This Information Bulletin will outline the requirements and process for a provider agency to request, be approved for, deliver, record, and report additional staff supports (53R/53D) for individuals who receive Community Integrated Living Arrangement (Program 60D CILA) or Developmental Training (Programs 31A or 31U DT) services funded through the Division of Developmental Disabilities' (DDD) Medicaid Waiver services.
When Initial Additional Staff Supports May Be Needed
The DDD may award additional staff supports to an eligible individual who is authorized for, enrolled in, and receiving services under the DDD's bill codes of 60D CILA or 31A or 31U DT services. An initial additional staff support request requires the submission of the Additional Staff Support and One- or Two-Person CILA Request (IL462-4424) and the Clinical Need Summary (IL462-4423). Both forms are used for initial additional staff support requests. Both forms must be filled out online or typed. A separate request must be submitted for each consumer.
An initial additional staff support request can be considered when the individual may have a short term duration or temporary condition that is likely to improve or end within a short period of time, such as:
- Recovery and rehabilitation from a medical event that require additional personal assistance
- Post hospital discharge
- Post surgical care within the CILA
The individual may also have long-term exceptional or extraordinary medical, physical and behavioral conditions or issues that require long-term additional staff supports. An initial additional staff support request should be submitted:
- When the individual needs the immediate services of additional staff supports while the service provider is assessing the individual's needs to address a long-term condition or issue
- or when the Division is evaluating the service provider's request for Long-Term Additional Staff Supports when and the long-term evaluation process cannot be reasonably completed before the initial short-term additional staff support hours are exhausted.
Additional staff is not awarded when staff responsibilities are to:
- Be available for "what if" scenarios, conditions or issues
- Keep the individual engaged in activities of daily living or community integration
- Supplement staffing levels
- Perform routine tasks or duties expected of direct care staff
- Perform general or regular staff assistance with the individual to complete or document, such as goals/objectives, run assigned programs, activities of daily living, community integration, administer medication, routine daily activities and duties and responsibilities in the individual's ISP.
NOTE: Additional staff may work with the individual on any of the above; however, the additional staff's primary responsibility is to address extraordinary medical, physical or behavioral issues.
The DDD will award initial staff support requests of up to 750 hours for 53R and 53D up to 230 hours. The initial allocations are to cover up to two (2) months of individual staff supports in a CILA or DT setting. The initial allocation of additional staff can afford the provider agency the staff resources necessary to meet an intense staffing need while preparing a request for long-term additional staff supports. (See Information Bulletin on Long-Term Additional Staff Support Requests)
Provider Application for Initial Additional Staff Supports
The request process for an initial additional staff support is abbreviated to expedite the approval process when unexpected or crisis circumstances develop. All initial additional staff support requests are submitted to the appropriate Individual Service Coordination (ISC) Agency who will in turn forward within one (1) business day (Monday - Friday) the initial additional staff support request to the appropriate Region Facilitator or Bureau of Transition Services Representative (BTS).
The initial additional staff support request must be submitted by the requesting provider agency within one (1) business day (Monday - Friday) of initiating additional staff supports for any individual. Provides that must initiate additional staff supports after normal business hours (Monday - Friday) during the week, on a holiday or weekend must submit the initial additional staff support request on the first business day following the start of additional staff supports.
It is the provider's responsibility to ensure that the ISC staff received the initial additional staff support request and that DDD staff person (Regional Facilitator or BTS) is also notified of the submission. The provider will indicate the name of the ISC agency, date and time the initial additional staff support request was sent to the ISC agency. The DDD will not be responsible for misdirected or undelivered requests.
The initial request from a provider requires the submission of: Additional Staff Support and One- or Two-Person CILA Request (IL462-4424) and the Clinical Need Summary (IL462-4423). These forms must be filled out online or typed. Handwritten copies will not be accepted.
- Identify the individual's name, Social Security Number, Medicaid RIN, Requesting Agency Name, Agency FEIN and Agency ID number
- Fill in the Date of the Request
- Check whether the request is for 60D CILA or 31U DT
- Check "Initial" to indicate whether the request is for an Initial, Long-Term, or Renewal of a Long-Term Additional Staff Support Request
- The CILA or DT provider will print, sign, date and provide an email contact address on the request before forwarding to the ISC Agency for review
Clinical Need Summary (IL462-4423)
- Fill in the individual's name, Social Security number, and Medicaid RIN, Requesting Agency Name, Agency FEIN and Agency ID number
- Provide a brief narrative explanation of the individual's medical, physical, and/or behavioral needs that require one-to-one staff supports. The narrative should be concise in the explanation of the individual's need
- Specify in quantifiable terms the duties and responsibilities the additional staff will be performing
- Identify in quantifiable terms the daily schedule when additional staff will be carrying out the duties and responsibilities specified above
- Attach the Clinical Need Summary Form to the Additional Staff Support Request.
Both forms are forwarded to the appropriate PAS/ISC/ISSA agency for review and signature. The PAS/ISC/ISSA agency has one (1) business day to review and forward to the DDD. Upon receipt, review and approval, the DDD will set the effective date for additional staff supports for two (2) days prior to the Division's receipt of the request.
Evaluation and Response to Requests for Initial Additional Staff Supports
DDD (Region/BTS staff) will:
- Date Stamp receipt of all initial additional staff support requests; and
- Within three (3) business days of receipt will approve or deny the request based on information submitted and will forward to the Bureau of Community Reimbursement (BCR) for a response letter; and
- BCR will issue either an award or denial letter within two (2) business days of receipt of the initial additional staff support request from Region/BTS staff;
The award or denial letter shall include:
- The Agency Name
- The Individual's Name and SSN
- Whether the award or denial is for 53R and/or 53D
- If approved, the date the initial 53R and/or 53D is to be effective
- If denied, the reason for denial of the request
The ISC Agency and Region/BTS will be copied on all award and denial letters
Delivery of Additional Staff Supports
Upon approval, the provider will be responsible to ensure documentation necessary to verify the additional staff support services:
- Additional staff supports must be provided by a staff person who is assigned to the individual approved for additional staff supports
- The additional staff person should not perform duties or responsibilities except for the individual for time that is to be billed for additional supports
- The assigned additional staff person must document their duties in the individual's record for time billed for additional staff supports
- The manner in which additional staff supports are to be delivered must be specified in the individual's service and behavior plan, such as: within arm's length, within line-of-sight, in a certain proximity to the individual, etc.
Service Reporting and Billing of Additional Staff Supports
Billing for CILA (60D) and DT (31U or 31A) additional staff support hours are entered in ROCS only after the 53R/53D service has been provided to the individual. Providers billing for 53R/D hours must maintain an auditable record of the additional staff assigned to an individual.
The provider will ensure documentation to verify the provision of additional staff support services. The DDD and others may evaluate additional staff supports through, but not limited to, the following:
- Individual progress notes
- Staff schedules
- Agency payroll records
- Follow-up reports from professionals, consultants, ISSA, CART, and SST
The maximum billing for 53R is 24 hours for any given day the person is not attending a day program or participating in an "At-Home" day services such as a Saturday, Sunday or holiday. The maximum billing for 53D is 5 hours for any given day the person attends a certified developmental training sight which qualifies for 31A or 31U billing. The Annual maximum for 53D is 1,200 hours as defined in Rule 119 as 240 days being the minimum days of operation and five (5) being the minimum number of hours of operation. Some DT providers operate longer hours but the DDD does not fund additional staff supports for longer hours of operation.
The DDD will recover bills paid for undocumented additional staff support hours when providers have inappropriately billed 53R/53D. A provider who inappropriately bills for 53R/53D may also be sanctioned by the DDD. Sanctions can range from prohibited future billing of 53R/53D to revocation of the provider's CILA license, DT certification and/or contract with the Department of Human Services.
When long-term additional staff supports may be needed to meet an individual's medical, behavioral or physical issues, it is the provider's responsibility to promptly secure the services of professionals to assess the individual, make recommendations and develop program plans to address the individual's needs, participate in a case conference, and assist in preparing the long-term additional staff support request. (See Information Bulletin on Long-Term Additional Staff Support Request)
CILA Additional Staff Supports (53R)
The individual must be reported as "P" for present in CILA to be able to bill for 53R hours. Billed 53R hours on a bed hold or day absent in 60D CILA will result in the 53R billing being rejected or recouped.
If additional support staff is required 24 hours, the maximum 53R hours that may be billed is 19 hours (Monday - Friday), and 24 hours Saturday, Sunday or holidays when the individual would not be participating in day programming.
If additional support staff is required for "awake hours" in a CILA, a maximum of 53R hours that may be billed is 11 hours (Monday - Friday) and 16 hours Saturday, Sunday or holidays when the individual would not be participating in day programming.
DT Additional Staff Supports (53D)
The maximum 53D hours that may be billed daily for an individual in a developmental training program is five (5) hours. The provider must have reported 31A or 31U hours in DT during their first 220 days of operation to be able to bill for 53D hours. Billed 53D hours cannot exceed the lowest of either five (5) hours or the billed 31A/31U hours for any day during the provider's first 220 days of operation in a state fiscal year. Billed 53D hours that are greater than the reported 31A/31U hours during the provider's first 220 days of operation will result in the 53D to be rejected or recouped. The DT provider may only bill for 53D without corresponding 31U or 31A hours after 220 days of operation during any state fiscal year. Billable additional staff supports (53D) are not awarded for or are to be billed when the individual is attending any other day program other than 31U or 31A. A service provider delivering and/or billing 53D supports for an individual who is authorized for 31U DT services as a part of their Home-Based Support Services (HBS) must not bill more 53D staff supports than are documented in the individual's HBS service and financial plans.
Monitoring of Additional Staff Supports
The DDD and/or PAS/ISC/ISSA may review initial and long-term additional staff support through, but not limited to, the following:
- Direct observation and additional staff individual progress notes
- Staff schedules
- Agency payroll records
- Follow-up reports from professionals, consultants, ISSA, CART, and SST
The DDD and/or PAS/ISC/ISSA agency may conduct unannounced on-site visits to provide an objective oversight, provide feed-back guidance and monitor:
- Delivery of approved additional staff support for the individual
- Individual's response to, and continued need for, additional staff supports
- Effectiveness of additional staff supports in preventing, controlling or deflecting critical incidents
In the event the PAS/ISC/ISSA agency has any concerns associated with the implementation of the additional staff support, they will follow the protocol laid out in "Problem and Conflict Resolution: Addressing Issues, Solving Problems, Troubleshooting" an attachment to Information Bulletin DD.11.010 - "ISSA Guidelines: Problem and Conflict Resolution."
The DDD shall systemically evaluate billing of 53R/53D. The evaluation of 53R/53D billing could require service providers to supply documentation of the provision of CILA or DT additional staff support services.