service
1 delivered meal = 1 unit
Service Authorization
Services must be provided according to the Vendor Authorization provided by the NWICA Case Manager.
Documentation Requirements
Client signature sheet and/or route log signed by driver. *Note: Medicaid requires client signatures.
Monthly invoice must include:
Signature information as described above
Cash Match/Project Income and In-Kind supporting documentation
Nutritional education, health information and surveys must be part of the home delivered meal program.
Applicable Funding Sources
Older American’s Act TIII, NSIP, CHOICE, Waiver
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Home Health Aide Services (HOHE)
Applicable Rules and Regulations
Section 4012 of the Indiana Division on Aging Operations Manual; 410 IAC 7.9 Home Health Agencies –
Definitions; 455 IAC 1 & 2 – Home and Community Based Services rule; IC 16-27-1 Licensure of Home Health
Agencies; Section 10042 of the Indiana FSSA CHOICE Manual; and NWICA all define service as follows:
Service Description
Home health aide services include all health monitoring activities performed in the home, supervision of
medication, and dressing changes under the supervision of a nurse as required by federal Home Health
Agency standards.
Allowable Activities
Allowable Services include:
Assistance with personal hygiene and grooming under the following circumstances
Need for skilled skin care
Need for skilled transfer
Need for skilled assistance with dressing
Consumer has poor balance, is in a weakened state and/or has a high risk for falls
Consumer is at high risk for skin breakdown
Ambulation Assistance under the following circumstances:
Skilled transfers are required with the ambulation
Mechanical lift device is used
Consumer has poor balance, is in a weakened state and/or has a high risk for falls
Consumer is still being trained in initial use of adaptive equipment
Observation and reporting to nurse is needed when Consumer has a new cast
Skilled skin care is needed
Transferring Assistance under the following circumstances:
Consumer unable to assist with transfer
Mechanical lift device is used
Consumer has poor balance, is in a weakened state and/or has a high risk for falls
Consumer still being trained in initial use of adaptive equipment
Need for skilled skin care
May include use of a transfer belt or gait belt to assist, transfer from bed to chair (and back), use of a
mechanical lift such as a Hoyer lift, transfer into and out of bathing areas (i.e. shower/tub) transferring onto
and off the toilet and in and out of a motor vehicle.
Assistance with positioning/turning as follows:
Consumer is not able to identify to staff when his/her position needs to be changed
Skilled skin care is required with position change
Consumer has contractures requiring special positioning
Consumer has communicable disease or draining wounds
Therapeutic bed (Clinitron, Stryker, Circle) is used
Consumer has casts or traction equipment
Consumer is unconscious or dying
Consumer is at risk for aspiration
Assistance with range of motion as follows:
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When prescribed by a nurse or other health care professional such as a physician or therapist.
May include passive range-of-motion, or working with simple traction, fractures, casts, dislocations,
paralysis, contractures, unconscious Consumer or technology-dependent Consumer
Other activities as allowed by the Home Health Agency in compliance with federal requirements
Activities Not Allowed
Services outside the scope of practice for a Home Health Aide are not allowable under home health aide
services.
Provider Requirements
Provider must be licensed by the Indiana State Department of Health. To provide services under CHOICE
funding, the provider must also be certified as a Medicaid Waiver provider.
Unit of Service
¼ hour = 1 unit
Service Authorization
Services must be provided in accordance with the Vendor Authorization issued by the NWICA Case Manager.
Documentation Requirements
Documentation required by the Indiana State Department of Health Licensure
Documentation compliant with the Indiana Health Coverage Programs Provider Bulletin BT200371,
Documentation Standards for Home and Community-Based Services Waiver Programs
NWICA monthly service progress report
Funding Source(s)
Funding sources include Title III, SSBG, and CHOICE.
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Home Health Supplies and Assistive Devices (ATCH, ATCM, SUPP)
Applicable Rules and Regulations
Section 4001 of the Indiana Division on Aging Operations Manual; Section 10037 & 10053 of Indiana FSSA
CHOICE Manual; Section 7 of the Indiana Division of Aging Waiver Provider Manual; and NWICA all define
services as:
Service Description
NWICA defines Home Health Supplies as supplies not covered under other funding sources such as private
insurance, Medicare, or Medicaid. Supplies may include but are not limited to incontinence supplies,
nutritional supplements, skin care ointment, medical gloves, etc.
NWICA defines Assistive Device as an item which is used to increase, maintain, or improve functional
capabilities. Such devices are intended to replace functional abilities lost to the individual because of his or
her disability and must be used in performing Activities of Daily Living (ADL) or Instrumental Activities of
Daily Living (IADL).
For all individuals whose independence can be enhanced through the use of an Assistive Device, the
following types of items may be approved.
Adaptive eating utensils
Adaptive kitchen utensils
Adaptive telephones with large numbers
Bath/shower chair: with or without transfer bench
Dressing aids
Gait belt
Grab bars
Hand held shower unit
Medication reminder units
Raised toilet seat
Reacher/grabber
Shampoo tray for bed bath
Walker basket
Walker wheels
Wander devices: for individuals with dementia only
Activities Not Allowed
Devices that are covered by Medicare, Medicaid, or private insurance will not be approved. Funds may not
be used to purchase assistive devices that are not of direct benefit to the individual. Funds cannot be used
to purchase, repair, or otherwise pay for dentures, hearing aids or glasses. NWICA will not approve the
following items:
Appliances (non-adapted)
Automobiles
Batteries
Blood pressure monitors
Clothing
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Computer/computer software
Dentures/Dental Care
Eating utensils (non-adapted)
Exercise equipment
Eye glasses
Fans
Furniture (non-adapted)
Golf carts
Health club memberships
Hearing aids
Heating pads
Home maintenance/repairs/remodeling/new construction
Hospital bed
Kitchen utensils (non-adapted)
Massage devices
Mattresses
Medical supplies
Medicare and Medicaid covered items
Medications (prescribed or over-the-counter)
Modified secondary home entrance/exit
Muscle stimulators
Orthotics (prosthetic shoes, lifts, braces)
Oxygen equipment
Pads/Pillows/Cushions
Physical therapy devices
Ramp enclosure
Repairs/modifications to items purchased by Medicare, Medicaid or private insurance
Scales
Scooter/carts for outdoor transportation
Service/support animals
Smoke alarms
Support hose/stockings
Swimming pool accessories
Therapies
Toothbrushes (non-adapted)
A second wheelchair as a reserve/backup
Provider Requirements
Provider must be licensed by the Indiana Board of Pharmacy. To provide services under CHOICE funding, the
provider must also be certified as a Medicaid Waiver provider.
Unit of Service
1 supply or device = 1 unit.
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Service Authorization
Services must be provided in accordance with the Vendor Authorization issued by the NWICA Case Manager.
Home Health Supplies and Assistive Devices must be approved by the Northwest Indiana Community Action
(NWICA) and comply with all applicable medical and manufacturing standards. Items that do not appear on
the above “approved” and “not approved” lists may be considered by NWICA. Determinations will be made
based on the individual’s unique circumstances as they apply to the current definitions, policies and
procedures. A denial letter must accompany requests for items generally covered by Medicare, Medicaid, or
private insurance
Documentation Requirements
Documentation required by the Indiana Board of Pharmacy Licensure
Documentation compliant with the Indiana Health Coverage Programs Provider Bulletin BT200371,
Documentation Standards for Home and Community-Based Services Waiver Programs
NWICA monthly service progress report
The delivery date and type of any supply, and/or
The installation/delivery date of any assistive device, and
The maintenance date of any assistive device
Funding Source(s)
Funding sources include Title III, SSBG, and CHOICE
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Home Repair/Maintenance Services (HCP)
Applicable Rules and Regulations
Section 4014 of the Indiana Division on Aging Operations Manual; and Section 10045 of the Indiana FSSA
CHOICE Manual all define service as:
Service Description
Home Repair/Maintenance and minor home repair services are planned and monitored maintenance and
minor repair activities essential to health and safety.
Home Repair may be made to an owner or renter occupied single-family dwelling. The intent of the service
shall be to make the dwelling habitable and shall not be done to improve the appearance of the property.
Service activities shall be performed in order of priority. Repairs made to correct life threatening conditions
and/or conditions that pose a health or safety hazard to the older adult or person with disabilities will be top
priority.
Allowable Activities
The Home Repair and Maintenance Services program dollars shall be used only for repairs that directly
correct and/or prevent health and/or safety hazards.
Home Repair/Maintenance and minor home repair activities may include:
plumbing, heating, and electrical malfunction repair or replacement;
storm door, window, and screen repairs;
gutter and roof patching;
heavy cleaning; and
broken step repairs;
Health and safety alterations may include installation of:
handrails;
ramps;
deadbolts;
smoke detectors;
locks; and
window bar
Ground maintenance services may include limited lawn moving, snow removal, and minimal yard cleanup to
assure safe entrance and departure from the premises.
Time spent in assessing the job, obtaining the supplies, performing planned activities, and cleaning up.
Travel time between work sites.
Activities Not Allowed
Service providers will not be paid for such activities as:
Billing for more than the actual time of each staff person delivering services, even when more than one
client is simultaneously benefiting from the service; and
Billing for home repair services which cannot be documented as avoiding a clear and present health/safety
hazard. Services may not be provided for aesthetic purposes only.
Provider Requirements
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To provide services under CHOICE funding, the provider must also be certified as a Medicaid Waiver
provider. If the Indiana State Department of Health implements a Personal Service Agency Licensure, all
providers will need to be in compliance with these licensing requirements.
Unit of Service
¼ hour = 1 unit
Service Authorization
Services must be provided in accordance with the Vendor Authorization issued by the NWICA Case Manager.
Documentation Requirements
Documentation compliant with the Indiana Health Coverage Programs Provider Bulletin BT200371,
Documentation Standards for Home and Community-Based Services Waiver Programs
NWICA monthly service progress report
Funding Source(s)
Funding sources include Title III, CHOICE, SSBG, Older Hoosier Funds, and local funds.
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Homemaker Services (HMK)
Applicable Rules and Regulations
455 IAC 1 & 2 – Home and Community Based Services Rule; IC 16-27-4 Licensure of Personal Service
Agencies; Section 4013 of the Indiana Division on Aging Operations Manual; Section 7 of the Indiana Division
of Aging Waiver Provider Manual; Section 10044 of the Indiana FSSA CHOICE Manual; and NWICA all define
service as:
Service Description
Homemaker services offer direct and practical assistance with household tasks and related activities.
Homemaker services assist the older adult person with disabilities who has experienced a loss in the ability
to perform the instrumental activities of daily living to remain in a clean, safe, healthy home environment.
Homemaker services are provided when the client is unable to meet these needs or when an informal
caregiver is unable to meet these needs for the client.
Allowable Activities
Homemaker services provided for housekeeping tasks which may include:
dusting and straightening furniture
cleaning floors and rugs by wet/dry mop and vacuum sweeping;
cleaning the kitchen, including washing dishes, pots, and pans; cleaning the outside of appliances and
counters and cupboards; cleaning ovens and defrosting and cleaning refrigerators;
maintaining a clean bathroom, including cleaning the tub, shower, sink, toilet bowl, and medicine cabinet,
emptying and cleaning commode chair/urinal;
laundering clothes in the home or Laundromat, including washing, drying, folding, putting away, ironing, and
basic mending repair;
changing linen and making beds;
washing insides of windows;
removing trash from the home;
choosing appropriate procedures, equipment, and supplies; improvising when there are limited supplies,
keeping equipment clean and in its proper place; and
Homemaker services may provide assistance with meals/nutrition that may include:
shopping, including putting food away; and
making meals, including special diets under the supervision of a registered dietitian or health professional.
Homemaker services may include completing the following essential chores or errands:
grocery shopping;
household supply shopping;
prescription pick up;
food stamp pick up; and
assistance with correspondence
Homemakers do not transport clients. Errand related tasks are completed on behalf of the client.
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Activities Not Allowed
Services requiring hands-on personal care or any activity that must be provided by a licensed health
professional care service are not allowed.
Homemaker services that benefit household members only.
Provider Requirements
Pursuant to state law, NWICA requires its providers of Homemaker services to be licensed either as a Home
Health Agency or a Personal Service Agency. To provide services under CHOICE funding, the provider must
also be certified as a Medicaid Waiver provider.
Unit of Service
¼ hour = 1 unit
Service Authorization
Services must be provided in accordance with the Vendor Authorization issued by the NWICA Case
Manager.
Documentation Requirements
Documentation required by the Indiana State Department of Health Personal Service Agency Licensure.
Documentation compliant with the Indiana Health Coverage Programs Provider Bulletin BT200371,
Documentation Standards for Home and Community-Based Services Waiver Programs
NWICA monthly service progress report.
Funding Source(s)
Funding sources include Title III, SSBG, CHOICE, Older Hoosier Funds, and other local funds.
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Personal Emergency Response System (PRSI, PRSM)
Applicable Rules and Regulations
455 IAC 1 & 2 – Home and Community Based Services rule; Section 4001 of the Indiana Division on Aging
Operations Manual; Section 7 of the Indiana Division of Aging Waiver Provider Manual; Section 10050 of the
Indiana FSSA CHOICE Manual; and NWICA define the service as:
Service Description
Personal Emergency Response System (PERS) is an electronic device that enables individuals at high risk of
institutionalization to secure help in an emergency. The system is connected to the person's phone and
programmed to signal a response center once a "help" button is activated. Professionally trained PERS staff
assesses the nature of the emergency and obtains appropriate help for the individual as necessary.
Allowable Activities
PERS services shall include the following approved, reimbursable activities when PERS is identified on the
individual’s Service Plan:
Installation and maintenance of PERS equipment in the participant’s home by appropriately trained staff.
(PRSI; only one unit of PRSI may be authorized and billed for each authorized equipment type)
PERS equipment which provides the participant with the ability to reliably activate an immediate emergency
signal to the surveillance/response center.
PERS equipment which has an uninterruptible power source.
PERS equipment which is appropriate to the individual’s cognitive, physical, and medical condition.
Information and training to the participant (and caregivers, as necessary) regarding the use of the PERS
equipment.
Continuous surveillance of signaling equipment for activated signals by the surveillance/response center 24
hours per day, 365 days per year. (PRSM; one unit per month of PRSM may be authorized and billed for
monitoring of signaling equipment.)
Scheduled testing of all in-home equipment at least every 30 days to ensure that equipment is functional.
A telephone line monitor that ensures that telephone connections are maintained between the PERS
equipment in the home and the surveillance/response center.
A direct response to the participant within 60 seconds by surveillance/response center professional staff
who has been trained in emergency response and who use an established response protocol over the PERS
equipment and/or the telephone.
An emergency telephone communication from the surveillance/response center in accordance with an
established protocol to a local response network including friends, neighbors, police, fire, and/or
ambulance, depending on the nature of the emergency.
A response by professional staff who has been trained in emergency response and who use response
protocols for each participant.
Detailed documentation of responses to all activated signals.
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Detailed technical and operations manuals which describe PERS elements, including PERS equipment
specifications, installation, functioning, and testing, staff training requirements, emergency response
protocols, and record keeping and reporting procedures.
Service Limitations
PERS services are limited to those individuals who live alone, or who are alone for significant parts of the
day, who are alone for any period of time and have a written plan for increasing the duration of time spent
alone as a means of gaining a greater level of independence, or who have no regular caregiver for extended
periods of time, and who would otherwise require extensive routine supervision.
PERS services are limited to individuals who are able to effectively utilize PERS equipment.
Provider Requirements
PERS providers comply with the following:
All legal requirements set by the Federal Communication Commission
Equipment must meet the Underwriters Laboratories, Inc. (UL) standards for home health care signaling
equipment
To provide services under CHOICE funding, the provider must also be certified as a Medicaid Waiver
provider.
Unit of Service
PRSI ( Personal Emergency Response System Install) – one installation = one unit
PRSM (Personal Emergency Response System Monitoring) – one unit of monitoring may be billed each
month equipment is authorized by NWICA to be in the home
Service Authorization
Services must be provided in accordance with the Vendor Authorization issued by the NWICA Case Manager.
Documentation Requirements
It is required that the agency maintain a record that documents the date that the service is started, the
dates that it is provided, and the date it is terminated.
The provider shall maintain documentation of routine testing of equipment and shall present such
documentation upon request by NWICA.
The provider shall maintain detailed documentation of responses to all activated signals
Documentation compliant with the Indiana Health Coverage Programs Provider Bulletin BT200371,
Documentation Standards for Home and Community-Based Services Waiver Programs
NWICA monthly service progress report
Funding Source(s)
Funding sources include SSBG, CHOICE, Older Hoosier Funds, Title III, and Program income.
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Respite (RNUR, RHHA, RATT, RHMK)
Applicable Rules and Regulations
455 IAC 1 & 2 – Home and Community Based Services rule; Section 4025 of the Indiana Division on Aging
Operations Manual; Section 10052 of the Indiana FSSA CHOICE manual all define services as:
Service Description
Respite care services are those services provided temporarily or periodically to older adults or persons with
disabilities to relieve the usual unpaid caregiver. Service may be provided in the client’s or caregiver’s home
or in a nursing facility or other location, depending on the funding source involved and individual program
requirements. Respite care is provided to assist a family in keeping an older adult or person with disabilities
in the home.
Allowable Activities
Respite care services may provide:
homemaker services;
attendant care;
home health aide services;
skilled nursing services; or
services provided in a facility.
Activities Not Allowed
services that duplicate any other service provided under the client’s plan of care.
provision of services to an older adult or person with disabilities who is without a usual caregiver.
Provider Requirements
To provide services under CHOICE funding, the provider must also be certified as a Medicaid Waiver
provider. Providers providing skilled services must be licensed by the Indiana State Department of Health. In
2006, the Indiana State Department of Health will be implementing a Personal Service Agency Licensure. All
providers will need to be in compliance with these licensing requirements.
Unit of Service
1/4 hour of allowable activity = 1 unit of service
Service Authorization
The NWICA case manager will provide the provider a vendor authorization specifying the client and service
information.
Documentation Requirements
Documentation must include:
The reason for the respite
The location where the service was rendered
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The type of respite provided
Provider ensures the absence of the usual caregiver while respite services are being provided.
Documentation required by the Indiana State Department of Health Personal Service Agency Licensure
and/or Indiana State Department of Health Personal Service Agency Licensure.
Documentation compliant with the Indiana Health Coverage Programs Provider Bulletin BT200371,
Documentation Standards for Home and Community-Based Services Waiver Programs.
NWICA monthly service progress report.
Funding Source(s)
Funding for respite care services may be available through SSBG, Title III, CHOICE, program income, and local
funds.
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Skilled Nursing (SKNU)
Applicable Rules and Regulations
Section 4012 of the Indiana Division on Aging Operations Manual; 410 IAC 7.9 Home Health Agencies –
Definitions; 455 IAC 1 & 2 – Home and Community Based Services rule; IC 16-27-1 Licensure of Home Health
Agencies; all define service as:
Service Description
Service provided by a Registered Nurse (RN) or Licensed Practical Nurse (LPN) to provide services such as
blood draws, wound care, catheter changes, diabetic education, IV therapy, colostomy care, and medication
set-up.
Allowable Activities
Activities allowable for licensed skilled nurses to provide including but not limited to the activities listed
under service description.
Activities Not Allowed
Activities not required to be performed by an LPN or RN
Activities which are allowable under other funding sources
Provider Requirements
A licensed home health agency employing licensed nursing staff
Unit of Service
¼ hour = 1 unit
Service Authorization
Services must be provided in accordance with the Vendor Authorization issued by the NWICA Case
Manager.
Documentation Requirements
Documentation required by the Indiana State Department of Health Licensure
Documentation compliant with the Indiana Health Coverage Programs Provider Bulletin BT200371,
Documentation Standards for Home and Community-Based Services Waiver Programs
NWICA monthly service progress report.
Funding Source
Funding sources include CHOICE, TIII, and SSBG.
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Transportation Services (TRAN)
Applicable Rules and Regulations
Section 4029 of the Indiana Division on Aging Operations Manual and Section 10055 of the Indiana FSSA
CHOICE Manual define service as:
Service Description
Transportation Services ensure older adults and persons with disabilities (particularly those persons living in
rural areas) access to services that help them remain independent. All Transportation Services shall comply
with Federal Transit Authority (FTA), Federal Department of Transportation (DOT) and Indiana Department
of Transportation (INDOT) rules and regulations as well as applicable codes, including the Americans with
Disabilities Act (ADA) regulations for public transit.
Allowable Activities
A one-way trip for the purpose of healthcare, social activities, shopping, etc. for the purpose of assisting
individuals to access services and remain independent. When demand exceeds services available, the
provider shall prioritize the types of transportation that will be provided. Prioritization would be as follows:
Trips for medical reasons
Trips for nutritional purposes
Shopping
Socialization purposes
Activities Not Allowed
Activities not listed above
Provider Requirements
All providers must properly maintain vehicles which include:
A standard list of items checked each day the vehicle in service is used.
Procedures in place that require the vehicle be out of service until such corrections are made of specific
items that would include:
Brakes
Fuel
Emergency Equipment
Seat belts
All vehicles shall have an inspection every 6 months or as recommended by the vehicle manufacturer.
Drivers providing service under the agreement must possess at least a Class C CDL with a passenger
endorsement. If equipment dictates, drivers must possess the appropriate license to operate the vendor’s
vehicles.
In addition to standard insurance coverage, transportation vendors must have Ambulatory coverage in a
minimum amount of $1.5 million, Wheelchair Accessible coverage in a minimum amount of $1.5 million and
General Vehicle Liability in a minimum amount of $1 million. Policies must list NWICA as an additional
insured. Vendor is responsible for submitting updated Certificates of Insurance as applicable.
Unit of Service
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1 one-way trip = 1 unit
Service Authorization
For transportation services provided with Title III funds, no NWICA service authorization is required for
services provided by contracted providers. Transportation providers must ensure eligibility requirements (60
years of age or older) are met.
For transportation services provided through CHOICE and/or SSBG, services must be provided in accordance
with the Vendor Authorization issued by the NWICA Case Manager.
Documentation Requirements
Client demographic information and trip information entered into INsite/NAPIS on a monthly basis. Vehicle
inspection reports and client intake forms must be available for review at the provider’s office.
Funding Source(s)
Funding sources may include Title III, CHOICE and SSBG depending on provider qualifications and contractual
requirements.
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Standard Operating Procedures for HCBS
Provider Qualifications
In order to become an approved provider of HCBS, an entity shall do the following:
Under CHOICE a Service Provider must be Medicaid Waiver Certified; and
meet the current minimum service provider requirements as specified; and
Be a provider of an approved nursing facility level of care Medicaid waiver service or a home and community
based service listed in 455 IAC 2-5-1. Appendix A
Show proof of licensure or certification from the state of Indiana, if a license is required.
Certify that, if approved, the entity will provide HCBS using only personnel who meet the qualifications
defined in this manual.
Retain, and have readily available, a copy of the most current executed signed provider agreement
appropriate to the funding program and the provided service.
Assure and document compliance with the executed provider agreement or contract and this rule.
In order to maintain approved status as a provider of HCBS, an entity must do the following:
Continue to maintain minimum standards set out in this manual.
Successfully complete the renewal process, as determined by NWICA.
Receive written notice of renewal to be maintained by the provider.
Orientation and Training
Service providers must maintain a written plan for orienting new staff. New program staff must receive
orientation and training which includes at a minimum:
introduction to the program,
Vendor policies and procedures,
maintenance of records and files (as appropriate),
organizational standards and expectations for ethical behavior,
confidentiality and, as appropriate, HIPAA compliance, and
emergency procedures
Direct care staff will also receive orientation and training including first aid, CPR, universal precautions, and
the aging process. Issues addressed under the aging process may include, though are not limited to:
cultural diversity
dementia
cognitive impairment
mental illness
abuse and exploitation
communicable and infectious diseases
communication techniques
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food handling and sanitation
Service providers must also maintain a written annual training plan which includes at least the following:
Dates of training
Topics of training
Presenters
Goals to be accomplished
Staff required to attend
Evidence of implementation of orientation and training plans must be available for review at the service
provider’s offices.
Personnel Policies and Procedures
Employees must have access to service provider personnel policies and procedures.
Personnel policies and procedures must include at least the following:
Job Descriptions
Service providers maintain written job descriptions for each position in the organization. Job descriptions
include minimum qualifications for the position and major duties required of the position.
Hiring procedures
Service providers have a written procedure for conducting reference, employment and criminal background
checks on each prospective employee or agent.
Written hiring procedures prohibit employing or contracting with a person convicted of crimes including at
least the following:
A sex crime (IC 35-42-4)
Exploitation of an endangered adult (IC 35-46-1-12)
Abuse or neglect of a child (IC 35-42-2-1)
Failure to report battery, neglect, or exploitation of an endangered adult or dependent (IC 35-46-1-13)
Theft occurring within 10 years prior to the date of application for employment (IC 35-43-4; IC 16-27-25(a)(5)
Murder (IC 35-42-1-1)
Voluntary manslaughter (IC 35-42-1-3)
Involuntary manslaughter (IC 35-42-1-4)
Battery (IC 35-42-2)
Service providers have a written procedure for conducting license verifications. The verifications include at
least the following:
Licensed professionals must be checked for findings through the Indiana Professional Licensing Agency.
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All employees, regardless of their current status as a nurse’s aide or home health aide, must be checked for
findings from the Indiana State Department of Health Nurse Aide Registry.
Service providers can visit http://www.in.gov/services.htm to complete these searches online.
Performance Evaluation
Performance evaluations should be conducted with each employee at least annually. Procedures for
performance evaluations should include a face to face meeting with the employee to discuss performance
strengths and areas for improvement. Documentation of the annual performance evaluation should be
maintained in the personnel file.
Disciplinary Action/Performance Enhancement
Each service provider has written policies and procedures regarding disciplinary action and/or performance
enhancement. The policies and procedures list examples of infraction that will result in disciplinary action or
performance enhancement actions. Examples include, but are not limited to, the following:
Falsifying client records
Breach of confidentiality
Improper treatment of client
Being under the influence of alcohol or illegal substance
Stealing from client or vendor
Excessive absenteeism
Failure to report to work
Availability of management staff
Management staff or designated supervisory individuals are available during all hours of operation/service
provision to consult with program staff, if necessary.
Relatives as caregivers
An individual who is a legally responsible relative of an eligible consumer (including a parent of a minor
individual or a spouse) cannot provide services for that individual for compensation under the Agreement
with NWICA except as otherwise stated in IC 12-10-10-9(b).
Personnel Files
Personnel files have documentation of the following:
Employee/agent is at least 18 yrs old
Direct care staff have current CPR certification
Orientation/training documentation
Reference checks
Criminal background checks prior to service provision
Current job description
Current certification/licensing
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Documentation that licensed professionals have been checked for findings through the Indiana Professional
Licensing Agency AND that non-licensed employees have been checked for findings from the Indiana State
Department of Health Nurse Aide Registry
Proficiency testing
Annual performance evaluations
Current TB test or chest x-ray
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Service Provision
Receiving a Referral from NWICA
Prospective consumers complete an initial screening to determine their level of need and their functional
and financial eligibility for home and community based services under NWICA funding sources. If eligibility
requirements are met, the consumer is referred to our Case Management department.
Our Case Managers are trained and certified to assess each consumer’s situation and to assist the consumer
in developing a Plan of Care designed to support the consumer’s independence and ability to remain in their
home and community. The consumer and Case Manager develop a menu of services, and then the
consumer receives a list of vendors who contract with NWICA to provide the desired services.
Consumers choose their own vendors. They may make their selections by any process or criteria that they
choose and the Case Manager is not permitted to influence that decision.
Once the consumer has chosen their provider(s,) for services under our CHOICE, SSBG and TIII funding
sources, the Case Manager prepares the Vendor Authorization. (See Sample on next page.) The Vendor
Authorization indicates the approved services, dates and number of units. Services must be provided within
the authorized dates and must not exceed the number of units as indicated. Units may not be moved from
one month to another without written authorization from the Case Manager. When the Vendor
Authorization is completed, the Case Manager sends a copy to each vendor selected by the consumer.
For Aged and Disabled or Traumatic Brain Injury Medicaid Waiver Consumers, once the consumer has
chosen their providers(s) for services under the Medicaid Waivers, the Case Manager prepares the CostComparison Budget (CCB). The CCB indicates the approved services, dates and number of units requested
and is submitted to the state for approval. Once the CCB is approved at the state level, a Notice of Action is
generated by the state and sent electronically to the AAA and all vendors with authorized services on the
CCB. The vendor is able to open CCB notifications and Notices of Action simply by entering the last 4 digits
of the consumer’s social security number which service providers should include in each client’s file.
Vendors should not provide services to a consumer for whom they do not have a current Vendor
Authorization or Notice of Action. Vendors who provide services without current authorizations run the risk
of not receiving reimbursement for those services. Vendors should notify the consumer that their
authorization to provide the services has ended and encourage the consumer to contact the case manager
to discuss the situation.
Any services provided other than as indicated on the Vendor Authorization or Notice of Action sent by the
state will not be allowable; however, service providers have more frequent face to face contact with
consumers than do Case Managers. If a service provider believes that services are not authorized
appropriately, the provider should contact the Case Manager to discuss the situation further. NWICA
appreciates this feedback from providers and believes that it strengthens our partnership as we mutually
care for consumers.
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Service Provider Policies Regarding Service Provision
Vendors maintain written policies and procedures regarding service provision which include at least the
following:
Rights of service recipients
Each service provider maintains a written statement of consumer rights. This statement is provided to
consumers at the start of care and is reviewed with new employees at orientation. The statement includes
at least the following rights.
Receive Information.
Each Participant has the right to receive information about the service provider, the provider’s policies and
procedures, services, staff, and the consumer’s rights and responsibilities.
Dignity and Privacy.
Each consumer is guaranteed the right to be treated with respect and with due consideration for his or her
dignity and privacy.
Receive information on available service options.
Each consumer is guaranteed the right to receive information on available service options and alternatives,
presented in a manner appropriate to the consumer’s condition and ability to understand.
Participate in decisions.
Each consumer is guaranteed the right to participate in decisions regarding his or her health care, including
the right to refuse treatment.
Free from restraint or seclusion.
Each consumer is guaranteed the right to be free of any form of restraint or seclusion used as a means of
coercion, discipline, convenience or retaliation.
Copy of records.
Each consumer is guaranteed the right to request and receive a copy of his or her records, and to be
informed of the procedure for requesting records.
Free exercise of rights.
Each consumer is free to exercise his or her rights, and that the exercise of those rights does not adversely
affect the way the consumer is treated by the service provider.
Freedom to Change Provider.
Service providers shall not impose any limitation on the consumer’s freedom to change providers.
Abuse, Neglect and Exploitation
In Indiana, any person who has reason to believe that a consumer is a victim of abuse, neglect or
exploitation is obligated to make a report to Child Protective Services (CPS), Adult Protective Services (APS)
or to the police.
"Reason to believe" means that the evidence available to that person, if presented to other individuals of
similar background and training, would make those individuals think that the consumer has been abused or
neglected.
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The law (I.C. 12-10-3) requires all individuals with reason to believe a disabled adult is being abused,
neglected, or exploited to make a report to Adult Protective Services (APS) and/or local law enforcement.
Failure to make a report is considered a Class B misdemeanor. In Indiana a Class "B" misdemeanor
conviction carries a penalty of imprisonment for a fixed term of up to one hundred eighty (180) days and a
fine up to $1000.00.
Service providers will also inform the case manager any time a report is made regarding the abuse, neglect
or exploitation of a consumer of services under the agreement; however, it is still the service provider’s
obligation to report to the appropriate authorities. Informing the case manager does not relieve the
service provider of their duty to report.
If you have reason to believe an individual is being abused, neglected or their safety is in jeopardy in
anyway, you are required to report to proper authorities immediately.
How to Make a Report to Adult Protective Services
An APS report should be filed within the county where the endangered person lives as soon as possible upon
indication that there may be a problem.
When making a report to APS have as much of the following information as possible:
The endangered adult’s name, address, phone number, age, and physical or mental capacity
Alleged perpetrator’s name, address, phone number, and relationship to the endangered adult
Nature and extent of the abuse, neglect, or exploitation
Any additional information that may be helpful
REMEMBER YOU DO NOT NEED TO DETERMINE IF THE ABUSE OR NEGLECT IS OCCURING BUT YOU ARE
RESPONSIBLE AS A CITIZEN OF THE STATE OF INDIANA TO REPORT IT.
ADULT PROTECTIVE SERVICES CONTACT INFORMATION:
Lake County Referrals
(219) 755-3863
Porter County Referrals
(219) 326-6808 ext. 505
Jasper, Newton, Pulaski, and Starke County Referrals
(219) 326-6808 ext. 420
Your local law enforcement agency can also be contacted.
Wellness Checks by Local Law Enforcement
If an emergency requires a wellness check, the consumer’s local police department should be contacted
immediately and asked to conduct a “Wellness Check”. You will need the client’s name and address and any
available contact information for caregivers or family members. Police will generally notify the requestor
after visiting the individual.
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Communicable/infectious disease
An infectious disease is one in which an organism has invaded the body and has the potential of spreading
into multiple systems. A contagious disease is one in which an organism can spread from one individual to
another.
Service providers will establish policies and procedures regarding infectious and contagious diseases for
both employees and consumers.
Discharge/Termination process
Each service provider must establish a written service procedure which includes formal written notification
of the termination of services and documentation in client files. The written notification must state the
reason for the termination, the effective date, and advise about the right to appeal. Reasons for
termination may include, but are not limited to the following:
the client’s decision to stop receiving services;
reassessment which determines a client to be ineligible;
improvements/changes in the client’s condition so they no longer are in need of services;
permanent institutionalization of client in an acute care or long term care facility
The service provider becomes unable to continue to serve the client.
Service providers are required, under the agreement, to give thirty (30) days advance notice of any
termination of services initiated by the provider. Notice shall be provided to the client/caregiver and to the
NWICA Case Manager. If the consumer initiates the termination of services, written notice from the vendor
shall be provided to the Case Manager within 10 days of termination by the consumer.
Transfer of records upon change of provider
Pursuant to 455 IAC 2-8-3, if an individual changes providers for a home and community based service, the
original provider shall transfer copies of all records related to the individual to the new provider:
within five (5) calendar days; and
in compliance with HIPAA regulations
See Appendix A for the complete text of 455 IAC 2, Indiana’s Home and Community Based Services Rule.
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Incident Reporting
All vendors are required to comply with the Indiana Division of Aging Incident Reporting Policy. All
reportable incidents and unusual occurrences shall be reported to the Indiana Division of Aging in the
manner prescribed. See Appendix B for the text of the Indiana Division of Aging Policy.
Service providers will also inform the case manager any time an incident report is made regarding a
consumer of services under the agreement; however, it is still the service provider’s obligation to report to
the appropriate authorities. Informing the case manager does not relieve the service provider of their duty
to report.
Service Areas
Each Service Provider indicated in the application for a contract the areas in which they were willing to
provide services. The agreement was issued with this understanding. If, for any reason, a Service Provider
needs to change the service areas designated in their proposal/contract, a written request should be
submitted to Quality Assurance.
Staffing
Service Providers agree to provide sufficient staffing to commit to the service(s) and time period(s)
authorized on the Vendor Authorization.
Service Providers agree to provide backup for their own staff in the event that a scheduled worker is unable
to fulfill their assignment. Backup staff must meet the qualifications for the service that is authorized.
Service Providers are required to promptly notify the client and the client’s Case Manager if any schedule
disruption occurs. Consistent schedule disruptions may result in probation or suspension of the agreement.
Minimum Visit Times
Any service provider desiring to establish a minimum visit length longer than 2 hours must obtain written
permission from NWICA.
Staffing with more than one staff person
When the safety of a staff person is a concern, the option of staffing with two persons for half the
authorized time may be requested. (For example: service authorized for 2 hours every week could be
provided by 2 people at once for 1 hour every week.) Request must be made to and approved by the
consumer’s Case Manager.
Procedure:
Service Provider submits written request to Case Manager, explaining the extenuating circumstances
contributing to the concern for the staff person’s safety.
The Case Manager will contact the consumer to discuss the concerns and the proposed plan for service.
If approved, the Case Manager will send the Service Provider a Plan of Care noting that service by 2 staff
members at the same time will be allowable.
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Progress Reports
The Service Provider is responsible to notify the case manager regarding any changes in the consumer’s
status, including, but not limited to: missed service; service refusal; consumer request for service
termination; hospitalization; change in physical; mental or emotional state; death; change in living
arrangements; unresolved consumer complaints or grievances; any other significant issues regarding the
consumer and/or services.
In addition to ongoing communication with the Case Manager which is documented in the consumer’s file,
Case Managers may periodically request a progress report from the vendor. The Case Manager will specify,
at the time of the request, what type of information they are requesting.
Documentation
Service providers maintain, in the provider's office, documentation of all services provided to an individual.
Documentation related to an individual shall be maintained by the provider per HIPAA guidelines. Service
Providers shall maintain the documentation required by the following:
The Service Definition applicable to the services the provider is providing to an individual.
The professional standards applicable to the provider's profession.
The individual's plan of care.
Client Files
Client files contain at least the following information:
Authorization for services
The individual’s full name
Telephone numbers for emergency services that could be required for the individual
Documentation of coordination/communication between vendor and NWICA including case notes, progress
reports, and other correspondence
Evidence of client notification when the regular worker or appointment was changed.
Case manager notification when the services were not provided as authorized.
Consent by the individual or the individual’s legal representative for emergency treatment for the individual,
if applicable
Documentation, including but not limited to the following information, of all services rendered for the last
45 days:
Changes in the individual’s physical condition or mental status during the last 45 days
Any unusual event such as vomiting, choking, falling, disorientation or confusion, behavioral problems, or
seizures occurring during the last 45 days
The response of the provider to the observed change or unusual event
All documentation of medication administered for the last 45 days, where applicable
Documentation should be kept chronologically and must include the following information for verification of
service claim:
Date of Service
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Arrival & departure time
Tasks performed
Tasks performed are appropriate to job description/scope of service
Signatures of client and service provider
Additional Notes Regarding Documentation
All documentation errors must be corrected using the following, universally accepted, method of drawing a
line through the entry (in ink). Do not obliterate the word, but enter the correct information, and initial and
date the change.
Signatures are required to authenticate all documentation of services rendered. While it is recommended
that a full signature be used for each entry, each individual entry must be signed, including, at a minimum,
the first initial and last name. If the first initial and last name is used, a master signature file must be
maintained. The file must contain a complete (first and last name) signature and the corresponding initial
and last name to be used for documentation purposes. If a service requires a certain licensure level, for
example health services provider in psychology (HSPP) for level 1 behavior management, that individual
must include his or her title or credential in the signature.
The payer source must be identified on each piece of documentation for verification of billing. This clarifies
which payer source the documentation supports for billing activity, for example: waiver, CHOICE, SSBG, and
Title III. Most clients should not be receiving AAA payer/funds home health service and waiver services
concurrently on a consistent basis. AAA payer/funds may be used for spend-down; however, home health
service hours should be used next, followed by waiver services and finally AAA payer/funds hours to meet
any needs not covered by the other programs. For clients receiving more than one service, the hours should
be broken out and clearly credited to the appropriate payer source.
(Indiana Health Coverage Programs Document Standards for Home and Community-Based Waiver Programs
BT200371 December 19, 2003) See Appendix C.
Rounding of Units
Each service definition specifies the unit by which a particular service is billed. Certain units of service are
billed in 15-minute increments and some are billed in 60-minute increments. There is no procedure for
billing a partial unit of service. If a partial unit is rendered, units should be accrued to the end of the current
month of service. At the end of the current month of service, partial units can be rounded to the next whole
unit when calculation units of service provided. When rounding of units occurs at the end of the billing
month, the following guidelines can be used by providers:
15-minute units of service:
Any partial unit of service eight minutes of more is rounded up to a 15-minute unit of service.
Any partial unit of service seven minutes or less must not be rounded up and therefore should not be billed.
60-minute units of service:
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Any partial unit of service 30 minutes or more is rounded up to a 60-minute unit of service.
Any partial unit of service 29 minutes or less must not be rounded up and therefore should not be billed.
Quality Assurance & Quality Improvement
Provider has a QA/QI system in place.
The QA/QI system is reviewed and updated annually.
The QA/QI system includes at least the following:
A method for measuring consumer satisfaction
Documentation of efforts to improve provision of services based on customer satisfaction results
An annual assessment of the appropriateness and effectiveness of each service provided to an individual
A method for analyzing data regarding reportable incidents and services provided
Documentation of efforts to improve service provision to reduce occurrences of reportable incidents
Reimbursement to Providers
The State of Indiana transitioned to a new statewide accounting system on September 16, 2009.
Reimbursement from NWICA is dependent on the State of Indiana's payment terms, which are described
below.
As allowed in the administrative code, the State of Indiana issues payments 35 days after the invoice date.
We wanted to explain to you how this impacts our reimbursement times. (Please note that this only applies
to Area Agency on Aging funding sources including CHOICE, SSBG, and Title III. This will not impact
reimbursement for Community Services Intake services.)
Currently, providers are required to submit invoices to us by the 5th business day of each month following
the month in which services were provided. Invoices submitted to us by the 5th are processed into our
system by the 20th and we invoice the State by the 20th of each month. If they wait 35 days to reimburse us,
we will receive payment from them around the 25th of the following month. NWICA then issues checks to
our providers on Friday of the same week we receive funds. This means that providers have waited
approximately 60 days to receive payment for services rendered. In an effort to alleviate this cash flow
problem, NWICA offers the opportunity to submit invoices twice each month per the following guidelines.
A provider may choose to bill for services provided between the 1st and the 15th of the month. These
invoices would be due to NWICA on the 20th of the month. A second invoice could then be submitted for
services provided between the 16th and the last day of the month. These invoices would be due to NWICA
on the 5th business day of the following month (please refer to the Provider Invoice Schedule on page 44).
Whether a provider chooses to bill once or twice a month, invoices for all services provided during that
month must be received at NWICA by the 5th business day of the following month. There will be no
exceptions.
Here are some additional suggestions that will help ensure timely payment:
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


Submit your invoices to NWICA in a timely manner.
Make sure your invoices are complete and have all necessary documentation. This will minimize
delays caused by adding unnecessary steps to the process.
Check invoice folders on SharePoint regularly/often to ensure that any corrections necessary are
submitted as soon as possible. (For instructions/more information on NWICA’s electronic billing via
SharePoint, see page 51 below).
We also need to be sure that providers understand that, though the Division of Aging says they’ll reimburse
us at 35 days, in some cases it is taking longer than this.
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Provider Invoice Schedule
Services Provided Invoice Due
Jan 1‐ 15
Jan 1‐31
Feb 1‐15
Feb 1‐28
March 1‐15
March 1‐31
April 1‐15
April 1‐30
May 1‐15
May 1‐31
June 1‐15
June 1‐30
July 1‐15
July 1‐30
August 1‐15
August 1‐31
Sept 1‐15
Sept 1‐30
Oct 1‐15
Oct 1‐31
Nov 1‐15
Nov 1‐30
Dec 1‐15
Dec 1‐31
Jan 20
Feb 5
Feb 20
March 5
March 20
April 5
April 20
May 5
May 20
June 5
June 20
July 5
July 20
August 5
August 20
Sept 5
Sept 20
Oct 5
Oct 20
Nov 5
Nov 20
Dec 5
Dec 20
Jan 5
NWICA transmits
to State
Feb 5
Feb 20
March 5
March 20
April 5
April 20
May 5
May 20
June 5
June 20
July 5
July 20
August 5
August 20
Sept 5
Sept 20
Oct 5
Oct 20
Nov 5
Nov 20
Dec 5
Dec 20
Jan 5
Jan 20
Anticipated
Reimbursement to
NWICA*
March 10
March 25
April 10
April 25
May 10
May 25
June 10
June 25
July 10
July 25
August 10
August 25
Sept 10
Sept 25
Oct 10
Oct 25
Nov 10
Nov 25
Dec 10
Dec 25
Jan 10
Jan 25
Feb 10
Feb 25
No invoices will be
processed after
Feb – 5th bus. day
March - 5th bus.
day
April – 5th bus. day
May – 5th bus. day
June – 5th bus. day
July – 5th bus. day
Aug – 5th bus. day
Sept – 5th bus. day
Oct – 5th bus. day
Nov – 5th bus. day
Dec – 5th bus. day
Jan – 5th bus. day
44
HCBS Forms
Invoices
CHOICE
SSBG
Title III E – Family Caregiver
Title III B – In-Home Services
Title III B – Transportation
45
CHOICE Invoice
46
SSBG Invoice
47
Title IIIE Family Caregiver Invoice
48
Title IIIB In-Home Services Invoice
49
Transportation Invoice
50
HCBS Billing
Invoices are due to NWICA by the 5th calendar day after the close of the calendar month in which services were
delivered. For example, if services are provided to a consumer in June, the invoice is due to NWICA by July 5th.
Invoices received after the 5th will not be processed. There will be no exceptions.
Billing documents are submitted electronically to NWICA via SharePoint extranet system only (See below). Upon
receipt of signed service agreement, NWICA facilitates SharePoint remote access and training for all vendors.
Incorrect invoices will be returned to the service provider. Invoices returned for correction may be resubmitted.
Incorrect invoices will be uploaded by NWICA to a designated file folder location on SharePoint. Returned
invoices will include comments explaining any necessary correction(s). Resubmission of corrected invoices must
occur before NWICA prepares claims each month – no later than the 15th calendar date of the month. Providers
are expected to check their SharePoint folders frequently during invoice processing to ensure corrections are
processed and submitted in a timely matter. Questions regarding returned invoices should be directed to
NWICA’s Grants Management Accountant.
Complete Monthly Invoice as follows:
Complete Provider name, address and phone number.
Complete Consumer name, address, phone number and social security number.
Enter the Care Plan period from the current Vendor Authorization.
Enter the current Case Manager’s name.
Enter the Service Delivery Dates, i.e. May 1 – May 31, 2014.
Enter the total number of units of service provided to the consumer during the service delivery period in the
appropriate row.
Multiply the units by the unit rate and enter the amount in the Total Claim column.
Sign and date the invoice.
Complete SharePoint Billing Procedures as trained (See below)
Invoicing Via SharePoint
All providers will be contacted by NWICA IT Staff to have training coordinated for NWICA’s electronic invoicing
system. This individualized training will take the vendor’s software and hardware into account and should
suffice in enabling providers to complete invoicing on an ongoing basis.
Should any problems arise with this process post-training, a step-by-step guide is provided below that may assist
with troubleshooting. If systematic issues with invoicing cannot be resolved utilizing this tool, the appropriate
provider representative should contact NWICA IT staff to see about resolving the issue. Please note: NWICA IT
staff will provide support related to the function of our applications but they cannot provide support for
providers equipment.
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Instructions for Converting Invoice Documents for SharePoint Uploading
Separate all invoices to be scanned in by Funding Source. Scan them as organized in .PDF format to office
computer.
Open Invoice Document, click on File and select “PRINT” in the Windows Drop-down Menu.
In the PRINT SET UP screen, click the drop-down menu (top-center of the PRINT SET UP screen) and select
MICROSOFT OFFICE DOCUMENT IMAGE WRITER. Next to it click on Advanced and check “Print to File” option
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at the bottom the selection. Click “OK” then click “Print”
You will now be prompted to save the invoice (based on action taken in Step 3 above). When saving, be sure to
add the “.tiff” extension to the name of the file (example: “OctoberInvoice.tiff”).
Locate the newly created .tiff document on your computer, and upload to SharePoint.
(See posted SharePoint instructions for more info on how to do SharePoint uploading)
53
Appendix A 455 IAC 2: Home & Community Based Services Rule (460 Code now relocated to 455 IAC)
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56
57
58
59
60
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63
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Appendix B: Indiana Division of Aging Incident Reporting Policy
INCIDENT REPORTING POLICY FOR THE
DIVISION OF AGING
DOCUMENT CONTROL
Document Information
Document Name:
Agency/Division:
Incident Reporting Policy
Division of Aging
Document Author:
Date:
REVISION HISTORY
Version
Date
Changes
0.1
01-10-07
Creation
1.0
02-09-07
Added Document Control and Signature Sections
Added Header and Footer
2.0
03-16-07
Revision
Signatures
Position/Title
Signature
Date
Author (required)
Sponsor (required)
Stakeholder (required)
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POLICY/PURPOSE STATEMENT
It is the policy of the Indiana Division of Aging (DA) to ensure the health and safety of all individuals
receiving services through the DA. This policy is established to identify and address both
immediate and potential risks to the health and safety of individuals receiving services as specified
in 455 IAC 2. This policy addresses incidents (reportable unusual occurrences).
II. STANDARDS
The DA ensures implementation of necessary safeguards to protect the health, safety and welfare
of individuals.
Anyone with knowledge of an incident that effects, or potentially effects, the individual’s health
and safety shall submit an incident report through the DDRS/DA Incident Reporting system
An initial report regarding an incident, allegation, or suspicion of abuse, neglect, or exploitation
shall be submitted within twenty-four (24) hours of the incident or having knowledge of the
incident.
Providers of home and community-based services are required to submit an incident report for
reportable unusual occurrences within forty-eight (48) hours of the time of the incident or
becoming aware of the incident.
Any staff suspected, alleged, or involved in incidents of abuse, neglect, or exploitation of an
individual will be immediately suspended from duty pending investigation by the provider.
DEFINITIONS
”Adult Protective Service” (APS) means the program established under IC 12-10-3.
”Aging staff” means any individual employed by the Division of Aging, or its designee.
”Case manager” means the certified and approved individual chosen by the individual and/or
family to coordinate the individual’s service.
”Child Protective Services” (CPS) refers to child protection services established under IC 31-33.
”Day”, as used in this policy, refers to a calendar day
The Division of Aging (DA) is the entity established in IC 12-10-1-2 to assist the constantly
increasing number of aged in: (1) maintaining self-sufficiency and personal well-being with the
dignity to which the years of labor entitle the person; and (2) realizing the aged person's maximum
potential as a creative and productive individual.
“Direct care staff” means a person or an agent or employee of a provider entity who provides
hands-on services to an individual while providing any of the following services including, but not
limited to: respite, attendant care, adult foster care, adult day services, assisted living, congregate
care, supported employment, structured day program, residential based habilitation,
transportation, health care coordination, occupational therapy, physical therapy, speech therapy,
or behavior management.
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“Division of Aging staff” means any individual employed by the Indiana Family and Social Services
Administration Division of Aging.
“Home and community-based services” or “HCBS” means supportive services provided within the
limit of available funding to an eligible individual and includes, but is not limited to, the following:
homemaker services, attendant care services under IC 16-18-2-28.5, respite care services and
other support services for primary or family caregivers, adult day services, home health services
and supplies, home delivered meals, transportation and self-directed attendant care services
provided by a registered personal services attendant under the applicable statute to individuals in
need of self-directed in-home care..
“Incident” means, for the purposes of this policy, a single episode (event) of a reportable unusual
occurrence. An incident involves a situation in which an individual or individuals have experienced
or are the subject of a reportable unusual occurrence. Multiple occurrences related to the same
type of issue are considered separate incidents. A separate incident report shall be filed at the
time each episode occurs.
“Individual” means a person who has been determined eligible for services by the DA. If the term is
used in the context indicating that the individual is to receive information, the term also includes
the individual’s legal representative.
“Legal representative” means any of the following:
(1) A guardian.
(2) A health care representative acting under IC 16-36-1.
(3) An attorney in fact for health care appointed under IC 30-5-5-16.
(4) An attorney in fact appointed under IC 30-5-5 who does not hold health care powers.
(5) The personal representative of the estate of a resident of a long term facility or client of home
care services as set forth in IC 12-10-13-3.3.
“Provider” or “service provider” means an entity approved by the DA to provide an individual with
agreed upon HCBS.
“Reportable unusual occurrence” includes, but is not limited to, the following:
Alleged, suspected, or actual abuse, neglect, or exploitation of an individual.
Alleged, suspected, or actual assault or abuse by an individual.
The death of an individual
A residence that compromises the health and safety of an individual due to any of the following:
A significant interruption of a major utility.
An environmental, structural, or other significant problem.
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Environmental or structural problems associated with a dwelling where individuals reside that
compromise the health and safety of the individuals.
A residential fire resulting in any of the following:
Relocation.
Personal injury.
Property loss.
Suspected or observed criminal activity by:
a staff member, employee, or agent of a provider;
a family member of an individual receiving services; or
the individual receiving services;
when the care of the individual is impacted or potentially impacted.
Injuries of unknown origin.
Suicidal ideation or a suicide attempt that had the potential to cause physical harm, injury, or
death.
A major disturbance or threat to public safety created in the community by the individual. The
threat can be:
toward anyone, including staff; and
in an internal setting; and
need not be outside the individual’s residence.
Admission of an individual to a nursing facility, excluding respite stays.
A significant injury to an individual, including, but not limited to, the following:
A fracture.
A burn greater than first degree.
Choking that requires intervention.
Contusions or lacerations.
An injury that occurs while an individual is restrained.
Police involvement when there is an arrest.
A missing person.
Inadequate staff support for an individual, including inadequate supervision, with the potential for
endangering the health or welfare of the individual.
“Sentinel Event” means an unexpected occurrence involving serious physical or psychological
injury or the risk thereof. Serious injury specifically includes a loss of limb or function. The phrase
"or risk thereof" includes any process variation for which a recurrence would carry a significant
chance of a serious outcome. A distinction is made between an adverse outcome that is related to
the natural course of an individual's illness or diagnoses or major loss of function, or risk thereof,
that is associated with the treatment/supports, or lack of treatment/supports, for that condition or
diagnosis. The following are considered Sentinel Events even if the outcome was not major
permanent loss of function:
Suspected or actual abuse, neglect or exploitation.
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The unexpected death of an individual.
Attempted suicide which results in physical harm and/or injury to the individual AND the need for
around-the-clock care (regardless of what type of facility).
Suspected rape, sexual assault or sexual exploitation against or by a person receiving services.
Major disturbance or threat to public safety created in the community by the individual (the threat
can be toward anyone including staff and can be in an internal setting – does not have to be on the
street).
Police involvement when there is an arrest of the individual.
Serious physical harm and/or injury of known origin to the individual requiring in-patient
hospitalization; Serious physical harm and/or injury to the individual of unknown origin (broken
bones, serious lacerations, etc.); Significant change in physical and/or mental health status of the
individual (significant increase in seizure activity, aspiration pneumonia, initial diagnosis of
terminal disease, significant increase in behavioral issues, etc.); Adverse conditions where an
individual is placed at significant risk, possibly due to failure of staff/provider to support the
individual's needs (staff not being there when they are assigned to be, staff doing improper patient
transfer techniques, etc.).
Elopements / missing persons that put the individual and/or others at significant risk.
“Support team” means the case manager, the individual who is or may be receiving services
administered through the Division of Aging, and any other person or entity the individual chooses
to develop a plan to safely reside in the community.
PROCEDURES
Identification of a Reportable Incident
Responsible Entities
Anyone with direct monitoring responsibilities including, but not limited to, the following
individuals:
Case Managers
Division of Aging staff
Direct care staff
Other provider staff, agent, or officer
Action
Any individual who, as a result of service provision, oversight or monitoring, identifies a event or
concern that is, or could be, a reportable unusual occurrence, including a Sentinel Event and/or a
suspected or actual incident of abuse, neglect or exploitation, shall:
Make a determination as to whether the incident or alleged incident represents:
Suspected or actual abuse, neglect or exploitation and/or death; and/or
A Sentinel Event; and/or
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A “reportable unusual occurrence”;
Reports such events in accordance with this policy and any other applicable state reporting
requirements.
Reporting
Responsible Entities
Anyone with direct monitoring responsibilities including, but not limited to, the following
individuals:
Case Managers
Division of Aging staff
Direct care staff
Other provider entity staff, agent or officer
Actions
An initial report regarding an incident shall be submitted in accordance with this policy and as soon
as the reporter becomes aware of or receives information about an incident.
Incident reports involving suspected or actual abuse, neglect or exploitation, and/or a death, are
reported within 24 hours of the occurrence or knowledge of the occurrence in the currently
approved format.
Incident reports involving Sentinel Events are reported within 24 hours of the occurrence or
knowledge of the occurrence in the currently approved format.
All other incidents are reported within 48 hours of the occurrence or knowledge of the occurrence
in the currently approved format.
All incidents (including incidents that are also Sentinel Events and/or events that meet the criteria
for suspected or actual abuse, neglect or exploitation) are filed through the DDRS/DA Incident
Reporting system.
Specific requirements may also apply to incident reporting depending on the nature of the incident
described below:
APS or CPS Reporting:
If an event or concern is found to meet the criteria for suspected or actual abuse, neglect or
exploitation including the death of an individual, the incident is reported immediately by the
individual with knowledge of the suspected or actual abuse, neglect or exploitation or death to
APS or CPS as appropriate.
The incident is reported in accordance with Indiana Criminal Code APS or CPS reporting
requirements.
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NOTE: Providers that employ a staff person involved in an incident shall suspend staff involved in
the incident pending provider investigation.
A narrative shall be provided to APS or CPS (as appropriate) and shall include the following:
The name of the person contacted.
The phone number of the contact.
The county of the contact.
No later than twenty-four (24) hours of the occurrence or knowledge of the occurrence, an
incident report is also reported in the DA incident reporting system.
The incident is coded as a Sentinel Event.
A copy of the incident report shall be forwarded to:
The individual or legal representative
The service provider, if applicable
The case manager
APS/CPS, as applicable
Any other applicable service provider identified
The Area Agency on Aging, as applicable
Local law enforcement when applicable
Incident reports involving Sentinel Events (except incidents meeting the criteria for suspected or
actual abuse, neglect or exploitation including the death of an individual, which should have been
reported immediately by the individual with knowledge of the suspected or actual abuse, neglect
or exploitation or death. See Section (3)(a)):
Are reported within 24 hours of the occurrence or knowledge of the occurrence in the currently
approved format.
Are coded as a Sentinel Event incident and the type of the event is noted in the index section of
the incident report within the automated system.
A copy of the incident report shall be forwarded to:
The individual or legal representative
The service provider, if applicable
The case manager
APS/CPS, as applicable
Any other applicable service provider identified
The Area Agency on Aging, as applicable
Local law enforcement when applicable
If an incident initial report is received late and meets the criteria for a sentinel event, the
incident will be coded as sentinel – no matter how late the report is.
All other incidents:
Are reported within 48 hours of the occurrence or knowledge of the occurrence in the currently
approved format.
Are coded as appropriate in the incident reporting system and the type of event noted in the index
section of the incident report within the automated system.
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A copy of the incident report shall be forwarded to:
The individual or legal representative
The service provider, if applicable
The case manager
Any other applicable service provider identified
The Area Agency on Aging, as applicable
Review of Incidents
Responsible Entities
DA Staff or designee
Actions
Initial incident reports will be reviewed within 7.5 working hours of receipt, by DA staff or designee
(reviewer).
The reviewer will determine if:
appropriate notifications have been made,
APS or CPS referral has been made, if required
the incident meets criteria for a Sentinel Event
formal follow-up reports are required
The reviewer will request additional information from the submitter or the Case Manager when
additional information is required to make these determinations.
The reviewer will instruct the submitter to make notifications to APS, CPS, Case Manager or other
entities when this has not been done.
The reviewer will also notify APS or CPS when appropriate.
The reviewer will review an individual’s incident history to identify trends or special needs, and
may make recommendations for systemic changes.
If the reviewer determines that the health, safety, and welfare concerns have been successfully
resolved, the incident will be closed.
If a feasible plan to resolve the incident is documented in the initial incident report, the reviewer
will:
Confirm implementation of the plan, through communications with the AAA, provider, family
members, informal caregivers, and consumer, as appropriate; and
Ensure the desired outcome was achieved (e.g. situation is resolved and individual’s health and
welfare are safeguarded); and
If the incident is resolved close the incident; or
If the incident is deemed, by the reviewer, to not be resolved appropriately:
Refer the incident to the DA Director or designee; and
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Require additional follow-up reports until the incident is resolved.
The reviewer will assign coding appropriate to the incident, including designating Sentinel Event
status.
The reviewer will ensure the incident information is included in the incident database.
The reviewer will send notification of any report specific to a Sentinel Event to appropriate
individuals within the Division of Aging, such as the Medicaid Waiver supervisor, Quality Assurance
Liaison, Quality Assurance Specialist, ISDH and the Office of Medicaid Policy and Planning .
The reviewer will send to the Case Manager notification of the need for follow-up reports.
If the individual does not have a Case Manager, the Division of Aging will designate a DA staff
person as responsible for follow up.
In situations where it would be a conflict of interest for the Case Manager to perform follow-up
activities, the Division of Aging will designate a DA staff person as responsible for performing these
activities.
Follow-up Activities
Responsible Entities
Case Managers
Division of Aging
Other provider entities
Actions
The provider of case management services or, in the event there is no case manager, the
designated DA staff, must contact the individual and other support team members as needed, to
discuss and address the incident and related issues and concerns.
The provider of case management services or, in the event there is no case manager, the
designated DA staff, shall submit an incident follow-up report summarizing steps taken and plans
identified to resolve the initial incident, and the current status of the situation.
The incident follow-up report will be submitted in the prescribed incident follow-up report format
within seven (7) days of the date of the initial incident report, and every seven (7) days thereafter.
Incidents that are not resolved within twenty-one (21) days of the date of the initial incident shall
be referred to the DA Director or designee for additional action.
Follow-up reporting shall continue every seven (7) days until the incident is deemed resolved by
the DA.
Follow-up incident reporting shall be copied to the Quality Assurance Specialist immediately upon
receipt
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The Quality Assurance Specialist within the Division of Aging responsible for Sentinel Event followup will take the steps necessary including communication with case managers, AAAs, other
providers, family members and informal to verify or ensure that immediate threats to the
individual’s health and welfare are addressed and resolved, and will document this in the
individual’s Division of Aging incident record.
All information required by the reviewer to be submitted must also be submitted to the individual
or the individual’s legal guardian and to the provider of case management services.
Weekly status reports of the open sentinel events will be reviewed by the Quality Assurance
Liaison.
On a monthly basis, the Quality Assurance Liaison will review the open incident reports requiring
follow up.
Through the weekly and monthly reports, the Quality Assurance Liaison will analyze, and track the
incident reports, review for trends, review for appropriate corrective action and will make
recommendations to the Sanctions Committee or Quality Improvement Executive Committee, as
appropriate for sanctions or quality improvement procedures that should be implemented.
Non-compliance with this policy may result in actions taken by the Division of Aging to include:
Shall not authorize continuation of services to an individual or individuals by the provider
Shall not authorize receipt of services by individuals not already receiving services from the
provider at the time the determination is made that the provider did not implement a corrective
action plan to the reasonable satisfaction of the Division of Aging
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Appendix C: IHCP Bulletin BT200371 – Documentation Standards for HCBS
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Appendix D: Older Americans Act Title III C
From the U.S. Code Online via GPO Access [wais.access.gpo.gov][Laws in effect as of January 3,
2006][CITE: 42USC3030e]
TITLE 42--THE PUBLIC HEALTH AND WELFARE
CHAPTER 35--PROGRAMS FOR OLDER AMERICANS
SUBCHAPTER III--GRANTS FOR STATE AND COMMUNITY PROGRAMS ON AGING
Part C--Nutrition Services
subpart i--congregate nutrition services
Sec. 3030e. Grants for establishment and operation of nutrition projects
The Assistant Secretary shall carry out a program for making grants to States under State plans
approved under section 3027 of this title for the establishment and operation of nutrition projects(1) which, 5 or more days a week (except in a rural area where such frequency is not feasible (as
defined by the Assistant Secretary by regulation) and a lesser frequency is approved by the State
agency), provide at least one hot or other appropriate meal per day and any additional meals
which the recipient of a grant or contract under this subpart may elect to provide;
(2) which shall be provided in congregate settings, including adult day care facilities and
multigenerational meal sites; and
(3) which may include nutrition education services and other appropriate nutrition services for
older individuals.
(Pub. L. 89-73, title III, Sec. 331, as added Pub. L. 95-478, title I,Sec. 103(b), Oct. 18, 1978, 92 Stat.
1536; amended Pub. L. 102-375,title III, Sec. 313, Sept. 30, 1992, 106 Stat. 1238; Pub. L. 103171,Sec. 3(a)(13), Dec. 2, 1993, 107 Stat. 1990; Pub. L. 106-501, Title III,Sec. 312(c), Nov. 13, 2000,
114 Stat. 2252.)
Amendments
2000--Par. (2). Pub. L. 106-501 inserted “, including adult daycare facilities and multigenerational
meal sites” before semicolon.
1993--Pub. L. 103-171 substituted “Assistant Secretary” for “Commissioner” in introductory
provisions and par. (1).
1992--Par. (1). Pub. L. 102-375 inserted “(except in a rural area where such frequency is not
feasible (as defined by the Commissioner by regulation) and a lesser frequency is approved by the
State agency)”after “week” and struck out before semicolon at end “, each of which assures a
minimum of one-third of the daily recommended dietary allowances as established by the Food
and Nutrition Board of the National Academy of Sciences-National Research Council”.
Effective Date
Subpart effective at close of Sept. 30, 1978, see section 504 of Pub. L. 95-478, set out as an
Effective Date of 1978 Amendment note under section 3001 of this title.
106
Nutrition Projects for Elderly Under Prior Provisions, Qualified Under Successor Provisions, Eligible
for Funds Under Such Provisions; Discontinuance of Payments for Ineffective Activities
Operation of predecessor projects under successor provisions, see section 501(b) of Pub. L. 95478, set out as a note under section 3045of this title.
From the U.S. Code Online via GPO Access [wais.access.gpo.gov][Laws in effect as of January 3,
2006][CITE: 42USC3030f]
TITLE 42--THE PUBLIC HEALTH AND WELFARE
CHAPTER 35--PROGRAMS FOR OLDER AMERICANS
SUBCHAPTER III--GRANTS FOR STATE AND COMMUNITY PROGRAMS ON AGING
Part C--Nutrition Services
subpart ii--home delivered nutrition services
Sec. 3030f. Grants for establishment and operation of nutrition projects for older individuals
The Assistant Secretary shall carry out a program for making grants to States under State plans
approved under section 3027 of this title for the establishment and operation of nutrition projects
for older individuals which, 5 or more days a week (except in a rural area where such frequency is
not feasible (as defined by the Assistant Secretary by regulation) and a lesser frequency is
approved by the State agency),provide at least one home delivered hot, cold, frozen, dried,
canned, or supplemental foods (with a satisfactory storage life) meal per day and any additional
meals which the recipient of a grant or contract under this subpart may elect to provide.
(Pub. L. 89-73, title III, Sec. 336, as added Pub. L. 95-478, title I,Sec. 103(b), Oct. 18, 1978, 92 Stat.
1536; amended Pub. L. 102-375,title III, Sec. 314, Sept. 30, 1992, 106 Stat. 1238; Pub. L. 103171,Sec. 3(a)(13), Dec. 2, 1993, 107 Stat. 1990.)
Amendments
1993--Pub. L. 103-171 substituted “Assistant Secretary” for “Commissioner” in two places.
1992--Pub. L. 102-375 inserted “(except in a rural area where such frequency is not feasible (as
defined by the Commissioner by regulation) and a lesser frequency is approved by the State
agency)" after "week" and struck out before period at end, each of which assures a minimum of
one-third of the daily recommended dietary allowances as established by the Food and Nutrition
Board of the National Academy of Sciences-National Research Council”.
Effective Date
Subpart effective at close of Sept. 30, 1978, see section 504 of Pub. L. 95-478, set out as in
Effective Date of 1978 Amendment note under section 3001 of this title.
107
From the U.S. Code Online via GPO Access [wais.access.gpo.gov][Laws in effect as of January 3,
2006][CITE: 42USC3030g]
TITLE 42--THE PUBLIC HEALTH AND WELFARE
CHAPTER 35--PROGRAMS FOR OLDER AMERICANS
SUBCHAPTER III--GRANTS FOR STATE AND COMMUNITY PROGRAMS ON AGING
Part C--Nutrition Services
subpart ii--home delivered nutrition services
Sec. 3030g. Efficiency and quality criteria
The Assistant Secretary, in consultation with organizations of and for the aged, blind, and
disabled, and with representatives from the American Dietetic Association, the Dietary Managers
Association, the National Association of Area Agencies on Aging, the National Association of
Nutrition and Aging Services Programs, the National Association of Meals Programs, Incorporated,
and any other appropriate group, shall develop minimum criteria of efficiency and quality for the
furnishing of home delivered meal services for projects described in section 3030f of this title. The
criteria required by this section shall take into account the ability of established home delivered
meals programs to continue such services without major alteration in the furnishing of such
services.
(Pub. L. 89-73, title III, Sec. 337, as added Pub. L. 95-478, title I,Sec. 103(b), Oct. 18, 1978, 92 Stat.
1536; amended Pub. L. 97-115,Sec. 10(e), Dec. 29, 1981, 95 Stat. 1601; Pub. L. 100-175, title I,Sec.
182(n), Nov. 29, 1987, 101 Stat. 967; Pub. L. 102-375, title III,Sec. 315, Sept. 30, 1992, 106 Stat.
1239; Pub. L. 103-171,Sec. 3(a)(13), Dec. 2, 1993, 107 Stat. 1990.)
Amendments
1993--Pub. L. 103-171 substituted “Assistant Secretary” for “Commissioner”.
1992--Pub. L. 102-375 inserted “the Dietary Managers Association, “after “Dietetic Association,”.
1987--Pub. L. 100-175 substituted “National Association of Area Agencies” for “Association of Area
Agencies”.
1981--Pub. L. 97-115 substituted “National Association of Nutrition and Aging Services Programs”
for “National Association of Title VII Project Directors”.
Effective Date of 1987 Amendment
Amendment by Pub. L. 100-175 effective Oct. 1, 1987, except not applicable with respect to any
area plan submitted under section 3026
(a)of this title or any State plan submitted under section 3027(a) of this title and approved for any
fiscal year beginning before Nov. 29, 1987,see section 701(a), (b) of Pub. L. 100-175, set out as a
note under section 3001 of this title.
108
From the U.S. Code Online via GPO Access [wais.access.gpo.gov][Laws in effect as of January 3,
2006][CITE: 42USC3030g-21]
TITLE 42--THE PUBLIC HEALTH AND WELFARE
CHAPTER 35--PROGRAMS FOR OLDER AMERICANS
SUBCHAPTER III--GRANTS FOR STATE AND COMMUNITY PROGRAMS ON AGING
Part C--Nutrition Services
subpart iii--general provisions
Sec. 3030g-21. Nutrition
A State that establishes and operates a nutrition project under this chapter \1\ shall\1\ So in original. Title III of Pub. L. 89-73, as amended, contained parts and subparts, but not
chapters.
(1) solicit the advice of a dietitian or individual with comparable expertise in the planning of
nutritional services, and
(2) ensure that the project(A) provides meals that(i) comply with the Dietary Guidelines for Americans, published by the Secretary and the Secretary
of Agriculture,
(ii) provide to each participating older individual(I) a minimum of 33\1/3\ percent of the daily recommended dietary allowances as established by
the Food and Nutrition Board of the Institute of Medicine of the National Academy of Sciences, if
the project provides one meal per day,
(II) a minimum of 66\2/3\ percent of the allowances if the project provides two meals per day,
and
(III) 100 percent of the allowances if the project provides three meals per day, and
(iii) to the maximum extent practicable, are adjusted to meet any special dietary needs of program
participants,
(B) provides flexibility to local nutrition providers in designing meals that are appealing to program
participants,
(C) encourages providers to enter into contracts that limit the amount of time meals must spend
in transit before they are consumed,
(D) where feasible, encourages arrangements with schools and other facilities serving meals to
children in order to promote intergenerational meal programs,
(E) provides that meals, other than in-home meals, are provided in settings in as close proximity to
the majority of eligible older individuals' residences as feasible,
109
(F) comply \2\ with applicable provisions of State or local laws regarding the safe and sanitary
handling of food, equipment, and supplies used in the storage, preparation, service, and delivery
of meals to an older individual,
\2\ So in original. Probably should be “complies”.
(G) ensures that meal providers carry out such project with the advice of dietitians (or individuals
with comparable expertise), meal participants, and other individuals knowledgeable with regard to
the needs of older individuals,
(H) ensures that each participating area agency on aging establishes procedures that allow
nutrition project administrators the option to offer a meal, on the same basis as meals provided to
participating older individuals, to individuals providing volunteer services during the meal hours,
and to individuals with disabilities who reside at home with and accompany older individuals
eligible under this chapter,\1\
(I) ensures that nutrition services will be available to older individuals and to their spouses, and
may be made available to individuals with disabilities who are not older individuals but who reside
in housing facilities occupied primarily by older individuals at which congregate nutrition services
are provided, and
(J) provide \3\ for nutrition screening and, where appropriate, for nutrition education and
counseling.
\3\ So in original. Probably should be “provides”.
(Pub. L. 89-73, title III, Sec. 339, as added Pub. L. 106-501, Title III, Sec. 313, Nov. 13, 2000, 114
Stat. 2252.)
Codification
Pub. L. 106-501, Sec. 313, which directed amendment of subpart 4 of part C of title III of the Older
Americans Act of 1965 (Pub. L. 89-73)by striking section 339 and inserting this section, was
executed in this subpart, which is subpart 3 of part C of title III of the Act, by repealing prior
section 3030g-21, and inserting this section, to reflect the probable intent of Congress and the
redesignation of subpart 4 of part C of title III of the Act as subpart 3 by Pub. L. 106-501,Sec.
312(b).
Prior Provisions
A prior section 3030g-21, Pub. L. 89-73, title III, Sec. 339, as added Pub. L. 102-375, title III, Sec.
317, Sept. 30, 1992, 106 Stat.1241, related to compliance with dietary guidelines prior to repeal by
Pub. L. 106-501, title III, Sec. 313, Nov. 13, 2000, 114 Stat. 2252. See Codification note above.
110
From the U.S. Code Online via GPO Access [wais.access.gpo.gov][Laws in effect as of January 3,
2006][CITE: 42USC3030g-22]
TITLE 42--THE PUBLIC HEALTH AND WELFARE
CHAPTER 35--PROGRAMS FOR OLDER AMERICANS
SUBCHAPTER III--GRANTS FOR STATE AND COMMUNITY PROGRAMS ON AGING
Part C--Nutrition Services
subpart iii--general provisions
Sec. 3030g-22. Payment requirement
Payments made by a State agency or an area agency on aging for nutrition services (including
meals) provided under part A, B, or C of this subchapter may not be reduced to reflect any increase
in the level of assistance provided under section 3030a of this title.
(Pub. L. 89-73, title III, Sec. 339A, as added Pub. L. 102-375, Title III, Sec. 317, Sept. 30, 1992, 106
Stat. 1241.)
Prior Provisions
Prior sections 3030h to 3030l were repealed by Pub. L. 106-501,title III, Sec. 314(1), Nov. 13, 2000,
114 Stat. 2253.
Section 3030h, Pub. L. 89-73, title III, Sec. 341, as added Pub. L.100-175, title I, Sec. 140(d), Nov.
29, 1987, 101 Stat. 945; amended Pub. L. 102-375, title I, Sec. 102(b)(6), (10)(C), Sept. 30, 1992,
106Stat. 1201, 1202; Pub. L. 103-171, Sec. 3(a)(13), Dec. 2, 1993, 107Stat. 1990, authorized a grant
program for States.
Section 3030i, Pub. L. 89-73, title III, Sec. 342, as added Pub. L.100-175, title I, Sec. 140(d), Nov. 29,
1987, 101 Stat. 945; amended Pub. L. 102-375, title I, Sec. 102(b)(7), title III, Sec. 318,
Sept.30,1992, 106 Stat. 1201, 1241, defined “in-home services”.
Section 3030j, Pub. L. 89-73, title III, Sec. 343, as added Pub. L.
100-175, title I, Sec. 140(d), Nov. 29, 1987, 101 Stat. 945, provided for the State agency to develop
eligibility criteria.
Section 3030k, Pub. L. 89-73, title III, Sec. 344, as added Pub. L.100-175, title I, Sec. 140(d), Nov. 29,
1987, 101 Stat. 946, required that funds available under former part D of this subchapter be in
addition to funds otherwise expended.
Section 3030l, Pub. L. 89-73, title III, Sec. 351, as added Pub. L.100-175, title I, Sec. 141(d), Nov. 29,
1987, 101 Stat. 946; amended Pub. L. 102-375, title VII, Sec. 708(a)(2)(C), Sept. 30, 1992, 106Stat.
1292; Pub. L. 103-171, Sec. 3(a)(13), Dec. 2, 1993, 107 Stat. 1990,authorized program of grants to
satisfy special needs of older individuals.
111
Appendix E: CHOICE Guidelines
CHOICE MANUAL Revised
September 2012
Revised November 2007
Prepared by the Division of Aging Prepared by the
Division of Aging
112
TABLE OF CONTENTS
10000 Overview of CHOICE.......................................................................................... 3
10001 Code of Ethics.................................................................................................... 4
10002 AAA Contracts for Administration of CHOICE Funds ..................................... 5
10003 Public Records Requests.................................................................................. 5
10004 CHOICE Eligibility Determinations ................................................................... 5
10005 CHOICE Waiting List.......................................................................................... 8
10006 CHOICE Reduction in Service and Participant Termination Policy................ 8
10007 CHOICE Cost-Sharing ....................................................................................... 9
10008 Individual Cap on CHOICE Funds................................................................... 10
10009 Funding of Last Resort.................................................................................... 10
10010 CHOICE Funds and Medicaid.......................................................................... 11
10011 Covered Services............................................................................................. 12
10012 CHOICE and Hospice Services ....................................................................... 13
10013 CHOICE and Self-Directed Attendant Care .................................................... 14
10014 CHOICE Fund Prohibited Uses ....................................................................... 17
10015 Unusual Occurrences/Incident Reporting...................................................... 18
10016 CHOICE Applicant and Participant Appeals .................................................. 18
10017 CHOICE Plan .................................................................................................... 18
10018 AAA CHOICE Reporting .................................................................................. 20
10019 Case Management ........................................................................................... 21
10020 Plan of Care...................................................................................................... 25
10021 Confidentiality.................................................................................................. 28
10022 Provider Requirements – General .................................................................. 28
10023 Provider Requirements – Organizational Chart Guideline. ........................... 30
10024 Provider Requirements – Personnel Records ............................................... 30
10025 Provider Requirements – Personnel Policies and Manuals.......................... 31
10026 Provider Requirements – Maintenance of Records of Services Provided ... 33
10027 Provider Requirements – Data Collection Standards.................................... 33
10028 Provider Requirements – Billing Standards................................................... 33
10029 Provider Requirements – Disclosure of Financial Information..................... 33
10030 Provider Requirements – Insurance............................................................... 34
10031 Provider Requirements – Quality Assurance and Quality Improvement
System......................................................................................................................... 34
10032 Transfer of Individual’s Records Upon Change of Provider ......................... 35
10033 Provider Requirements – Procedures for Protecting Individuals................. 35
10034 Provider Requirements – Individual’s “No-Show” for a Service .................. 36
10035 Legally Responsible Individuals as CHOICE Providers................................ 36
10036 Provider Requirements – Coordination of Services and Plan of Care ......... 36
10037 Service Specific Provider Requirements – Adaptive Equipment Providers 37
10038 Service Specific Provider Requirements – Adult Day Services Providers .. 37
10039 Service Specific Provider Requirements – Attendant Care .......................... 37
113
10040 Service Specific Provider Requirements – Environmental Modifications ... 37
10041 Service Specific Provider Requirements – Family Caregiver Support......... 38
10042 Service Specific Provider Requirements – Home Health Services............... 38
10043 Service Specific Provider Requirements – Home Delivered Meals .............. 38
10044 Service Specific Provider Requirements – Homemaker ............................... 38
10045 Service Specific Provider Requirements – Home Repair and Maintenance
Services....................................................................................................................... 39
10046 Service Specific Provider Requirements – Information and Assistance ..... 39
10047 Service Specific Provider Requirements – Legal assistance services ........ 39
10048 Service Specific Provider Requirements – Nutrition Education ................... 39
10049 Service Specific Provider Requirements – Outreach Services..................... 39
10050 Service Specific Provider Requirements – Personal Emergency Response
Systems....................................................................................................................... 40
10051 Service Specific Provider Requirements – Pest Control Services ............... 41
10052 Service Specific Provider Requirements – Respite Care .............................. 41
10053 Service Specific Provider Requirements – Supplies ..................................... 43
10054 Service Specific Provider Requirements – Therapy Services ...................... 43
10055 Service Specific Provider Requirements – Transportation........................... 43
10056 Service Specific Provider Requirements for Self-Directed In-Home Care ... 44
10057 Provider Requirements – Warranties ............................................................. 45
10058 Provider Monitoring ......................................................................................... 46
10059 Provider Non-Compliance with Requirements .............................................. 47
10060 Provider Non-Compliance with Requirements That Endangers the Health or
Welfare of an Individual Such That an Emergency Exists ....................................... 48
10061 Provider – Revocation of Approval................................................................. 49
10062 Provider Appeals ............................................................................................. 49
10063 HCBS Providers – Resolution of Disputes..................................................... 50
10000
20000 Overview of CHOICE
The Community and Home Options to Institutional Care for the Elderly and Disabled
(CHOICE) program provides case management services, assessment, and in-home and
community services to individuals who are at least 60 years of age or persons of any
age who have a disability due to a mental or physical impairment and who are found to be
at risk of losing their independence. At least 20% of the AAA CHOICE service dollars
shall be utilized for individuals under the age of 60 with disabilities.
The CHOICE board has a range of oversight responsibilities as described in IC 12-10-11
and IC 12-10-10-11(b).
The Indiana Family and Social Services Administration (FSSA), Division of Aging (DA)
establishes CHOICE guidelines and procedures for the effective management of the
114
CHOICE program and provides a process for public input. The FSSA DA is responsible
for publishing CHOICE guidelines and procedures as part of the FSSA DA Operations
Manual (which are contained in this Section). Comments and recommendations specific
to these guidelines are accepted annually from the public.
The FSSA DA provides notice to the public of revisions in guidelines and procedures by
publishing any revisions of CHOICE guidelines and procedures in the CHOICE Board
meeting agenda and posting revisions of CHOICE guidelines and procedures before an
official CHOICE Board meeting in the office of the FSSA DA. Comments and
recommendations for revision may be given during any official CHOICE board meeting.
10001 Code of Ethics
All CHOICE providers or agents (including AAAs and CHOICE service providers) shall
abide by the code of ethics in this section
(Authority IC 12-10-10, 455 IAC 1.2-21.-, 455 IAC 1-4-11)
(1)
A provider shall do the following:
(A)
Provide professional services with objectivity and respect for the
independence, needs, and values of the individual receiving services.
(B)
Avoid discrimination on the basis of factors that are irrelevant to the
provision of services, including, but not limited to race, creed, gender, age, or
disability.
(C)
Provide sufficient objective information to enable an individual or the
individual’s guardian to make informed decisions.
(D)
Accurately present the professional qualifications and credentials of the
provider and of all employees and agents.
(E)
Require all employees or agents to assume responsibility and
accountability for personal and professional competence in the practice of the person’s
profession and provision of services under this article.
(F)
Require professional, licensed, or accredited employees or agents to
adhere to accepted industry standards for the employee’s or agent’s area of professional
practice.
(G)
Require all employees or agents to do the following:
i
Maintain the confidentiality of individual information consistent with the
standards of this article and all other laws and regulations governing confidentiality of
individual information, including the Health Insurance Portability and Accountability Act
(HIPAA).
ii
Conduct all practice with honesty, integrity, and fairness.
iii
Fulfill professional commitments in good faith.
iv
Inform the public and colleagues of services only by use of factual
information.
v
Refrain from the following:
115
(a)
Advertising or marketing services in a misleading manner.
(b)
Engaging in uninvited solicitation of potential individuals who are
vulnerable to undue influence, manipulation, or coercion.
(H)
evaluation.
Make reasonable efforts to avoid bias in any kind of professional
(I)
Notify the proper authority of any conduct that may cause harm or undue
influence toward a participant. This may include FSSA DA, Indiana State Department of
Health, licensing authorities, accrediting agencies, employers, or the State of Indiana
Attorney General.
10002 AAA Contracts for Administration of CHOICE Funds
The FSSA DA contracts with the AAAs to administer CHOICE funds
(Authority IC 12-10-10, 455 IAC 1-4-3, 455 IAC 1-4-11)
(1)
The FSSA DA enters into contracts with AAAs for the purpose of administering
CHOICE funds. Contracts are effective for a period of two (2) years. (2)
Contracted activities include but are not limited to:
(A)
budgeting;
(B)
case management;
(C)
oversight;
(D)
monitoring;
(E)
reporting;
(F)
quality assurance; and
(G)
submission of fiscal claims to the FSSA DA.
10003 Public Records Requests
As a public agency, each AAA shall make public records available in accordance with
Indiana’s Public Access Laws (Authority IC-5-14-3).
The AAA shall ensure the provisions of IC-5-14-3, as well as HIPAA requirements
regarding Protected Health Information (PHI) are followed when disclosing or making
public records available.
10004 CHOICE Eligibility Determinations
Individuals must meet specified eligibility requirements in order to participate in CHOICE.
(Authority IC 12-10-10, 455 IAC 1-4-1,455 IAC 1-4-5, 455 IAC 1-4-7(d) and (e), 455 IAC
1-4-11)
(1)
The CHOICE case manager shall conduct an eligibility determination for
individuals requesting services funded by CHOICE. In order to be eligible for
116
CHOICE funds an individual must:
(A)
B e at least sixty (60) years of age or disabled.
i
Age shall be verified as recorded on a birth certificate, driver’s license,
passport or other official government document. Case manager shall
document in case notes that age was verified using these documents;
ii "Disabled" refers to an individual with a severe chronic disability that
is attributable to a mental or physical impairment or combination of
mental and physical impairments that is likely to continue indefinitely;
(B) B
e an individual at risk of losing their independence.
i “Individual at risk of losing their independence” means the individual is
unable to perform two (2) or more activities of daily living as determined
through the use of an assessment.
The long-term care services eligibility screen developed by the
division shall be used by the case manager to assess the
applicant's risk of losing his or her independence and to assist in the development of a
plan of care if appropriate.
(C)
Have assets that do not exceed five hundred thousand dollars
($500,000). If applicant wishes to receive services but has assets in excess of five
hundred thousand dollars ($500,000), applicant may continue to receive services, but
obligation for payment is solely upon the client.
i
For applicants who have had a Medicaid determination within ninety
(90) days of application for CHOICE, the case manager shall obtain asset information
submitted to the Division of Family Resources (DFR) as part of the Medicaid eligibility
determination process, from the FSSA DA CHOICE representative.
(a)
The FSSA DA CHOICE representative shall provide the countable
resource amount for each of the following assets (resources) obtained from the ICES
system:
Checking and Savings Accounts
Certificates of Deposit
Individual Retirement Accounts (except MED Works) Stocks/Bonds/Mutual
Funds
Cash surrender value of life insurance (CSV) Vehicles
Non-income-producing Real Estate
Trust Funds
ii
For applicants who have not had a Medicaid eligibility determination
within ninety (90) days of application for CHOICE, the case manager shall:
(a)
Assist the applicant with gathering and completion of information
necessary for the applicant to submit an application for Medicaid to the DFR; and
(b)
Ensure the applicant has made application for Medicaid
assistance prior to authorizing interim CHOICE services pending completion of the
Medicaid eligibility determination as described in Section 12 of the Division of Aging
Operations Manual.
117
(c)
Upon completion of the Medicaid eligibility determination, the case
manager shall obtain asset information from the FSSA DA CHOICE representative as
described in (C)(i) above.
(d)
If applicant is denied Medicaid eligibility due to a failure to comply
with the DFR requests, the applicant will be denied eligibility for CHOICE, as well.
(e)
If determination of eligibility has not been made within 90 calendar
days of the Medicaid application being submitted to the DFR, the respective AAA shall
contact the FSSA DA CHOICE
representative for assistance.
(f)
For all CHOICE clients, who are not already a Medicaid client, the
respective AAA shall have that individual’s Medicaid status reconsidered on an annual
basis or upon a substantial change in financial or medical status.
(g)
Any applicant who is eligible for specific benefits and/or services
from Medicaid but refuses those benefits and/or services from Medicaid will be ineligible
for those specific benefits and/or services from CHOICE.
iii
The CHOICE applicant must complete and sign the CHOICE Asset
Attestation Form (Attachment 1) attesting that the information
obtained from the Medicaid eligibility determination process continues
to accurately reflect their assets, including type and amount.
(a)
If the applicant’s assets have changed, the case manager shall
refer the applicant to DFR for a Medicaid eligibility redetermination.
iv
shall:
If the applicant has assets in excess of $500,000, the case manager
(a)
Inform the applicant of their obligation to assume responsibility for
payment of CHOICE service costs; and
(b)
services.
Determine if the applicant wishes to continue to receive CHOICE
v
If the individual wishes to receive, or continue to receive, CHOICE
services, the case manager shall ensure the individual is billed for
100% of the cost of CHOICE services in accordance with CHOICE
billing procedures.
vi
If the individual does not wish to receive, or continue to receive,
CHOICE services, the case manager shall determine whether access to CHOICE
services is essential to the individual’s health and welfare.
(a)
If the case manager believes lack of access to CHOICE services
places the individual at risk of neglect or harm, the case manager shall:
File an incident report documenting the circumstances; and Take no further action in
regard to CHOICE services until the FSSA DA CHOICE representative makes a
determination regarding how to proceed.
The FSSA DA CHOICE representative shall make this determination within three (3)
business days of notification by the case manager and shall notify the AAA in writing of
their determination.
118
(b)
If the case manager believes lack of access to CHOICE services
does not place the individual at risk of neglect or harm, the case manager shall:
Not authorize the individual to receive CHOICE services or shall ensure CHOICE
services are terminated, as appropriate.
10005 CHOICE Waiting List
AAAs are responsible for ensuring there is no CHOICE waiting list whenever feasible
and, when necessary, for maintaining the waiting list for their service area, submitting
required data and reports regarding the waiting list and monitoring individuals who are
on the waiting list.
(Authority IC 12-10-10, 455 IAC 1-4-3, 455 IAC 1-4-5, 455 IAC 1-4-11)
The CHOICE waitlist is comprised of individuals who have been assessed and are
waiting for Choice services. The I4A Waiting List Policy will provide written protocol for a
unified procedure to place patients on and off of the waiting list.
10006 CHOICE Reduction in Service and Participant Termination Policy
(Authority 455 IAC 1-4-7(e)(f))
CHOICE funding should be used after all other possible payment sources have been
identified and all reasonable efforts have been employed to utilize those sources.
The AAA shall reduce or disallow services that are paid by CHOICE in any of the
following circumstances:
a)
When the assessed level of need diminishes as established by an assessment.
b)
When the AAA's CHOICE service funds are insufficient to meet the service
commitment to current participants, all reasonable efforts have been made to secure
resources to avoid service reductions, the AAA has stopped performing new
assessments and care plans, and the AAA has adopted a fair and equitable
policy for distributing service reductions among participants.
c)
When an individual receiving services becomes eligible under a Medicaid home
and community-based services waiver and begins receiving those services that are
allowable through the Medicaid program.
d)
When a current participant becomes eligible for in-home and community services
from other sources for which he or she was not previously eligible and is
receiving those services.
e)
When other resources become available in the community and the individual
begins receiving those services that were not available at the time of the
development of the previous care plan.
f)
If services needed by the applicant, as determined by the assessment, would be
so costly that CHOICE payment for the needed services would cause the AAA to exceed
the allowable cost per individual determined by the division.
g)
When the individual or his or her CHOICE representative refuses to receive
services from other sources that would ensure that CHOICE is the funding of last resort.
The AAA shall terminate services that are paid by CHOICE in any of the following
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situations:
a)
When the individual's health or personal circumstances have improved so that he
or she no longer needs in-home and community-based services to maintain his
or her independence in a safe, non-institutional environment.
b)
When the health, welfare, or safety of the participant or of others who interact
with the individual can no longer be reasonably assured.
c)
When the services being provided are detrimental to the individual's health.
d)
When the individual or his or her CHOICE representative has fraudulently
obtained or misused CHOICE funded services.
e)
Upon the death of the individual receiving services.
f)
When the individual or his or her CHOICE representative refuses to comply with
cost sharing under section 8 of this rule.
g)
When the individual or his or her CHOICE representative voluntarily requests
termination.
h)
When the individual or his or her CHOICE representative refuses services
necessary for his or her health and well-being.
CHOICE Cost-Sharing
AAAs are responsible for determining and implementing cost-sharing requirements for
CHOICE. (Authority, IC 12-10-10, IC 12-10-11-8, 455 IAC 1-4-4, 455 IAC 1-4-8, 455 IAC
1-4-11)
(1)
Cost-sharing is not required for:
Participants whose income does not exceed one hundred fifty percent (150%) of the
federal income poverty level.
(2)
Cost sharing is required for participants with incomes over 150% FPL, unless the
cost share of services would result in an income falling below 151% of the FPL. The
participant is not obligated to pay the amount owed that would drop their income below
this level.
(A)
Participants with incomes over 150% FPL and up to 350% may be
charged a share of cost depending on their amount of income adjusted by allowable
deductions as specified in the Division of Aging Cost Share document.
The cost share increases by ½ of 1% for each 1% increase in the percent of poverty
over 150% FPL. The increase and corresponding dollar amount is also displayed in the
Division of Aging Cost Share document.
(B)
Participants with an income that exceeds three hundred fifty percent
(350%) of the federal poverty level (FPL) adjusted by any allowable deductions as
specified in Attachment 2, must pay 100% of the cost of CHOICE services except for
case management, the initial assessment and the development of the plan of care.
(C)
The case manager shall determine the cost share amount by entering
required income and service information into the FSSA DA data system. The data
system automatically generates the cost share amount.
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(3)
AAA.
The collection of each individual’s monthly cost share is the responsibility of the
(A)
If the cost share is equal to $9.99 or less annually, the AAA is not
required to collect the cost-share from the individual.
(4)
Cost Share Billing statements will be generated monthly and sent to the
appropriate CHOICE individuals by the AAA.
(5)
Cost share is not applied to case management, since this has been determined
by the FSSA DA to be an administrative service and not a direct service.
10008 Individual Cap on CHOICE Funds
CHOICE funds are subject to an individual cap.
(Authority IC 12-10-10, 455 IAC 1-4-11)
(1)
The FSSA DA has established a maximum level of expenditures of CHOICE
funds per individual (cap). The current cap amount per quarter is $13,517.
(2)
This cap is not to be applied monthly, but over a period of three (3) consecutive
months to coincide with the period covered by the plan of care.
(A)
period.
The cost of home modifications can be amortized over a twelve month
(3)
CHOICE case management is an administrative function of the AAA. It is
excluded from the cost cap.
(4)
The maximum level of expenditure will be calculated as a single cost amount for
the elderly and for persons with disabilities under sixty years of age.
(A)
(B)
basis.
This level of expenditure is calculated by the FSSA DA based on the
Skilled Nursing Facility (SNF) Index, and is adjusted annually.
The cap amount is provided to the AAAs by the FSSA DA on an annual
10009 Funding of Last Resort
CHOICE funds may only be utilized after all other available sources of funding of home
and community-based services (HCBS) have been accessed. CHOICE funding shall
be used only after all other possible payment sources have been identified and all
reasonable efforts have been employed to utilize those sources.
(Authority IC 12-10-10, 455 IAC 1-4-7, 455 IAC 1-4-11)
The AAA case manager shall conduct a review of all available sources of funding of
home and community-based services other than CHOICE supports for each individual
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determined eligible for CHOICE funds. The review shall include, but is not limited to:
(A)
Older Americans Act Funded HCBS such as Home Delivered Meals,
respite and adult day care services;
(B)
Medicaid state plan HCBS such as home health services, durable
medical (DME), non-emergency transportation, therapies, and targeted case
management;
(C)
Medicaid HCBS waiver services such as those included in the AD Waiver,
TBI Waiver, and DD Waiver;
(D)
Medicare services such as home health services and DME or special
services provided by Medicare Advantage (HMO) plans;
(E)
Services funded by the Ryan White Program;
(F)
Services funded by the Vocational Rehabilitation Program;
(G)
Food stamps;
(H)
Services funded by the Veteran’s Administration;
(I)
Services funded by HUD;
(J)
Title III-E caregiver funds; and
(K)
Other sources of HCBS.
10010 CHOICE Funds and Medicaid
Except as provided in subsections (1)(a)(ii) and (1)(B) below CHOICE funds may only
be utilized after an applicant has been determined ineligible for Medicaid or if currently
eligible for Medicaid, after a determination that the requested service(s) is not
available from Medicaid.
(Authority, IC 12-10-10, 455 IAC 1-4-7, 455 IAC 1-4-11)
(1)
CHOICE funds may not be authorized for any new client who has not applied
for, or received, a Medicaid eligibility determination within the last ninety days.
(A)
A new client who has not applied for Medicaid eligibility determination
within ninety (90) days of application for CHOICE, the case manager shall:
i
Assist the applicant with gathering and completion of information
necessary for the applicant to submit a Request for Assistance (for Medicaid) to the
DFR; and
ii
Ensure the applicant has made application for Medicaid assistance
prior to authorizing interim CHOICE services pending completion of Medicaid eligibility
determination.
(B)
CHOICE funds may be authorized for Medicaid applicants awaiting the
outcome of a Medicaid eligibility determination.
(2)
CHOICE funds and Medicaid spend down: If an eligible individual meets
Medicaid asset guidelines but has a spend down provision to satisfy, CHOICE services
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may be utilized while the spend down amount is being met.
(3)
CHOICE funds may be authorized for Medicaid recipients following a
determination by the case manager and/or FSSA DA that Medicaid state plan services
and HCBS waiver services for which the individual is eligible do not meet the identified
need for which CHOICE funds are being requested.
(A)
If the individual is a Medicaid recipient, the case manager must review
whether the requested service is available or could be available under the Medicaid state
plan or under a HCBS waiver in which the individual is enrolled.
(B)
If the requested service is denied by Medicaid (in the case of Medicaid
state plan services) or by the HCBS waiver case manager or other HCBS waiver decision
maker (in the case of HCBS waiver services), but an alternative service is authorized,
the individual must access this Medicaid state plan or HCBS waiver alternative service.
(1) CHOICE funds cannot be used to fund alternative and/or more costly services or
supports as an alternative to one that is available from another funding source because of
individual preference, convenience or other factors unrelated to need. For example,
CHOICE funds may not be authorized to purchase a specific type of van modification
when a less costly van modification that can meet the individual’s
needs has been authorized from another funding source.
(2) If the individual refuses to access the authorized or available Medicaid state plan or
HCBS waiver service, the case manager must issue a CHOICE denial and notice of right
to appeal in accordance with Section 100016.
(C)
If the requested service is denied by Medicaid (in the case of Medicaid
state plan services) or by the HCBS waiver case manager or other HCBS waiver decision
maker (in the case of HCBS waiver services), and an alternative service is not
authorized or available, the service or support may be funded by CHOICE (subject to all
other CHOICE funding restrictions.)
(4)
CHOICE participants determined ineligible for Medicaid must reapply for a
Medicaid eligibility determination each time their circumstances change in a manner that
could affect eligibility (e.g. result in a determination they are eligible for Medicaid).
(A)
The case manager shall assist the participant with gathering and
completion of information necessary for the applicant to submit a Request for Assistance
(for Medicaid) to the DFR and shall monitor the outcome of the Medicaid eligibility
determination process.
10011 Covered Services
CHOICE funds may only be used to purchase specified services.
(Authority IC 12-10-10, 455 IAC 1-4-11,455 IAC 1.2-5-1(e))
CHOICE funded services are limited to:
(A)
Adaptive aids and devices.
(B)
Adult day services.
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(C)
Attendant care.
(D)
Case management services.
(E)
Environmental modifications.
(F)
Family caregiver support.
(G)
Home health services.
(H)
Home delivered meals.
(I)
Homemaker.
(J)
Home repair and maintenance services.
(K)
Information and assistance.
(L)
Legal assistance services.
(M)
Nutrition education / counseling.
(N)
Outreach services.
(O)
Respite care.
(P)
Therapy services.
(Q)
Transportation.
(R)
Self-directed attendant care services provided by a registered personal
services attendant under the applicable statute to persons in need of self- directed inhome care.
(S)
Other services necessary to prevent institutionalization of eligible
individuals when feasible as authorized on the plan of care.
10012 CHOICE and Hospice Services
CHOICE participants may receive Medicare and/or Medicaid hospice services and
CHOICE funded services and supports, but these services must be coordinated to
ensure non-duplication of services and payment.
(Authority, IC 12-10-10, 455 IAC 1-4-11)
(1)
The case manager, upon learning of an individual’s election (or plan to elect) the
hospice benefit under Medicare and/or Medicaid, shall contact the individual and the
hospice case manager to review the need to coordinate services.
(A)
Hospice services include a range of services designed to address the
needs of individuals with a terminal illness. Services include: nursing services; medical
social services; physician services; counseling services, including dietary and
bereavement counseling; short-term inpatient care, including respite care; medical
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appliances and drugs; home health aide and homemaker services; physical therapy;
occupational therapy; and speech-language pathology services. In addition, Medicare
covers any other service that is specified in the hospice plan of care, and for which
payment may otherwise be made under Medicare.
The most common hospice services in danger of duplication with
CHOICE-funded services are home health aide and homemaker services. Hospice,
except when provided as an inpatient service, provides intermittent services that do not
include sitter or companion services. Services are not designed, for example, to provide
care, to enable a caregiver to go to work.
(B)
The case manager must review the hospice plan of care and reduce
CHOICE services that are duplicative of services contained in the hospice plan of care
and terminate CHOICE-funded respite services, for as long
as the individual remains enrolled in hospice. A CHOICE recipient may
not refuse hospice services in order to continue to receive a comparable service funded
by CHOICE.
(C)
When an individual elects hospice services, they may not receive paid
respite services funded by CHOICE but instead must utilize hospice respite services, if
not a duplicate service.
(D)
The CHOICE case manager and hospice case manager should explain to
the individual the services covered through both programs and the reductions that are
being made and the reasons for the reductions (e.g. to ensure non-duplication of services
and payment).
10013 CHOICE and Self-Directed Attendant Care
AAAs must inform CHOICE participants of their right to choose to self-direct
personal attendant services. CHOICE participants may choose to self-direct personal
attendant services as specified in this section.
(Authority, IC 12-10-10, IC 12-10-17.1, 455 IAC 1-4-11)
(1)
CHOICE participants may choose to self-direct personal attendant services if
they are an "individual in need of self-directed in-home care".
(A)
An ”individual in need of self-directed in-home care” means a disabled
individual, or person responsible for making health related decisions for the disabled
individual, who:
i
is approved to receive Medicaid HCBS waiver services or is a
CHOICE participant;
ii
is in need of attendant care services because of impairment;
iii
requires assistance to complete functions of daily living, self-care, and
mobility, including those functions included in attendant care services;
iv
chooses to self-direct a paid personal services attendant to perform
attendant care services; and
v
assumes the responsibility to initiate self-directed in-home care and
exercise judgment regarding the manner in which those services are
delivered, including the decision to employ, train, and dismiss a personal services
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attendant.
(B)
"Attendant care services" means those basic and ancillary services, which
the individual chooses to direct and supervise a personal services attendant to perform,
that enable an individual in need of self-directed in- home care to live in the individual's
home and community rather than in an institution and to carry out functions of daily
living, self-care, and mobility.
(C)
"Basic services" means a function that could be performed by the
individual in need of self-directed in-home care if the individual were not physically
disabled. The term includes the following:
i
vehicles.
ii
iii
iv
v
vi
Assistance in getting in and out of beds, wheelchairs, and motor
Assistance with routine bodily functions.
Health related services.
Bathing and personal hygiene.
Dressing and grooming.
Feeding, including preparation and cleanup.
(D)
“Health related services" means those medical activities that, in the written
opinion of the attending physician submitted to the case manager of the individual in need
of self-directed in-home care, could be performed by the individual if the individual were
physically capable, and if the medical activities can be safely performed in the home, and:
i
are performed by a person who has been trained or instructed on the
performance of the medical activities by an individual in need of self- directed in-home
care who is, in the written opinion of the attending physician submitted to the case
manager of the individual in need of self-directed in-home care, capable of training or
instructing the person who will perform the medical activities; or
ii
are performed by a person who has received training or instruction
from a licensed health professional, within the professional's scope of practice, in how to
properly perform the medical activity for the individual in need of self-directed in-home
care.
(E)
"Licensed health professional" means the following:
A registered nurse.
A licensed practical nurse.
A physician with an unlimited license to practice medicine or osteopathic
medicine.
A licensed dentist.
A licensed chiropractor. A licensed
optometrist. A licensed pharmacist.
A licensed physical therapist.
A certified occupational therapist. A certified
psychologist.
A licensed podiatrist.
A licensed speech-language pathologist or audiologist.
(F)
"Ancillary services" means services ancillary to the basic services
provided to an individual in need of self-directed in-home care who needs at least one (1)
of the basic services (as defined in section 4 of this
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chapter). The term includes the following:
i
Homemaker type services, including shopping, laundry, cleaning, and
seasonal chores.
ii
Companion type services, including transportation, letter writing, mail
reading, and escort services.
iii
Assistance with cognitive tasks, including managing finances,
planning activities, and making decisions.
(2)
Individuals self directing their own care health related services must have the
approval of their attending physician.
(A)
The case manager must maintain an attending physician’s written opinion
in the individual’s case file regarding the opinion of the individual’s attending physician
that the health related services could be performed by the individual if the individual were
physically capable, and if the medical activities can be safely performed in the home, and:
i
are performed by a person who has been trained or instructed on the
performance of the medical activities by an individual in need of self- directed in-home
care and, in the written opinion of the attending physician, the individual in need of selfdirected in-home care is capable of training or instructing the person who will perform the
medical activities; or
ii
are performed by a person who has received training or instruction
from a licensed health professional, within the professional's scope of practice, in how to
properly perform the medical activity for the individual in need of self-directed in-home
care.
(3)
Responsibilities for self-directed care:
(A)
The individual in need of self-directed in-home care is responsible for
recruiting, hiring, training, paying, certifying any employment related documents,
dismissing, and supervising in the individual's home during service hours a personal
services attendant who provides attendant care services for the individual.
(B)
If an individual in need of self-directed in-home care is less than twentyone (21) years of age or unable to direct in-home care because of a brain injury or mental
deficiency, the individual's parent, spouse, legal guardian, or a person possessing a valid
power of attorney may make employment, care, and training decisions and certify any
employment related documents on behalf of the individual.
(C)
An individual in need of self-directed in-home care or an individual under
subsection (B) and the individual's case manager shall develop an authorized plan of
care. The authorized plan of care must include a list of weekly services or tasks that must
be performed to comply with the authorized plan of care.
(4)
Parents of minor individuals, spouses, or other adults legally responsible
relatives for the individual may not provide attendant care services for
compensation under this legislation.
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(5)
Providers of CHOICE-funded self-directed care must comply with the
requirements set forth in IC 12-10-17.
(6)
Upon request, the FSSA DA will provide to an individual in need of self-directed
in-home care the following:
(A)
A list of personal services attendants who are registered with the division
and available within the requested geographic area will be provided without charge,
(B)
A copy of the information of a specified personal services attendant who
is registered with the FSSA DA. The division may charge a fee for shipping, handling,
and copying expenses.
(7)
The individual in need of self-directed in-home care and the personal services
attendant must each sign a contract, in a form approved by the FSSA DA, that
includes, at a minimum, the following provisions:
(A)
The responsibilities of the personal services attendant.
(B)
services.
The frequency the personal services attendant will provide attendant care
(C)
The duration of the contract.
(D)
The hourly wage of the personal services attendant. The wage may not
be less than the federal minimum wage or more than the rate that the recipient is eligible
to receive under a Medicaid home and community based services waiver or the
community and home options to institutional care for the elderly and disabled program for
attendant care services.
(E)
Reasons and notice agreements for early termination of the contract. (8) A
personal services attendant who is hired by the individual in need of selfdirected in-home care is an employee of the individual in need of self-directed in- home
care. The division and the AAA are not liable for any actions of a personal services
attendant or an individual in need of self-directed in-home care. A personal services
attendant and an individual in need of self-directed in-home care are each liable for any
negligent or wrongful act or omission in which the person personally participates.
10014 CHOICE Fund Prohibited Uses
CHOICE funds may not be used for some purposes or activities.
(Authority IC 12-10-10, 455 IAC 1-4-7, 455 IAC 1-4-11)
Choice funds may not be used to:
(1)
purchase services or supports available from another funding source, including
but not limited to: Medicare, private long-term care insurance, Vocational Rehabilitation,
Medicaid state plan and Medicaid HCBS waivers.
(2)
purchase real estate.
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(3)
provide care or services to an individual residing in an institution. However, funds
may be used for assessment and plan of care development for current residents in
institutions who could return to their homes if determined to be eligible for the CHOICE
program. Assisted living facilities are not considered institutional settings.
Home modification is an exception and will be acceptable for an individual residing in an
institution if used to transition an individual back into the home. However, the individual
would need to have been an active CHOICE client prior to the institutionalization.
10015 Unusual Occurrences/Incident Reporting
Any person with direct monitoring responsibilities shall report all incidents that meet the
definition of a reportable unusual occurrence in accordance with the requirements of
Indiana FSSA DA Incident Reporting Policy.
(Authority IC 12-10-10, 455 IAC 1.2-8-2, 455 IAC 1-4-11)
All incidents classified as reportable unusual occurrences shall be reported to the DA, and
to APS or CPS when applicable, and in accordance with the FSSA DA Incident Reporting
Policy. Refer to the Indiana FSSA DA Incident Reporting Policy for definitions, policy and
procedure.
10016 CHOICE Applicant and Participant Appeals
CHOICE applicants have a right to appeal AAA decisions regarding eligibility or services
to be provided. (Authority IC 12-10-10, 455 IAC 1-4-3, 455 IAC 1-4-11 IAC 1-4-10)
Refer to Section 3007 of the Division of Aging Operations Manual.
10017 CHOICE Plan
A CHOICE Plan must be submitted each year with the Area Plan or Area Plan Update.
The CHOICE Plan must include procedures for making CHOICE program information
available to applicants, participants and the public.
CHOICE Plan Contents and Format:
Section 1 – Intake and Referral Process
Description of the referral and intake process, including eligibility determination
protocols and method of eligibility notification.
Section 2 – Assessment Process
Description of the assessment process, format, and procedures used by AAA case
managers including methodology for ensuring completion of ninety-day face-to-face
assessments of CHOICE participants.
Section 3 – Nursing Home Outreach
Describe the outreach and follow up methods for offering assessments to current
nursing home residents who apply for CHOICE.
Section 4 – Hiring Practices
Describe the methods of recruitment, screening, and hiring of staff.
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Section 5 – Care Plan Development Process
Description of the procedures used to develop the plan of care including a timeline
for the development process from start to implementation of services. Also a
description of the role the individual and/or their family play in the development of
their care plan.
Section 6 – Area and Community Support Services
A list of all available long-term support services, both public and private, within the
area.
Section 7 – Case Management and Service Coordination
Policies and procedures for the case management and service coordination.
Section 8 – Coordinating CHOICE with Other Funding Sources
Policies and procedures for coordinating CHOICE with Medicaid state plan services,
HCBS waiver services and other funding sources for in- home and community-based
services. Describe the methodology for determining priority funding, last resort funding,
and preventing duplication of services among funding sources.
Section 9 – QA/QI Plan
Description of quality assurance (QA) and quality improvement (QI) plan for CHOICE
services consistent with FSSA DA QA/QI requirements for HCBS.
Section 10 – Plans of Care Evaluation and Monitoring
Description of internal methods of evaluating plans of care to ensure participants are
receiving quality services and direction. Describe how plans of care are selected for
review, who conducts the monitoring, what criteria is used to evaluate the
appropriateness of service and stewardship of funding, and the frequency of monitoring.
Include policies and procedures for conducting QIPs internally and in collaboration with
FSSA DA or its contractor.
Section 11 – Follow up and Incident Reporting
Description of processes and procedures for participant follow up and incident reporting.
Section 12 – Mortality Reviews
Policies and procedures for responding to mortality reviews conducted by FSSA in
accordance with the FSSA DA Mortality Review Policy for HCBS.
Section 13 – Cost Sharing
Description of CHOICE cost sharing plan procedures, including cost share collection
methods.
Section 14 – Complaint and Appeal Procedures
Description of complaint and appeal procedures, which include the process for
notifying applicants or participants of the right to an administrative hearing, which
incorporates the FSSA DA Complaint Policy for HCBS.
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Section 15 – Waiting List
Description of policies and procedures for operating, maintaining and clearing the AAA
waiting list for CHOICE services in accordance with the requirements contained in these
CHOICE Guidelines.
Section 16 – Budget
Budget Narrative and breakdown of spending in accordance with the contract between
AAA and FSSA DA on the following categories:
1.
A Breakdown of Proposed Spending on Consumer Services
2.
Assessments
3.
Care Plan Development
4.
Reassessments
5.
AAA Administration
6.
Any Other Appropriate Costs
Section 17 – Provider Selection
Description of processes and procedures for selecting service providers. Including
methods for ensuring a variety of CHOICE providers for participants to choose
from.
10018 AAA CHOICE Reporting
Before October 1 st of each year, the AAA is required to report both programmatic and
fiscal information from the previous state fiscal year, July 1 to June 30, to the FSSA DA.
FSSA DA uses the data to prepare a report for review by CHOICE Board and the Indiana
General Assembly (Authority IC 12-10-10, 455 IAC 1-4-11).
(1)
Each AAA shall provide an annual report that details:
(A)
The amount of CHOICE funds spent;
(B)
Administrative expenses for CHOICE;
(C)
The use of CHOICE funds in supplementing the funding of services
provided to individuals through other programs;
(D)
The waiting list for CHOICE including numbers of persons on the waiting
list, movement off the waiting list and actions taken to clear the waiting list;
(E)
The number, capacity and types of participating CHOICE providers;
(F)
An examination of CHOICE participants’:
i
ii
iii
Demographic characteristics;
Impairment and medical characteristics;
Reportable unusual occurrences/incidents;
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iv
Grievances and Appeals;
v
Length of time receiving CHOICE services in 30 day increments; and
vi
The number of CHOICE participants leaving the CHOICE program by
month, their reason for leaving and final disposition.
(G)
CHOICE participant outcomes;
(H)
have:
A determination of the estimated number of CHOICE applicants who
i
ii
and
iii
performed;
(I)
100004); and
one (1) assessed activity of daily living that cannot be performed;
two (2) assessed activities of daily living that cannot be performed;
three (3) or more assessed activities of daily living that cannot be
Children’s CHOICE and CHOICE/TANF expenditures (see Section
(J)
The AAA will complete the cost share report generated from INsite and
send to FSSA DA on a quarterly basis.
(K)
Choice data for each month must be entered into INsite by the 10th of the
following month.
10019 Case Management
Case Manager Qualifications
( Authority IC 12-10-10, IC 12-10-10-1, 455 IAC 1.2, 455 IAC 1-4-3, 455 IAC 1-4-11)
Case managers must meet specific requirements regarding qualifications and
certification in order to be eligible to perform CHOICE program-related duties. Case
managers must be employees of the AAA formally assigned to carry out the AAA’s
responsibility for case management.
Case managers and applicants must meet the following qualifications:
(A)
Possess a degree or licensing as described below:
i
Bachelor's Degree in social work, psychology, gerontology, sociology,
counseling, nursing; or
ii
A license as a Registered Nurse with one year of experience in
human services; or
iii
A Bachelor's Degree in any other field with a minimum of two years,
full-time direct service experience with the elderly or persons with disabilities. This
experience must include assessment, plan of care development, implementation, and
monitoring.; or
iv
A Master's Degree in a related field may substitute for the required
experience.
(B)
A current limited criminal history obtained from the Indiana State Police
Central Repository, as prescribed in 455 IAC 1.2-6-2. Applicants with any criminal
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convictions including, but not limited to, the following may not be certified:
i
ii
iii
iv
v
vi
vii
viii
ix
(C)
A sex crime (IC 35-42-4).
Exploitation of an endangered adult (IC 35-46-1-12).
Abuse or neglect of a child (IC 35-42-2-1).
Failure to report battery, neglect, or exploitation of an endangered
adult or dependent (IC 35-46-1-13).
Theft (IC 35-43-4), except as provided in IC 16-27-2-5(a)(5).
Murder (IC 35-42-1-1).
Voluntary manslaughter (IC 35-42-1-3).
Involuntary manslaughter (IC 35-42-1-4).
Battery (IC 35-42-2).
Applicants have the right to appeal adverse determinations.
Criminal or Juvenile History Appeals: The subject of a record may initiate a challenge as
to the accuracy/completeness of any entry on his/her record. For Indiana entries on the
report, challenges should be directed to: Indiana State Police, Records Division, Indiana
Government Center North, Room N302, 100 North Senate Ave., Indianapolis, IN 46204.
For federal entries on the report, challenges should be directed to: FBI, Criminal Justice
Information Services (CJIS) Division, ATTN: SCU, Mod. D-2, 1000 Custer Hollow Road,
Clarksburg, WV 26306. All Other Criminal/Civil History Appeals: The local DCS office will
provide contact information for the appropriate agency.
Case Manager Certification
The AAA makes decisions regarding certification based upon the submitted
documentation. The decision regarding certification is sent to the candidate with a copy
sent to the FSSA DA. Each AAA must certify case managers according to the following
criteria:
(A)
The applicant’s compliance with and completion of all applicable provider
requirements.
(B)
The applicant’s demonstrated qualifications and abilities to determine the
needs of community alternatives to institutional placement available. Case managers
must have knowledge of the disabilities/conditions of the persons served by CHOICE.
(C)
Be at least eighteen (18) years of age, competent to provide services,
and demonstrate the ability to communicate.
i
Possess a current, valid state-issued driver’s license if the employee
will be transporting an individual and provide proof of current insurance on the vehicle
used to transport
(1)
CHOICE case managers must complete training specific to the CHOICE program
before performing CHOICE program-related duties.
(A)
All case managers must attend the FSSA DA “Case Management
Orientation” within the first six months of employment with an AAA and obtain at least 20
hours of additional training each year. (10 of which must be DA approved)
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(B)
Case Manager Orientation Training is exclusive to new case managers.
Case managers who have already attended Case Manager OrientationTraining shall not
be invited to attend a second time.
Case Manager Non-Compliance
CHOICE case managers who do not comply with CHOICE program requirements will be
subject to corrective action up to and including decertification (Authority IC 12-10-10,
455 IAC 1-4-11)
(1)
A CHOICE case manager may be subject to corrective action and/or decertified
for failure to comply with CHOICE requirements, including provider requirements
specified in this Chapter.
(A)
Corrective action shall be initiated at the option of the AAA and may
include, but is not limited to:
i
ii
iii
and/or
iv
Removal from an active caseload for retraining;
Attendance at prescribed training sessions;
One-to-one follow along by a case manager assigned by the AAA;
Suspension for a prescribed period of time followed by any of (i)
through (iii) above.
A CHOICE case manager will be decertified (de-activated) as of the case manager’s last
date of employment. A case manager shall NOT be decertified for a temporary
absence, such as for maternity, medical, or family leave.
Case Management Responsibilities and Standards
(Authority IC 12-10-10, 455 IAC 1.2-17-7, 455 IAC 1.2–17-2455 IAC 1-4-11, 455 IAC 14-2, 455 IAC 1.2-8-1, 455 IAC 1.2-9-2)
Each AAA is responsible for performance and oversight of “case management” functions
for CHOICE and the standards by which case managers operate, which include:
(A)
Assessing the individual to determine functional impairment level and
corresponding need for services;
(B)
Identifying all sources of funding, services and supports other than
CHOICE. CHOICE is last resort funding.
(C)
Developing a plan of care that addresses the individual's needs; Case
managers will ensure that “person centered planning” is utilized in the development of
the individual’s CHOICE plan of care and while they receive services.
(D)
Reviewing and explaining to the individual/guardian the services that will
be provided and obtaining all required signatures on the plan of care before submitting it
to the Area Agency on Aging. Any plan of care requiring State approval will not be
implemented prior to obtaining State approval.
(E)
Supervising the implementation of services for the individual; Case
managers shall ensure a maximum response time between implementation of the initial
plan of care and the first monitoring contact will be no more than thirty (30) calendar
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days. Case managers will complete face-to-face contact with each individual a minimum
of every ninety (90) days to assess the quality and effectiveness of the plan of care.
(F)
Advocating on behalf of the individual's interests; Case managers will
communicate the individual’s needs, strengths and preferences to appropriate persons
including CHOICE providers and other persons of
the individual’s choosing. Case managers will regularly inform individual’s of their right to
refuse treatment or seek a change to their plan of care.
(G)
Monitoring the quality of community and home care services provided to
an eligible individual and ensuring that plan of care objectives are being met. Case
managers will document within seven (7) days, in the chronological narrative, each
contact with the individual and with the providers.
(H)
Determining the cost effectiveness of using in-home and community
services as alternatives to traditional care or services. Case managers will monitor the
services being provided to ensure good stewardship of the funding.
(I)
Reassessing the plan of care to determine the continuing need or
termination of services. At least two of these face-to-face contacts per year will be in the
home setting. Case managers will complete annual assessments and care plan updates
with the individual in a timely manner to avoid gaps in service authorization.
(J)
Providing each individual/guardian with clear and easy to understand
instructions for contacting the case manager. The case manager will also provide
additional information and procedures for individuals who may need assistance or have
an emergency that occurs before or after business hours.
(K)
Providing information and referral services to individuals in need of
community and home care services; Case managers will provide, at a minimum but not
limited to, a state information guide as provided by the Division of Aging to individuals
on how to choose a provider and will assist the individual to evaluate potential service
providers.
(L)
Performing record keeping and data collection activities, including the
import and export of case records at a minimum of every seven (7) calendar days; Case
managers will keep all files in a standardized format and sequence and provide the State
ready access to all case manager documentation shall a request be made.
(M)
Providing community education regarding the case management system.
(N)
Establishing relationships with existing service providers and
collaborating with the other service providers to coordinate services
consistent with the participant’s plan of care.
(O)
Providing continuous supervision of case managers. Ensuring compliance
with all DA issued manuals, as well as all federal, state, and local law,
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and all FSSA policy, rules, regulations and guidelines.
(P)
Ensuring the case management system has access to administrative and
support services.
(Q)
Facilitating and monitoring the formal and informal supports that are
developed to maintain the individual’s health and welfare in the community.
(R)
Ensuring confidentiality of individual information. Case managers will
maintain privacy and confidentiality of all individual records and follow all applicable
guidelines set forth in this section regarding record access.
(S)
Performing an assessment and planning for discharge from an
institutional setting.
(T)
Maintaining the highest professional and ethical standards.
(U)
Ensuring individuals have a free choice of service provider, and of case
manager, and shall have the right to change any provider or case manager. Case
managers will provide to individuals a list of potential providers the services offered.
(V)
Ensuring unusual occurrences/incidents made known to the case
manager are reported and addressed in accordance with the FSSA DA Incident
Reporting Policy for HCBS and in accordance with Indiana mandatory reporting
requirements when applicable.
(W)
CHOICE.
Conducting follow-up evaluations for individuals terminated from
(X)
home
Coordinate services when other payer sources are providing care in the
10020 Plan of Care
The case manager shall initiate a plan of care and work with the individual or his or her
designated CHOICE representative, to develop the plan of care with respect to the
individual’s unique needs and wishes.
(Authority IC 12-10-10, 455 IAC 1-4-3, 4, 5, 6, 455 IAC 1.2-19-1, 455 IAC 1-4-11)
The case manager shall initiate a CHOICE plan of care for each person eligible for
CHOICE regardless of the applicant's income and assets, except when:
(A)
The applicant or his or her CHOICE representative does not want to
proceed with the development of a plan of care;
(B)
The applicant or his or her CHOICE representative refuses to release the
information that is necessary to develop a plan of care; and/or
(C)
The AAA does not have the resources, within the available funds, to
develop and carry out a plan of care.
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Preliminary Information Gathering
The case manager shall have available or gather the following information concerning
the participant prior to initiation of the plan of care:
(1)
The needs and wants of a participant or his or her designated CHOICE
representative including their health, welfare, and request for self-directed care.
(2)
All services available regardless of funding source or community resource
provider.
(3)
A list of service s the participant is eligible for and the funding available for each
of those services.
Plan of Care Development
The plan of care shall be developed in collaboration with the individual or his or her
designated CHOICE representative and shall include a formal description of goals,
objectives, and strategies designed to enhance independence.
CHOICE plans of care shall be developed within 14 calendar days of the date of the
assessment, except when the AAA does not have the resources, within the available
funds, to develop and carry out a plan of care. When funds are not available, development
of a plan of care shall be deferred until such time as funds become available. When
funding becomes available, the plan of care shall be developed within 14 days of
availability of these funds. At that time the previous assessment shall be reviewed and
revised, if needed, prior to completion of the plan of care.
The long-term care services eligibility screen developed by the FSSA DA shall be used by
the AAA to assess the applicant's risk of losing his or her independence and to assist in
the development of a plan of care, if appropriate.
The participant has the right to be involved in the formulation of the plan of care and shall
be involved at every stage of decision making regardless of their care or living situation.
The applicant, or their CHOICE representative, may decide whether family or others may
participate in the development of the plan of care and updates that may follow.
During the development of the plan of care, necessary communication assistance shall
be provided at no cost to the participant.
Each plan of care shall include services that may be funded by CHOICE when
necessary to meet an individual’s assessed needs and subject to specific CHOICE fund
limitations.
Each plan of care must be developed in accordance with limitations specific to
CHOICE funds.
i
CHOICE funds may be used for services authorized under the
CHOICE program.
ii
Some services that may be funded with CHOICE funds require
additional documentation to establish necessity and appropriateness of the service.
iii
CHOICE funds are the funding of last resort.
iv
CHOICE funds may not be authorized for any individual who has not
applied for, or received, a Medicaid eligibility determination within the last ninety days.
v
There is an individual cap on CHOICE funds that must be applied
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during plan of care development.
(D)
Each plan of care shall address:
i
The individual’s personal goals in key life areas including home life,
health care, community participation and self-direction;
ii
The individual’s daily living needs and preventative health care needs
as well as any other identified needs;
iii
The services needed to maintain independence.
iv
The cost of the services still needed.
v
The sources of all services and support available to meet the
individual’s needs whether paid or unpaid, including the payment sources of those
services and the no-cost or voluntary services that can be provided to meet the
individual's needs.
vi
The requested and authorized CHOICE service(s) when necessary to
meet an individual’s assessed needs and subject to specific CHOICE fund limitations.
The plan of care shall specify for each authorized CHOICE service;
(a)
The frequency of the service(s);
(b)
The duration of the service(s);
(c)
The provider of the service(s);
(d)
Any special instructions specific to the service(s); and
(e)
Provisions for back-up services and emergencies.
(E)
The plan of care must be signed by the applicant or by his or her CHOICE
representative.
i
If the case manager has reason to believe that an individual lacks the
capacity to make a knowing and informed decision regarding his or her own care, the
case manager shall consult with the individual's physician. The individual's physician
shall make a determination regarding the individual's capacity to make a knowing and
informed decision. If the physician determines that the individual lacks the capacity to
make a knowing and informed decision regarding his or her own care, the plan of care
and any revisions must be approved and signed by the individual's CHOICE
representative.
ii
If the individual is physically unable to sign the application or plan of
care, but has the capacity to make a knowing and informed decision regarding his or her
own care, the individual may indicate his or her assent and authorize another to sign.
iii
There shall be documentation in the case file that the individual
(and/or representative, if any) has reviewed and approved the plan of care.
(F)
Notwithstanding the fact that an individual needs a CHOICE
representative, the case manager shall work and consult with the individual who will be
receiving the services and shall take his or her preferences into consideration when
developing a plan of care, to the extent that the individual's health or safety is not
threatened. The case manager shall ensure the individual, individual’s legal
representative if applicable, and providers of services regardless of whether the
services
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are CHOICE services or received from another sources, are provided with copies of
relevant documentation.
i
Copies of relevant documentation shall include information on
individual rights, an individual’s plan of care, how to file complaints with FSSA DA, and
requesting appeals concerning issues and disputes relating to the services provided to
the individual.
ii
A copy of the plan of care shall be given to the applicant/participant or
his or her designated CHOICE representative upon completion of the plan of care, upon
revision to the plan of care and at any other
time upon request.
10021 Confidentiality
(Authority P.L. 104-91)
The AAA shall maintain individual case records for each individual who applies for or
receives services. These records shall be maintained for a minimum of seven years
after the individual’s termination from the program or other final action.
The AAA shall maintain the confidentiality of CHOICE files and records at all times. Such
files and records shall not be disclosed except:
(1)
(2)
to the individual or their CHOICE representative;
to a person representing the individual in an appeal from a CHOICE decision;
(3)
to the division or other state agencies for purposes of securing in-home and
community services;
(4)
to an adult or child protective services investigator under IC 12-10-3 and IC 31-611-3;
(5)
under court order; or
(6)
as authorized by the individual or their CHOICE representative.
The AAA shall use CHOICE records for purposes of the CHOICE program and for the
coordination of other related services only.
10022 Provider Requirements – General
CHOICE funded services may only be provided by authorized service providers.
(Authority, IC 12-10-10, 455 IAC 1.2, 455 IAC 1-4-3, 455 IAC 1-4-11)
(1)
Each AAA shall arrange for the provision of individually needed CHOICE
services through local provider agencies or individuals who are approved to provide
CHOICE-funded services.
(2)
Providers of self-directed attendant care services funded under CHOICE are
exempt from the following provisions, but are required to comply with Section
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10013, Self-Directed Attendant Care.
(3)
In order to become an approved CHOICE provider of HCBS, an entity shall do
the following:
(A)
Meet the current minimum service provider requirements as specified in
this Chapter or show proof of licensure or certification from the state of Indiana, if a
license is required.
i
Providers that are licensed and regulated by the Indiana State
Department of Health (ISDH) shall be deemed approved for those licensed services.
ii
For services not licensed by the ISDH, the provider must meet all
other requirements to provide the specified service(s).
(B)
consumers.
Be certified and/or enrolled to provide services for CHOICE program
(C)
Certify that, if approved, the entity will provide HCBS using only persons
who meet the qualifications specified in this Chapter.
(D)
Retain, and have readily available, a copy of the most current executed
signed provider agreement or contract as applicable.
(E)
Assure and document compliance with the executed provider agreement
or contract and the requirements of this Chapter.
(F)
Comply with the following:
i
Applicable federal, state, county, or municipal regulations that govern
the operation of the agency.
ii
FSSA laws, rules, and policies.
(G)
Provide proof of the following:
iii
That insurance is in force as prescribed in 455 IAC 1.2-11-1 and 455
IAC 1.2-12-1(4).
iv
That any employee, agent, or staff of the provider agency meets all
standards and requirements for the specific services the person will be providing.
v
That licensed health professionals are checked for findings through
the Indiana professional licensing agency.
vi
That certified home health aides and/or certified nursing assistants
are checked for finding on the aide registry through the Indiana
professional licensing agency.
(H)
(H) Obtain a current limited criminal history obtained from the Indiana
state police central repository, as prescribed in 455 IAC 1.2-15-2(b)(2), for each employee
or agent involved in the direct management, administration, or provision of services before
providing direct care to individuals receiving services.
i
Providers may not be, or may not employ or contract with, a person
convicted of crimes including, but not limited to, the following:
(a)
A sex crime (IC 35-42-4).
(b)
Exploitation of an endangered adult (IC 35-46-1-12).
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(c)
Abuse or neglect of a child (IC 35-42-2-1).
(d)
Failure to report battery, neglect, or exploitation of an endangered
adult or dependent (IC 35-46-1-13).
(e)
Theft (IC 35-43-4), except as provided in IC 16-27-2-5(a)(5).
(f)
Murder (IC 35-42-1-1).
(g)
Voluntary manslaughter (IC 35-42-1-3).
(h)
Involuntary manslaughter (IC 35-42-1-4).
(i)
Battery (IC 35-42-2).
ii
Criminal or Juvenile History Appeals: The subject of a record may
initiate a challenge as to the accuracy/completeness of any entry on his/her record. For
Indiana entries on the report, challenges should be directed to: Indiana State Police,
Records Division, Indiana Government Center North, Room N302, 100 North Senate
Ave., Indianapolis, IN 46204. For federal entries on the report, challenges should be
directed to: FBI, Criminal Justice Information Services (CJIS) Division, ATTN: SCU, Mod.
D-2, 1000 Custer Hollow Road, Clarksburg, WV 26306. All Other Criminal/Civil History
Appeals: The local DCS office will provide contact information for the appropriate agency.
(I)
Obtain and submit a current document from the nurse aide registry of the
Indiana State Department of Health verifying that each unlicensed employee or agent
involved in the direct provision of services has no finding entered into the registry, if
applicable, before providing direct care to individuals receiving services.
(J)
Ensure staff providing direct care for CHOICE participants:
i
Are at least eighteen (18) years of age.
ii
Are competent to provide services according to the individual’s plan of
care.
iii
Demonstrate the ability to effectively communicate.
iv
Submit a copy of a current negative TB test or negative chest x-ray
that is completed annually.
v
Possess a current, valid state-issued driver’s license if the employee
will be transporting an individual. Provide proof of current insurance
on the vehicle used to transport an individual that meets current
Indiana requirements.
(K)
The provider shall maintain documentation that the provider meets the
requirements and maintains the minimum standards set out in this Chapter for
providing CHOICE-funded services.
10023 Provider Requirements – Organizational Chart Guideline.
CHOICE providers shall maintain and make available an organizational chart.
(Authority IC 12-10-10, 455 IAC 1.2-9-1,455 IAC 1-4-11)
10024 Provider Requirements – Personnel Records
CHOICE providers shall maintain in the provider’s office, files for each employee or
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agent of the provider.
(Authority, IC 12-10-10, 455 IAC 1.2-14-1, 455 IAC 1-4-11)
(1)
The files for each employee or agent who provides direct care shall contain the
following:
(A)
An annual negative tuberculin skin test or chest x-ray before providing
services, updated in accordance with recommendations of the Centers for Disease
Control.
(B)
Copies of the current, valid state-issued driver’s license and automobile
insurance information, updated when the insurance is paid, if the employee or agent will
be transporting an individual.
(C)
Limited criminal history information that meets the requirements of 455
IAC 1.2-6-2(3).
(D)
Verification of each training session attended by the employee or agent,
including substantiation of the following:
i
ii
iii
iv
The content.
The length of the training session.
Identification of the trainers.
Dated signatures of the trainers and the employee.
(2)
The files for each employee or agent who does not provide direct care shall
contain the following:
(A)
Limited criminal history information that meets the requirements of 455
IAC 1.2-6-2(3).
(B)
applicable.
Professional licensure, certification, or registration, including renewals, as
(C)
Verification of each training session attended by the employee or agent,
including substantiation of the following:
i
ii
iii
iv
The content.
The length of the training session.
Identification of the trainers.
Dated signatures of the trainers and the employee.
10025 Provider Requirements – Personnel Policies and Manuals
CHOICE providers, who use employees or agents to provide services shall adopt,
maintain and ensure compliance with personnel policies and manuals.
(Authority IC 12-10-10, 455 IAC 1.2-15, 455 IAC 1-4-11)
(1)
A provider or its agent shall adopt, maintain, and follow a written personnel
policy. The written personnel policy shall:
(A)
Be reviewed at least annually and updated as needed.
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(B)
Be provided to each employee or agent.
(C)
Include, but is not limited to, the following:
i
A procedure for conducting reference, employment, and criminal
background checks on each prospective employee or agent.
ii
A prohibition against employing or contracting with a person convicted
of crimes including, but not limited to, the following: (a)
A sex crime
(IC 35-42-4).
(b)
Exploitation of an endangered adult (IC 35-46-1-12).
(c)
Abuse or neglect of a child (IC 35-42-2-1).
(d)
Failure to report battery, neglect, or exploitation of an endangered
adult or dependent (IC 35-46-1-13).
(e)
Theft (IC 35-43-4), except as provided in IC 16-27-2-5(a)(5).
(f)
Murder (IC 35-42-1-1).
(g)
Voluntary manslaughter (IC 35-42-1-3).
(h)
Involuntary manslaughter (IC 35-42-1-4).
(i)
Battery (IC 35-42-2).
(D)
A process for evaluating the job performance of each employee or agent
at the end of the training period and annually thereafter, including a process for feedback
from individuals receiving services from the employee or agent.
(E)
Disciplinary procedures.
(F)
A description of grounds for disciplinary action against or dismissal of an
employee or agent.
(G)
A clear description of an employee’s rights and responsibilities, including
the responsibilities of administrators and supervisors.
(H)
A procedure to ensure compliance with HIPAA regulations.
(2)
A provider or its agent shall adopt and maintain a job description for each
position, including the following:
(A)
Minimum qualifications for the position.
(B)
Major duties required of the position.
(C)
The written personnel policy required by subsection (1).
(3)
A provider or its agent shall ensure compliance with and compile written policies
and procedures specified in this section into a written operations manual.
(A)
The operations manual shall be regularly updated and revised not less
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often than annually.
(B)
Upon the request of FSSA DA or its designee, the provider shall do either
of the following:
i
Supply a copy of the operations manual to FSSA DA or its designee,
or another state agency at no cost. FSSA DA will maintain the confidentiality of
proprietary information, as deemed appropriate.
ii
Make the operations manual available to FSSA DA or its designee, or
another state agency for inspection at the offices of the provider.
10026 Provider Requirements – Maintenance of Records of Services Provided
A CHOICE provider or its agents shall maintain, in the provider’s office, documentation
of all services provided to an individual.
(Authority, IC 12-10-10, 455 IAC 1.2-16, 455 IAC 1-4-11)
(1)
A CHOICE provider or its agents shall:
(A) Maintain, in the provider’s office, documentation of all services provided to an
individual.
(B)
Analyze and maintain the documentation required by the following:
i
to an individual.
ii
iii
CHOICE standards applicable to the services the provider is providing
The professional standards applicable to the provider’s profession.
The individual’s plan of care.
(2)
Documentation related to an individual and required by this article shall be
maintained by the provider per HIPAA guidelines following the end of service
provision by the provider or its agent to the individual or as specified in law or rule.
10027 Provider Requirements – Data Collection Standards
CHOICE providers shall comply with data collection and reporting standards.
(Authority IC 12-10-10, 455 IAC 1.2-9-4, 455 IAC 1-4-11)
A provider or its agent shall utilize the INsite state-approved data collection system.
10028 Provider Requirements – Billing Standards
CHOICE providers shall comply with billing standards.
(Authority IC 12-10-10, 455 IAC 1.2-9-4, 455 IAC 1-4-11)
10029 Provider Requirements – Disclosure of Financial Information
CHOICE providers shall comply with financial disclosure requirements specified in this
Section.
(Authority 455 IAC 1.2-10-1, 455 IAC 1-4-11)
(1)
(A)
(1) A provider or its agent shall do the following:
Maintain financial records in accordance with generally accepted
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accounting and bookkeeping practices.
(B)
Be audited as follows:
i
Under the direction of the provider agreement or contract.
ii
According to state board of accounts requirements and procedures for
the services contracted. http://www.in.gov/sboa/publications/
(2)
A provider will, upon request, provide to the AAA and/or FSSA DA copies of audit
findings.
10030 Provider Requirements – Insurance
CHOICE providers shall secure insurance as specified in this Section.
(Authority IC 12-10-10, 455 IAC 1.2-11-1, 455 IAC 1-4-11)
A provider shall secure insurance to cover at least personal injury, loss of life and
property damage to an individual caused by fire, accident, or other casualty arising from
the provision of services to the individual by the provider.
10031 Provider Requirements – Quality Assurance and Quality Improvement System
CHOICE providers or their agent shall have a written internal quality assurance
and quality improvement system in accordance with this Section.
(Authority IC 12-10-10, 455 IAC 1.2-9-5, 455 IAC 1-4-11)
(1)
A provider’s or its agent’s written internal quality assurance and quality
improvement system shall be:
(A)
Focused on the individual.
(B)
Appropriate for the services being provided.
(C)
Ongoing and updated at least annually.
(2)
The system described in subsection (1) shall include at least the following
elements:
(A)
guidelines.
An annual survey of individual satisfaction, in accordance with contract
(B)
Records of findings for annual individual satisfaction surveys.
(C)
Documentation of efforts to improve service delivery in response to the
surveys of individual satisfaction.
(D)
An annual assessment of the appropriateness and effectiveness of each
service provided to an individual.
(E)
i
(a)
A written process for the following, if applicable:
Analyzing data concerning the following:
Reportable incidents. Reportable incidents are those incidents
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specified in the Indiana FSSA DA Incident Reporting Policy.
(b)
Services provided.
ii
future incidents.
Developing and reviewing recommendations to reduce the risk of
10032 Transfer of Individual’s Records Upon Change of Provider
CHOICE funded services may only be provided by authorized service providers.
(Authority, IC 12-10-10, 455 IAC 1.2-8-3, 455 IAC 1-4-11)
If an individual changes providers for a home and community-based service, the case
manager shall facilitate the transfer of pertinent records related to the individual to the
new provider within five (5) calendar days while maintaining compliance with HIPAA
regulations.
10033 Provider Requirements – Procedures for Protecting Individuals
CHOICE providers shall develop procedures to protect individuals as specified in this
section.
(Authority, IC 12-10-10, 455 IAC 1.2-8-1, 455 IAC 1-4-11)
(1)
Each provider of services shall maintain specific written safety and security
policies and procedures for an individual.
(2)
Each provider of services shall train all employees or agents in implementing
written safety and security policies.
(3)
Each provider of services shall establish a written procedure providing for when
and how to notify law enforcement, APS, or CPS, as deemed appropriate and
emergency response agencies in an emergency or crisis.
(4)
Each provider of services shall establish a written procedure providing for
scheduling and completion of evacuation drills when providing services in locations
other than an individual’s own home (i.e. residential service providers and adult day
services providers.)
(A)
Adopting procedures that shall be followed in an emergency or crisis,
such as any of the following: a tornado, a fire, inclement weather.
(5)
Each provider of services shall establish a written procedure providing for:
administrative action against; investigating an
alleged violation by; disciplinary action against;
and
dismissal of an employee or agent of the provider;
if the employee or agent is involved in the alleged, suspected, or actual abuse, neglect,
exploitation, or mistreatment of an individual or a violation of an individual’s rights.
(6)
Each provider of services shall establish a written procedure for employees or
agents of the provider to report violations of the provider’s policies and procedures to
146
the provider.
(7)
Each provider of services shall establish a written procedure for the provider or
for an employee or agent of the provider, for informing:
APS or CPS as applicable;
an individual’s legal representative, if applicable;
the appropriate ombudsman;any person designated by the individual; and the provider of
CMS to the individual;
of a situation involving the alleged, suspected, or proven abuse, neglect, exploitation,
or mistreatment of an individual or the violation of an individual’s rights.
(8)
Each provider will inform individuals of their right to exercise any or all
guaranteed rights without:
restraint; interference;
coercion; discrimination; or
threat of reprisal;
by the provider, employee, or agent.
(9)
Each provider of services shall establish and make available to the individual; the
written protocol for reporting required reportable unusual occurrences to FSSA DA .
(10)
Each provider of services shall establish and make available to the individual
receiving services a written protocol informing the individual about the right to file a
complaint with FSSA DA and the process of filing a complaint with FSSA DA.
10034 Provider Requirements – Individual’s “No-Show” for a Service
CHOICE providers shall report individuals who do not report to a location as scheduled
for a service as an unusual occurrence in accordance with the requirements of Division
of Aging Incident Reporting Policies and Procedures.
(Authority IC 12-10-10,455 IAC 1.2-8-2, 455 IAC 1-4-11)
10035 Legally Responsible Individuals as CHOICE Providers
CHOICE-funded services may only be provided by legally responsible individuals as
specified in this section.
(Authority IC 12-10-10)
(1)
Relatives of CHOICE participants who complete the FSSA DA training program
established under IC 12-10-10-9(a) are eligible for reimbursement under CHOICE for
the provision of homemaker and personal care services to those participants.
(2)
An individual who is a legally responsible relative of an individual in need of selfdirected in-home care, including a parent of a minor individual and a spouse, is precluded
from providing attendant care services for compensation
10036 Provider Requirements – Coordination of Services and Plan of Care
(Authority IC 12-10-10; 455 IAC 1.2-19-1; 455 IAC 1-4-11)
147
Procedure.
1)
All entities responsible for providing service to an individual shall do the following:
(A)
Coordinate the services provided to an individual.
(B)
Share documentation regarding the individual’s well-being, as required by
the individual’s plan of care.
10037 Service Specific Provider Requirements – Adaptive Equipment Providers
CHOICE providers of adaptive equipment shall provide this equipment (see Section
4001 of DA Operations Manual).
Providers must meet requirements contained in the CHOICE guidelines as
applicable to the provider.
Adaptive equipment may be funded by CHOICE if the individual has no other source of
funding adaptive equipment.
(Authority IC 12-10-10; 455 IAC 1.2-9-6; 455 IAC 1.2-9-6; 455 IAC 1.2-20-1; 455 IAC
1.2-20-1; 455 IAC 1-4-11)
10038 Service Specific Provider Requirements – Adult Day Services Providers
CHOICE providers of adult day services shall implement services in accordance with the
requirements of Section 4003 of the DA Operations Manual.
Adult Day Services may only be funded by CHOICE if the individual has no other
source of funding.
Providers must meet requirements contained in the CHOICE Guidelines as
applicable to the provider.
(Authority IC 12-10-10; 455 IAC 1.2-9-6; 455 IAC 1.2-20-1; 455 IAC 1-4-11)
10039 Service Specific Provider Requirements – Attendant Care
CHOICE providers of attendant care services shall implement services in accordance
with the requirements of Section 4007 of the DA Operations Manual.
Attendant care services may only be funded by CHOICE if the individual has no
other source of funding.
Attendant Care Services are a HCBS Waiver service.
Providers must meet requirements contained in the CHOICE Guidelines as
applicable to the provider.
Providers must be licensed as either a home health agency or personal services
agency unless certified by FSSA
(Authority IC 12-10-10; 455 IAC 1.2-9-6; 455 IAC 1.2-20-1; 455 IAC 1-4-11)
10040 Service Specific Provider Requirements – Environmental Modifications
CHOICE providers of environmental modifications shall implement services in
accordance with the requirements of Section 4018 of the DA Operations Manual.
148
Environmental Modification Services may only be funded by CHOICE if the individual has
no other source of funding.
Providers must meet requirements contained in the CHOICE Guidelines as applicable to
the provider.
Environmental modifications are a HCBS Waiver service.
(Authority IC 12-10-10; 455 IAC 1.2-9-6; 455 IAC 1.2-20-1; 455 IAC 1-4-11)
(A)
Reimbursement for Environmental Modification Supports has a lifetime
cap of $15,000. Service and repair up to $500 per year, outside this cap, is permitted for
maintenance and repair of prior modifications. (If the
lifetime cap is fully utilized, and a need is identified, the case manager will work with other
available funding streams and community agencies to fulfill the need.)
10041 Service Specific Provider Requirements – Family Caregiver Support
Family Caregiver Support Program services may only be funded by CHOICE if the
caregiver has no other source of funding.
Providers must meet requirements contained in the CHOICE Guidelines as applicable to
the provider.
(Authority IC 12-10-10; 455 IAC 1.2-9-6; 455 IAC 1.2-20-1; 455 IAC 1-4-11)
10042 Service Specific Provider Requirements – Home Health Services
CHOICE providers of home delivered meals shall implement services in accordance with
the requirements of this Section.
(Authority IC 12-10-10; 455 IAC 1.2-9-6; 455 IAC 1.2-20-1; 455 IAC 1-4-11)
10043 Service Specific Provider Requirements – Home Delivered Meals
CHOICE providers of home delivered meals shall implement services in accordance with
the requirements of Section 8006 of the DA Operations Manual.
Home Delivered Meals may only be funded by CHOICE if the individual has no other
source of funding.
No more than two meals per day will be reimbursed under the CHOICE program.
Providers must meet requirements contained in the CHOICE Guidelines as applicable
to the provider.
(Authority IC 12-10-10; 455 IAC 1.2-9-6; 455 IAC 1.2-20-1; 455 IAC 1-4-11)
10044 Service Specific Provider Requirements – Homemaker
CHOICE providers of homemaker services shall implement services in accordance with
the requirements of Section 4013 of the DA Operations Manual.
Homemaker Services may only be funded by CHOICE if the individual has no other
source of funding.
Providers must meet requirements contained in the CHOICE Guidelines as
applicable to the provider.
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Providers must be licensed as a home health agency or a personal services agency
through ISDH
(Authority IC 12-10-10; 455 IAC 1.2-9-6; 455 IAC 1.2-20-1; 455 IAC 1-4-11)
10045 Service Specific Provider Requirements – Home Repair and Maintenance
Services
CHOICE providers of home repair and maintenance services shall meet specified
requirements and develop and implement safety and security policies and procedures
specified in Section 4014 of the DA Operations Manual
Home Repair and Maintenance Services may only be funded by CHOICE if the
individual has no other source of funding.
Providers must meet requirements contained in the CHOICE Guidelines as
applicable to the provider
(Authority IC 12-10-10; 455 IAC 1.2-9-6; 455 IAC 1.2-20-1; 455 IAC 1-4-11)
10046 Service Specific Provider Requirements – Information and Assistance
CHOICE providers of information and assistance services shall meet specified
requirements and develop and implement safety and security policies and procedures
specified in Section 4016 of the DA Operations Manual.
Information and Assistance Services may only be funded by CHOICE if the individual has
no other source of funding.
Providers must meet requirements contained in the CHOICE Guidelines as
applicable to the provider.
(Authority IC 12-10-10; 455 IAC 1.2-9-6; 455 IAC 1.2-20-1; 455 IAC 1-4-11)
10047 Service Specific Provider Requirements – Legal assistance services
CHOICE providers of legal assistance services shall meet specified requirements and
develop and implement safety and security policies and procedures specified in Section
4017 of the DA Operations Manual.
Legal Assistance Services may only be funded by CHOICE if the individual has no
other source of funding.
Providers must meet requirements contained in the CHOICE Guidelines as
applicable to the provider.
(Authority IC 12-10-10; 455 IAC 1.2-9-6; 455 IAC 1.2-20-1; 455 IAC 1-4-11)
10048 Service Specific Provider Requirements – Nutrition Education
CHOICE providers of nutrition education services shall meet specified requirements and
develop and implement safety and security policies and procedures specified in this
Section.
(Authority IC 12-10-10; 455 IAC 1.2-9-6; 455 IAC 1.2-20-1; 455 IAC 1-4-11)
10049 Service Specific Provider Requirements – Outreach Services
CHOICE providers of outreach services shall meet specified requirements and develop
150
and implement safety and security policies and procedures specified in Section 4021 of
the DA Operations Manual.
Outreach Services may only be funded by CHOICE if the individual has no other source of
funding.
Providers must meet requirements contained in the CHOICE Guidelines as
applicable to the provider.
(Authority IC 12-10-10; 455 IAC 1.2-9-6; 455 IAC 1.2-20-1; 455 IAC 1-4-11)
10050 Service Specific Provider Requirements – Personal Emergency Response
Systems
Personal Emergency Response Systems providers must meet specified requirements to
provide CHOICE-funded services.
(Authority IC 12-10-10; 455 IAC 1.2-18-1; 455 IAC 1-4-11)
Procedure.
Personal Emergency Response System (PERS) is an electronic device which enables
certain individuals at high risk of institutionalization to secure help in an emergency. The
individual may also wear a portable help button to allow for mobility. The system is
connected to the person’s phone and programmed to signal a response center once a
“help” button is activated. The response center is staffed by trained professionals.
(1)
(A)
Service Requirements/Allowable Activities:
PERS consists of:
i
Device Installation service; and
Ongoing monthly maintenance of device.
(2)
(A)
(3)
Service authorization requirements:
The case manager authorizes PERS.
Limitations/Exclusions
(A)
PERS is limited to those individuals who live alone, or who are alone for
significant parts of the day, and have no regular caregiver for extended periods of time,
and who would otherwise require extensive supervision.
(B)
Systems must meet Underwriters Laboratory (UL) and FCC regulations
prior to installation.
(C)
All devices must meet applicable state and local requirements and
regulations for licensure and/or certification for the type of system for which the
contractor is providing.
(4)
(A)
PERS providers must Meet all the provider requirements contained in the CHOICE guidelines
151
as applicable to the provider;
(B)
Be Qualified Contractors, Special Equipment Suppliers, Businesses,
Agencies, Organizations, or Individuals; and
(C)
Be knowledgeable of applicable standards of manufacturing, design, and
installation of the specific device installed.
(5)
Documentation requirements
(A)
PERS must be provided in accordance with the written Plan of Care
addressing specific needs determined by the individual’s assessment.
(6)
(A)
Billing requirements.
PERS is billing depends on the funding source.
10051 Service Specific Provider Requirements – Pest Control Services
CHOICE providers of pest control services shall implement services in accordance with
the requirements of this Section.
(Authority IC 12-10-10; 455 IAC 1.2-9-6; 455 IAC 1.2-20-1; 455 IAC 1-4-11)
10052 Service Specific Provider Requirements – Respite Care
CHOICE providers of respite services shall meet specified requirements and develop
and implement safety and security policies and procedures.
(Authority IC 12-10-10; 455 IAC 1.2-9-6; 455 IAC 1.2-20-1; 455 IAC 1-4-11)
Procedure.
(1)
Respite Care services are those services that are provided temporarily or
periodically in the absence of the usual caregiver.
(2)
Respite Care may be provided in the following locations: in an individual’s home,
in the private home of the caregiver, in an adult foster care home, or in a Medicaid
certified nursing facility.
(3)
The level of professional care provided under respite care services depends on
the needs of the client.
(A)
A client requiring assistance with bathing, meal preparation and planning,
specialized feeding, such as a client who has difficulty swallowing,
refuses to eat, or does not eat enough; dressing or undressing; hair and
oral care; and weight bearing transfer assistance should be considered for respite home
health aide under the supervision of a registered nurse.
(B)
A client requiring infusion therapy; venipuncture; injection; oral
medication; Hoyer lift; wound care for surgical, decubitus, incision, and so forth; ostomy
care; and tube feedings should be considered for respite nursing services.
(4)
Service Requirements/Allowable Activities:
(A)
Homemaker services
152
(B)
Attendant care
(C)
Home health aide services
(D)
Skilled nursing services
(E)
Nursing facility services.
(5)
Service authorization requirements:
(A)
The case manager authorizes respite care, except when required to be
provided in a nursing facility.
i
The case manager is required to receive prior authorization from the
Indiana Family and Social Services Administration (IFSSA) with a completed Request
for Approval to Authorize Services Form before Respite Care may be provided in a
nursing facility.
(6)
Limitations/Exclusions
(B)
Respite care shall not be used as day/child care to allow the persons
normally providing care to go to work.
(C)
Respite care shall not be used as day/child care to allow the persons
normally providing care to attend school.
(D)
Respite care shall not be used to provide service to a member while
member is attending school.
(E)
Respite care may not be used to replace skilled nursing services that
should be provided under the Medicaid State Plan.
(F)
Respite care must not duplicate any other service being provided under
the individual’s plan of care.
(G)
If an individual’s need for respite care services can be met by an LPN, but
an RN provides the service, the service may only be billed at the LPN
rate.
(4)
Respite care providers must -
(A)
Meet all the provider requirements contained in the CHOICE guidelines
as applicable to the provider;
(B)
i
ii
iii
iv
Be a:
Community Developmental Disabilities Agency; or
Licensed Home Health Agency; or
Medicaid Certified Nursing Facility; or
Individual .
(C)
Family members who are providing care giving to the participant may not
be paid to provide respites services (since respite services are designed to relieve the
153
caregiver during periods of brief absence from the individual).
(D)
Providers must be qualified to provide the “level” of respite care services
authorized by the case manager, or by FSSA DA for NF services.
(5)
Documentation requirements
(A)
Respite care must be provided in accordance with the written Plan of
Care addressing specific needs determined by the individual’s
assessment.
(B)
Documentation must include the following elements: the reason for the
respite, the location where the service was rendered and the type of
respite rendered. For example, respite Home Health Agency (HHA).
i
Documentation should include date and time, and at least the last
name and first initial of the respite care provider making the entry.
ii
If the person providing the service is a professional, the title of the
individual must also be included. For example, if a nurse is required to
perform the service then the RN title would be included with the name.
(6)
Billin g requirements.
(A)
Billing depends on the funding source.
10053 Service Specific Provider Requirements – Supplies
CHOICE providers of supplies shall implement services in accordance with the
requirements of this Section.
(Authority IC 12-10-10; 455 IAC 1.2-9-6; 455 IAC 1.2-20-1; 455 IAC 1-4-11)
10054 Service Specific Provider Requirements – Therapy Services
CHOICE providers of therapy services shall meet specified requirements and develop
and implement safety and security policies and procedures specified in this Section.
(Authority IC 12-10-10; 455 IAC 1.2-9-6; 455 IAC 1.2-20-1; 455 IAC 1-4-11)
10055 Service Specific Provider Requirements – Transportation
CHOICE providers of transportation services shall meet specified requirements and
develop and implement safety and security policies and procedures specified in this
Section.
(Authority IC 12-10-10; 455 IAC 1.2-12-1; 455 IAC 1-4-11)
Procedure.
(1)
The following provider types may be certified to provide transportation services:
(A)
Qualified public and private carriers.
(B)
Qualified individuals.
i
Individual personnel providing transportation must meet the
154
following requirements.
(a)
Have a valid Operator’s license under IC 9-24-3 for individuals
using private vehicles.
(b)
Have a valid Chauffeur’s license under IC 9-24-4 or an Indiana
Public Passenger Chauffeur’s license when driving a vehicle designed to transport fewer
than 15 people (IC 9-24-5).
(c)
Have a valid Indiana Commercial Driver’s license when operating
a vehicle designed to transport a minimum of 15 people (IC 9-246).
(d)
Have a safe, legal driving record.
(e)
Have auto insurance, including liability insurance.
(f)
Have properly licensed and maintained vehicles.
(2)
An approved provider of transportation services or its agent shall do the
following:
(A)
Maintain the vehicle or vehicles used in the provision of transportation
services in good repair.
(B)
Retain and make available upon request, records of regular and
appropriate maintenance.
(C)
i
ii
Assure the vehicle used for transportation services is properly registered:
with the Indiana Bureau of Motor Vehicles; or
in the state in which the owner of the vehicle resides.
(D)
Retain and make available upon request, documentation confirming the
provider has the appropriate insurance as required under Indiana law.
10056 Service Specific Provider Requirements for Self-Directed In-Home Care
CHOICE funded services may only be provided by authorized service providers.
(Authority IC 12-10-10; IC 12-10-17.1; 455 IAC 1-4-3; 455 IAC 1-4-11)
Procedure
(1)
An individual who is a legally responsible relative of an individual in need of selfdirected in-home care, including a parent of minor individual and a spouse, is precluded
from providing attendant care services for compensation.
(2)
An individual may not provide attendant care services for compensation for an
individual in need of self-directed in-home care services unless the individual is
registered.
(A)
An individual who desires to provide attendant care services must register
with the FSSA DA or with an organization designated by the division.
155
(B)
The FSSA DA shall register an individual who provides the following:
i
A personal résumé containing information concerning the individual's
qualifications, work experience, and any credentials the individual
may hold. The individual must certify that the information contained in
the résumé is true and accurate.
ii
The individual's limited criminal history check from the Indiana central
repository for criminal history information under IC 10-13-3 or another source allowed by
law.
(a)
The limited criminal history check and report must be updated
every two (2) years
(b)
Individuals who have lived outside of Indiana the two
years prior to registering will have to have a National criminal history check.
iii
If applicable, the individual's state nurse aide registry report from the
State Department of Health. This subdivision does not require an individual to be a
nurse aide.
iv
Three (3) letters of reference.
v
A registration fee. The FSSA DA establishes the amount of the
registration fee.
vi
Proof that the individual is at least eighteen (18) years of age.
vii
Any other information required by the FSSA DA.
(C)
A registration is valid for two (2) years.
(3)
A personal services attendant may renew the personal services attendant's
registration by updating any information in the file that has changed and by paying
the fee required under subsection.
(4)
A personal services attendant who is hired by the individual in need of selfdirected in-home care is an employee of the individual in need of self-directed in- home
care.
(A)
The division is not liable for any actions of a personal services attendant
or an individual in need of self-directed in-home care.
(B)
A personal services attendant and an individual in need of self-directed
in-home care are each liable for any negligent or wrongful act or omission
in which the person personally participates.
(5)
The FSSA DA and any organization designated by the FSSA DA shall maintain a
file for each personal services attendant that contains:
(A)
comments related to the provision of attendant care services submitted by
an individual in need of self-directed in-home care who has employed the personal
services attendant; and
(B)
the items described in subsection (2).
10057 Provider Requirements – Warranties
Warranties are required for applicable CHOICE-funded services.
156
(Authority IC 12-10-10; 455 IAC 1.2-18-1; 455 IAC 1-4-11)
Procedure.
(1)
All applicable services provided to an individual under the CHOICE program
including, but not limited to:
durable medical equipment;
personal emergency response system;
home modification; and vehicle
modifications;
shall supply a warranty effective for at least one (1) year from the date of new
installation or the date the individual received the new item, whichever is applicable.
10058 Provider Monitoring
CHOICE providers are routinely monitored to ensure compliance with applicable
requirements of this Chapter. Primary monitoring of CHOICE providers shall be a
function of the Area Agencies on Aging.
(Authority IC 12-10-10; 455 IAC 1-4-11; 455 IAC 1.2, Section 4)
Procedure.
(1)
FSSA DA periodically monitors CHOICE providers:
(A)
As stated in the current executed contract or provider agreement.
(B)
Upon receiving a complaint or report alleging a provider’s noncompliance
with the requirements of the CHOICE program.
i
If a person other than an individual receiving service files a complaint,
FSSA DA shall notify the person filing the complaint of completion of the following:
(a)
FSSA DA monitoring as a result of the complaint.
(b)
monitoring.
Any corrective action by the provider as a result of FSSA DA
(C)
As frequently as deemed necessary by FSSA DA.
(D)
According to FSSA DA approved policy.
(2)
FSSA DA monitors compliance with the requirements of the CHOICE program
through any of the following means:
(A)
Requesting and obtaining information from the provider.
(B)
On-site inspections.
(C)
applicable.
Meeting with an individual or the individual’s legal representative as
(D)
Reviewing provider records and the records of an individual.
(E)
Following-up on completed inspections, as frequently as deemed
157
necessary by the FSSA DA, to determine compliance after submission of a corrective
action plan by a provider to the FSSA DA.
(3)
The provider will submit to the FSSA DA any requested documentation within ten
(10) days from the date that the provider receives a report of findings unless otherwise
specified.
(4)
After an on-site inspection, FSSA DA shall issue a written report, which shall:
(A)
Document the findings made during monitoring.
(B)
Identify necessary corrective action.
(C)
Give the provider ten (10) days in which to complete the corrective action
plan unless otherwise specified.
(D)
Identify documentation needed from the provider to support the provider’s
completion of the corrective action plan.
(E)
Be submitted to the provider. (5)
A provider shall do the following:
(A)
If requested, complete a corrective action plan to the reasonable
satisfaction of FSSA DA within:
i
ii
the time period identified in the corrective action plan; or
another time period agreed upon by the FSSA DA.
(B)
Notify FSSA DA upon the completion of a corrective action plan.
(C)
Provide FSSA DA with all requested documentation.
10059 Provider Non-Compliance with Requirements
CHOICE providers who do not comply with CHOICE program requirements will be
sanctioned up to and including decertification.
(Authority IC 12-10-10; 455 IAC 1-4-11; 455 IAC 1.2, Section 5)
Procedure.
(1)
If a provider does not comply with the requirements of the CHOICE program or
does not submit and complete an acceptable, approved corrective action plan to the
reasonable satisfaction of FSSA DA within the time specified, FSSA DA shall not
authorize either or both of the following:
(A)
The continuation of services to an individual or individuals by the provider
if the services do not comply with the specified requirements.
(B)
The receipt of services by individuals not already receiving services from
the provider at the time the determination is made that the provider did not implement a
corrective action plan to the reasonable satisfaction of FSSA DA.
158
(2)
The decertification process is initiated by the Area Agency on Aging and the
FSSA DA will assist with the appeals process if necessary.
(3)
FSSA DA shall give written notice of FSSA DA’s action specific to provider noncompliance to the following:
(A)
The provider.
(B)
The individual receiving services from the provider.
(C)
The individual’s legal representative, if applicable. (4)
The written notice shall include the following:
(A)
complied.
The CHOICE program requirements with which the provider has not
(B)
The effective date, with at least thirty (30) days notice, of FSSA DA’s
action specific to the non-compliance(s).
(C)
The need for planning to obtain HCBS for an individual or individuals.
(D)
The provider’s right to seek administrative review of FSSA DA’s action.
10060 Provider Non-Compliance with Requirements That Endangers the Health or
Welfare of an Individual Such That an Emergency Exists
CHOICE providers are subject to special and expedited sanctions when the provider’s
noncompliance with CHOICE program requirements endangers the health or welfare of
an individual such that an emergency exists.
(Authority IC 12-10-10; 455 IAC 1-4-11; 455 IAC 1.2, Section 6)
Procedure.
(1)
If a provider’s noncompliance with CHOICE program requirements endangers
the health or welfare of an individual such that an emergency exists, as determined by
FSSA DA or its designee, FSSA DA may enter an order for any of the following:
(A)
Termination of continued authorization for the provider to:
i
endangered; or
ii
serve any individual whose health or safety is being seriously
provide any services under a HCBS program.
(B)
Denial of authorization for the receipt of services by individuals not
already receiving services from the provider at the time FSSA DA determines that a
provider’s noncompliance with this article endangers the health or safety of an
individual.
(2)
Any action taken under subsection (1) shall remain in effect until such time FSSA
159
DA determines the provider’s noncompliance is no longer endangering the health or
safety of an individual.
(3)
FSSA DA shall give written notice of an order under subsection (1) to the
following:
(A)
The provider.
(B)
The individual receiving services from the provider.
(C)
The individual’s legal representative, as applicable.
(4)
The written notice shall include the following:
(A)
not complied.
The requirements of the CHOICE program with which the provider has
(B)
A brief statement of the facts and the law leading to FSSA DA’s
determination that an emergency exists.
(C)
The need to immediately obtain services that comply with this article for
an individual or individuals.
(D)
The provider’s right to seek administrative review of FSSA DA’s action. (5)
The order issued under subsection (1) shall expire on the earlier of the following:
(A)
The date FSSA DA determines that an emergency no longer exists.
(B)
Ninety (90) days.
(6)
During the pendency of any related proceedings under IC 4-21.5, FSSA DA may
renew an emergency order for successive ninety (90) day periods.
10061 Provider – Revocation of Approval
CHOICE provider approval may be revoked by the FSSA DA under specified
circumstances. (Authority IC 12-10-10; 455 IAC 1-4-11; 455 IAC 1.2, Section 7)
Procedure.
(1)
The FSSA DA may revoke the approval of a CHOICE provider for any of the
following reasons:
(A)
The provider’s repeated noncompliance with CHOICE requirements.
(B)
The provider’s continued noncompliance with CHOICE requirements.
(C)
The provider’s noncompliance with CHOICE requirements that endangers
the health or welfare of an individual.
10062 Provider Appeals
160
If a CHOICE provider has an executed contract or provider agreement to provide a
service to an individual, the provider has the right to appeal decisions that adversely
affect the service provider.
(Authority IC 12-10-10; 455 IAC 1-4-11; 455 IAC 1.2-7-1)
Procedure.
(1)
The service provider shall make a written request for an appeal hearing to the
secretary of FSSA within fifteen (15) days of the date of an adverse decision.
(2)
The request must:
(A)
include a statement indicating with reasonable particularity the
issue the service provider wishes to be reviewed; and
(B)
be signed and dated by the service provider.
(3)
Appeal proceedings will be conducted by a FSSA-appointed administrative law
judge (ALJ) under IC 4-21.5.
(A)
Notice of the ALJ’s decision shall be sent also to any listed adversely
affected party.
10063 HCBS Providers – Resolution of Disputes
If a dispute arises between or among providers, the dispute resolution process set out in
this section shall be implemented.
Authority IC 12-10-10; 455 IAC 1.2-9-3; 455 IAC 1-4-11)
Procedure.
(1)
The resolution of a dispute shall be designed to address an individual’s needs.
(2)
The parties to the dispute and the individual shall attempt to resolve the dispute
informally through an exchange of information and possible resolution.
(3)
If these parties are not able to resolve the dispute within fifteen (15) calendar
days, each party must document, in writing, the issues in the dispute, their positions and
their efforts to resolve the dispute and the parties shall refer the dispute to FSSA DA or
its designee for resolution in coordinating the individual’s needs.
(4)
The parties shall abide by the decision.
(5)
A party adversely affected or aggrieved by FSSA DA’s decision may request an
administrative review of the decision under 455 IAC 1.2-7-1 within fifteen (15) calendar
days after the party receives written notice of the recommendation.
(A)
Administrative review proceedings shall be conducted under IC 4-21.5.
161
Attachment 1: CHOICE Eligibility Asset Attestation Form
Case manager – Record countable assets as determined by DFR on the basis of a
Medicaid eligibility determination below or attaché asset print out from DFR.
Date of determination
Note: If more than ninety days old, the applicant must be referred to DFR for a new
determination.
I, (insert individual’s name)
certify:
1)
That the items listed as assets, truthfully represent my total and current assets.
2)
That I will notify my case manager should my assets change prior to or at any
time during receipt of CHOICE services.
3)
That I will be responsible for paying for CHOICE services if my assets change
and are determined to exceed the allowable limit of $500,000 and I did knowingly
withhold such information.
Signature of Individual or representative
Date
162
Attachment 2: Cost-Sharing Detail
Categories of income to be recorded in INsite:
Interest Bearing Accounts
Pension
Social Security Retirement
Social Security Disability SSI
VA Benefit Child
Support Alimony
Earnings, Salaries, Tips
Worker's Compensation Net
Rental Income
Deemed Value From Fixed Assets
- Interest earned from any source, including the following:
o
saving and checking accounts
o
interest bearing accounts such as CDs, IRAs, stock/bonds
- Net amount of any pension received by individual. These may be from former
employment or a widow/widower.
- Social Security pension.
- Social Security Disability pension.
- Supplemental Security Income check.
- Veteran's Benefit.
- Child support.
- Alimony.
Income of Parents or Spouse
Disability Insurance
Other Income
Allowable Deductions from Income Recorded in INsite
Health Insurance Premiums
LTC
Medical Care
Psychological Care
Medicare Premiums
Unpaid Medical/Psych. Bills
Individual-Paid Services
Other Allowable Payments
163
Table 1: Cost Share Amounts Based on Final Income (Income minus Deductions)
Percent Individual State
Percent Individual State
Percent Individual State
of
of
of
Share %
Share
Share %
Share
Share % Share
Poverty
Poverty
Poverty
%
%
%
151
0.0
100.0
219
34.0
66.0
287
68.0
32.0
152
0.5
99.5
220
34.5
65.5
288
68.5
31.5
153
1.0
99.0
221
35.0
65.0
289
69.0
31.0
154
1.5
98.5
222
35.5
64.5
290
69.5
30.5
155
2.0
98.0
223
36.0
64.0
291
70.0
30.0
156
2.5
97.5
224
36.5
63.5
292
70.5
29.5
157
3.0
97.0
225
37.0
63.0
293
71.0
29.0
158
3.5
96.5
226
37.5
62.5
294
71.5
28.5
159
4.0
96.0
227
38.0
62.0
295
72.0
28.0
160
4.5
95.5
228
38.5
61.5
296
72.5
27.5
161
5.0
95.0
229
39.0
61.0
297
73.0
27.0
162
5.5
94.5
230
39.5
60.5
298
73.5
26.5
163
6.0
94.0
231
40.0
60.0
299
74.0
26.0
164
6.5
93.5
232
40.5
59.5
300
74.5
25.5
165
7.0
93.0
233
41.0
59.0
301
75.0
25.0
166
7.5
92.5
234
41.5
58.5
302
75.5
24.5
167
8.0
92.0
235
42.0
58.0
303
76.0
24.0
168
8.5
91.5
236
42.5
57.5
304
76.5
23.5
169
9.0
91.0
237
43.0
57.0
305
77.0
23.0
170
9.5
90.5
238
43.5
56.5
306
77.5
22.5
171
10.0
90.0
239
44.0
56.0
307
78.0
22.0
172
10.5
89.5
240
44.5
55.5
308
78.5
21.5
173
11.0
89.0
241
45.0
55.0
309
79.0
21.0
174
11.5
88.5
242
45.5
54.5
310
79.5
20.5
175
12.0
88.0
243
46.0
54.0
311
80.0
20.0
176
12.5
87.5
244
46.5
53.5
312
80.5
19.5
177
13.0
87.0
245
47.0
53.0
313
81.0
19.0
178
13.5
86.5
246
47.5
52.5
314
81.5
18.5
179
14.0
86.0
247
48.0
52.0
315
82.0
18.0
180
14.5
85.5
248
48.5
51.5
316
82.5
17.5
181
15.0
85.0
249
49.0
51.0
317
83.0
17.0
182
15.5
84.5
250
49.5
50.5
318
83.5
16.5
183
16.0
84.0
251
50.0
50.0
319
84.0
16.0
184
16.5
83.5
252
50.5
49.5
320
84.5
15.5
185
17.0
83.0
253
51.0
49.0
321
85.0
15.0
186
17.5
82.5
254
51.5
48.5
322
85.5
14.5
187
18.0
82.0
255
52.0
48.0
323
86.0
14.0
188
18.5
81.5
256
52.5
47.5
324
86.5
13.5
189
19.0
81.0
257
53.0
47.0
325
87.0
13.0
190
19.5
80.5
258
53.5
46.5
326
87.5
12.5
191
20.0
80.0
259
54.0
46.0
327
88.0
12.0
192
20.5
79.5
260
54.5
45.5
328
88.5
11.5
193
21.0
79.0
261
55.0
45.0
329
89.0
11.0
194
21.5
78.5
262
55.5
44.5
330
89.5
10.5
195
22.0
78.0
263
56.0
44.0
331
90.0
10.0
196
22.5
77.5
264
56.5
43.5
332
90.5
9.5
164
197
198
199
23.0
23.5
24.0
77.0
76.5
76.0
265
266
267
57.0
57.5
58.0
43.0
42.5
42.0
333
334
335
91.0
91.5
92.0
9.0
8.5
8.0
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
24.5
25.0
25.5
26.0
26.5
27.0
27.5
28.0
28.5
29.0
29.5
30.0
30.5
31.0
31.5
32.0
32.5
33.0
33.5
75.5
75.0
74.5
74.0
73.5
73.0
72.5
72.0
71.5
71.0
70.5
70.0
69.5
69.0
68.5
68.0
67.5
67.0
66.5
268
269
270
271
272
273
274
275
276
277
278
279
280
281
282
283
284
285
286
58.5
59.0
59.5
60.0
60.5
61.0
61.5
62.0
62.5
63.0
63.5
64.0
64.5
65.0
65.5
66.0
66.5
67.0
67.5
41.5
41.0
40.5
40.0
39.5
39.0
38.5
38.0
37.5
37.0
36.5
36.0
35.5
35.0
34.5
34.0
33.5
33.0
32.5
336
337
338
339
340
341
342
343
344
345
346
347
348
349
350
351
92.5
93.0
93.5
94.0
94.5
95.0
95.5
96.0
96.5
97.0
97.5
98.0
98.5
99.0
99.5
100.0
7.5
7.0
6.5
6.0
5.5
5.0
4.5
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
165