WIXLIB

43Supporting a Better Tomorrow Requirements for Day Settings Peoplemust be given an option of a nondisability-specific setting (employment inthe community) Statescan require all day services becommunity-based (no physical location)

44Supporting a Better Tomorrow Requirements for Day Settings Reverse integration alone is not a sufficientway to comply with settings requirements ofthe Final rule Some day settings will need to be closelyexamined as potentially isolating including: Sheltered workshops/PrevocationalFacility based Day Habilitation and/or DayServices-AdultFocus on community employment

45Supporting a Better Tomorrow About the settings requirements

46Supporting a Better Tomorrow Person CenteredPlanning Requirementsand Processes

47Supporting a Better Tomorrow How is Person-Centered PlanningChanging?

48Supporting a Better Tomorrow Don’t Dis My AbilitySay It To My Face VideoClick Here for Videohttps://www.youtube.com/watch?v mdOWCQEyUJs

49Supporting a Better Tomorrow Wolf Wolfensberger Theory ofSocial Role ValorizationIf people with disabilities can gainvalued social roles within ourcommunities, the chances of livinga good life go way up.

50Supporting a Better Tomorrow What does Society Value? Relationships Wealth Healthand Beauty Youth and Newness Independence Productivity Pleasurable Life

51Supporting a Better Tomorrow Hurtful Consequences ofFeeling Devalued Rejection LowSelf-Esteem Hopelessness Loneliness Distrust Withdrawn Anger

52Supporting a Better Tomorrow Supporting People to GainValued Social Roles in: Relationships Employment Hobbies Religion Civicactivities

53Supporting a Better Tomorrow Person-Centered PlanRequirements Plan of Services and Supports (PSS)Must be conducted at least annually withthe person’s TEAM (family, providers, friends,others the focus person wants at themeeting) At a minimum:Person and legal guardian (if applicable)Provider(s)

54Supporting a Better Tomorrow Person-Centered PlanRequirements Heightenedrole for SupportCoordinator/Targeted Case Manager inmonitoring PSS implementation Offersinformed choices to the personregarding the services and supports theyreceive and their providers Includesa method for the person torequest updates to the PSS at any time

55Supporting a Better Tomorrow Person-Centered PlanRequirements ThePSS must reflect: Servicesand supports important TO andFOR the person Theperson’s strengths and preferences

56Supporting a Better Tomorrow Person-Centered PlanRequirements The PSS must reflect:Alternative HCB settings that wereconsidered by/offered to the person(everyone ages 18 ) The setting in which the person resides ischosen by the person (everyone ages 18 ) Clinical and support needs as identifiedthrough an assessment of functional need(ICAP and Risk Assessment)

57Supporting a Better Tomorrow Person-Centered PlanRequirements ThePSS must document: Risk factors and the measures in place tominimize them (Risk Assessment Tool) Individualized back up plans and strategieswhen needed

58Supporting a Better Tomorrow Person-Centered PlanRequirements ThePSS must be understandable to theperson receiving services and supportsand individuals important in supportinghim or her Plain language and a manner accessible topeople with disabilities and those who havelimited English proficiency

59Supporting a Better Tomorrow Person-Centered PlanRequirements Mustidentify the individual and/or entityresponsible for monitoring the plan(Support Coordinator/Targeted Case Manager) Mustbe finalized and agreed to Informed consent of theperson/guardian in writing Signed by all individuals and providersresponsible for implementation

60Supporting a Better Tomorrow Person-Centered PlanRequirements Mustbe sent in writing to the person andothers involved in the plan Mustdocument any modifications to aperson’s HCB setting are supported by aspecific assessed need and justified in thePSS

61Supporting a Better Tomorrow Requirements for Modificationsto any Requirements of the FinalRule Thefollowing must be documented if aperson’s HCB setting is modified: A specific and individualized assessed need The positive interventions and supports used prior toany modifications to the PSS Less intrusive methods of meeting the need thatwere tried but did not work A clear description of the condition that is directlyproportionate to the specific assessed need

62Supporting a Better Tomorrow Documentation Requirements forModifications The following must be documented if aperson’s HCB setting is modified: Regular collection and review of data to measurethe ongoing effectiveness of the intervention Established time limits for periodic reviews todetermine if the modification is still necessary orcan be terminated An assurance that interventions and supports willcause no harm to the person Informed consent of the person in writing

63Supporting a Better Tomorrow About Person Centered Planning

64Supporting a Better Tomorrow Implementation of theFinal Rule

Supporting a Better Tomorrow Today65Statewide Transition Plan (STP) Thevehicle through which statesdetermine their compliance with therequirements for the home andcommunity-based settings Final Rule anddescribe to CMS how they will complywith the new requirements Mustinclude the state’s assessment of theextent to which its regulations, standards,policies, licensing requirements, and otherprovider requirements ensure settings willcomply with the requirements of the FinalRule

Supporting a Better Tomorrow Today66Statewide Transition Plan (STP) Mustdescribe actions the state proposesto assure full and on-going compliancewith the HCBS settings requirements, withspecific timeframes for identified actionsand deliverables Mustprovide opportunity for public input

Supporting a Better Tomorrow Today67Statewide Transition Plan Mississippi’s “Initial” STP was5/25/17 (started work in 2015) approvedThe state completed its systemicassessment and included the outcomes inthe STP Thestate clearly outlined remediationstrategies to rectify issues that thesystemic assessment uncovered and isactively working on those remediationstrategies Changesto DMH Operational Standards,Medicaid Administrative Code, ID/DDWaiver renewal, and IDD CSP Renewal

Supporting a Better Tomorrow Today68Statewide Transition Plan What Provider self assessments were sent out in2015 has been done to date?Yielded very little meaningful dataNew providers were not surveyedSystemic assessment of regulations, etc.DMH Site Visits for physical locationassessmentDevelopment of Survey Tool (based onCMS Exploratory Questions) to gatherinformation from people receiving servicesand staff Resultsto determine compliance must focuson experiences of the person

Supporting a Better Tomorrow Today69Examples of ExploratoryQuestions for ParticipantsAre you allowed to do activities with the people of your choice?Are you required to stay in one room/space? For example, canyou go outside for a break when you choose? Or change toanother activity?Tell me about the things you do in the community. Where doyou go? What do you do? Do staff ask you where you would liketo go?Do you have access to your money when you need it or want tobuy something?

Supporting a Better Tomorrow Today70Examples of ExploratoryQuestions for StaffDo people decide where they go and what they want to doeach day? Can someone choose to go with their friends or doesstaff keep group/housemates together?Do people decide what they eat, when they eat, where they eat,and with whom they eat?Do people have access to their money when they want it andcan they spend it on what they want?Can people choose how to cut and fix their hair? Do theydecide when to get their hair cut/fixed?Does you call people things like “honey” or “baby” or do youuse the person’s preferred name?

Supporting a Better Tomorrow Today71Examples of Observation SurveyAre people actively engaged in an activity or sitting idle?Describe.Are staff actively engaged with the people? Describe. Ifstaff is not actively engaged, what are they doing?Does staff speak appropriately to people, for example,baby talk or stern tone? Describe/give example.Do people move about freely? Or are they kept with agroup? Are there gates, locked doors, or other barriers toprevent people from entering or exiting certain areas of thesetting?

Supporting a Better Tomorrow Today72Statewide Transition Plan Whatis left to be doneaccording to CMS? Completecomprehensive site-specificassessments of ALL home andcommunity-based settings Independent contractor Draft remediation strategies and acorresponding timeline that will resolveissues that the site-specific settingsassessment process and subsequentvalidation strategies identified Independent contractor and State Remediation can be staggered

Supporting a Better Tomorrow Today73Statewide Transition Plan Whatis left to be done accordingto CMS? Outlinea detailed plan foridentifying settings that arepresumed to have institutionalcharacteristics, including qualitiesthat isolate HCBS beneficiaries, aswell as the proposed process forevaluating these settings andpreparing for submission to CMS forreview under Heightened Scrutiny DMH reviewed physical settings lastcalendar year

Supporting a Better Tomorrow Today74Statewide Transition Plan Whatis left to be done accordingto CMS? Developa process for communicatingwith people receiving services insettings that the state has determinedcannot or will not come intocompliance with the home andcommunity-based settings criteria Establishongoing monitoring andquality assurance processes that willensure all settings providing HCBScontinue to remain fully compliant withthe rule in the future DMH Certification Team

Supporting a Better Tomorrow Today75Statewide Transition Plan Service sites must be assigned to 1 of the following4 categories:1.Fully align with the Federal requirements2.Do not comply with the Federal requirements, but canwith modifications3.Cannot meet the Federal requirements and will nolonger be allowed to claim reimbursement fromMedicaid for waiver/1915i services and/or mustrelocate people receiving services4.Are presumptively non-home and communitybased but for which the state will providejustification/evidence to show that those settingsdo not have the characteristics of an institutionand do have the qualities of home andcommunity-based settings (to be evaluated byCMS through the heightened scrutiny process)

76Supporting a Better Tomorrow Meaningful OpportunitiesSupports

Supporting a Better Tomorrow Today77Rationale for MeaningfulOpportunities Supports Servicedeveloped in response to need toreduce reliance on PrevocationalServices provided in sheltered worksettings CMS states:“ services that teach job task specificskills for the primary purpose of completingthose tasks for a specific facility-based joband are not delivered in an integrated worksetting” are not covered Waiverservices Prevocational Services must be timelimited.”(CMS Informational Bulletin 9/16/2011)

Supporting a Better Tomorrow Today78Rationale for MeaningfulOpportunities Supports Mississippi is not the only state with overreliance on sheltered –vs – integrated work Some states are strugglingSome states have closed workshopsSome states are in process of closing workshopsPrevocational Services in sheltered workshopsisolate people from community, according toCMSFinal Rule examines access to the communityunder a very bright lightFinal Rule emphasizes the importance of work

Supporting a Better Tomorrow Today79Meaningful OpportunitiesSupports Development Responseto a need to break down “silos” ofservices and meet individual desires for lifegoals and outcomes Developed by an Employment WorkgroupEmployment Workgroup MembersCMHCsPrivate ProvidersBIDD StaffMedicaidAdvocatesDMH Regional Program Staff Combedthrough other states and theirdefinitions and activities Tried to take the best of all of them

Supporting a Better Tomorrow Today80Meaningful OpportunitiesSupports Combinesbest parts of Day Services –Adult/Day Habilitation/PrevocationalServices Meetsthe requirements of the Final Rule

Supporting a Better Tomorrow Today81Meaningful OpportunitiesSupports Meaningful Opportunities Supports must bedesigned to enable a person to enrich his or herlife and enjoy a full range of meaningful activitiesincluding: Opportunities to seek employment and work incompetitive integrated settings. Activities caninclude:Career exploration, including assessment of intereststhrough volunteer experiences Job tours Job shadowing Situational assessments Internships Access to WIN Job Centers or other job findingresources, etc.

Supporting a Better Tomorrow Today82Meaningful OpportunitiesSupports Referral to the Mississippi Department ofRehabilitation Services for any person interested inactively seeking competitive integratedemployment so that information gathered can beused to expedite eligibilityFull participation in community life to the samedegree of access as people not receiving ID/DDWaiver servicesControl of personal resources (e.g., the providercannot limit the use of someone’s personalresources as a means of coercion or punishment). Providers cannot restrict access to personalresources in any wayProviders must offer informed choice of theconsequences/risks of unrestricted access topersonal resources.

Supporting a Better Tomorrow Today83Meaningful OpportunitiesSupports Optimize, not regiment, a person's initiative,autonomy, and independence in making lifechoices related to: Developing, enhancing, and maintaining abilities inpersonal, social, and community activitiesIndependent living skillsPursuit of personal interests and hobbiesThe services are intended for people who: Are on a pathway to employmentAre employed part-time and would like go to aplace that offers both structured & unstructuredactivities, choices, and community participationwhen not workingHave declined employment opportunitiesAre of retirement age

Supporting a Better Tomorrow Today84Meaningful OpportunitiesSupports People receiving Meaningful OpportunitiesSupports may also receive SupportedEmployment or Job Discovery services as long asMeaningful Opportunities Supports services do notduplicate activities being provided by otherservices.The provider is required to allow at least one staffperson, invited by the person, who works withhim/her on a daily basis and who knows him/herbest, to attend the person’s PSS meeting Supervisory staff who do not have at least dailycontact with a person do not meet the staffattendance requirement, but may attend if invitedby the person in order to assist in writing the ActivitySupport Plan at a later time

Supporting a Better Tomorrow Today85Meaningful OpportunitiesSupports People are to be afforded respectful treatmentby staff. Providers must also ensure that peopleare free from coercion and restraintPeople must have access to food at any time,unless the person’s diet is prescribed by an M.D.,Nurse Practitioner or Licensed Dietician/Nutritionist. If a diet is prescribed, it must bedocumented in the PSS and Activity Support Planand be attached to both. The program mustassist the person in adhering to the prescribeddiet.The provider is not responsible for snacks andmeals unless a person did not bring his/hers. Inthat case the provider must provide a nutritiousmeal and snacks for the day for that person.

Supporting a Better Tomorrow Today86Meaningful OpportunitiesSupports Theprovider must provide opportunities forpeople to learn cooking skills, even if notproviding meals for everyone in the program Peoplemust have choices about the foodthey eat, if provided by the program Peoplemust have choices of when and withwhom they eat. These choices cannot beregimented

Supporting a Better Tomorrow Today87Meaningful OpportunitiesSupports Alsoinclude usual requirements regardinghealth and safety (square footage, etc.) Levelof staffing determined by ICAP ReimbursementAdultrate equal to Day Services –

Supporting a Better Tomorrow Today88Do We Comply withHCBS Final Rule? Dopeople choose who supportsthem? Do they choose where they live? Do they choose with whom theylive? Do they choose how they spendtheir time? Do they choose how they spendtheir resources?

Supporting a Better Tomorrow Today89How Do We Change? Move from superficial compliance toreal change Changeour mindset Support people in having choices andattaining what they value most Support them in engaging in theircommunity

90Supporting a Better Tomorrow

91Supporting a Better Tomorrow Contact InformationMississippi Department ofMental Healthdmh.ms.govBureau of Intellectual andDevelopmental Disabilities601-359-6243Ashley Lacoste, DirectorDivision of HCBSashley.lacoste@dmh.ms.gov601-359-6240Betty Pinion, DirectorIDD Community Support Programbetty.pinion@dmh.ms.gov(601)359-5797

Mississippi’s Waivers 3. Traumatic Brain Injury/Spinal Cord Injury Waiver a. No age restrictions b. Diagnosis of traumatic brain or spinal cord injury and medically stable. c. Nursing Home level of care d. MS Department of Rehabilitation Services e. Medicaid eligible (adjusted income) 4. Assisted