Interim Report - CILA Rate Work Group (April, 2009)

Introduction

This Interim Report presents the findings to date of the Community Integrated Living Arrangement (CILA) Rate Work Group's review of the CILA Rate Methodology. The CILA Individual Rate Determination Model rate methodology is described fully in the CILA User Guide, Cost Center Definitions, and Allowance Levels, July 2002, which can be found on the DHS web site.

The CILA Rate Work Group's two-fold charges were to:

  1. Identify and recommend changes in the methodology that could have a short-term and immediate effect of enhancing services and supports in the community services system in ways that advance the adequacy, quality, and quantity of this part of the system to the forefront, and
  2. Identify additional areas of potential changes in the reimbursement methods that could be considered for the longer-term.

The reader is referred to the Statewide Advisory Council (SAC) Rate Committee Interim Report Introduction and Overview for a discussion regarding the overall framework of the following principle charges:

  1. Develop rate proposals that are adequate, fair, and equitable.
  2. Create statistical models for each rate component or sub-component by identifying the data elements and processes.
  3. Break proposals into part that can be independently implemented.
  4. Develop rate proposals that are "shelf ready" to implement as opportunities to do so are presented.

This paper reflects an overall recommendation followed by two major sections of findings and recommendations from the Work Group:

  1. Recommendations: Section 1 includes items the Work Group has reviewed.
  2. Additional Review and Research Recommendations: Section 2 reflects items the Work Group has identified but additional work is recommended.

Background

The Work Group's work and findings are based upon a review of the components and elements of the current CILA rates and rate methodology and the work of short-lived focus groups that concentrated on staffing considerations (e.g., ratios), financial values (e.g., wage rates), and setting sizes (e.g., funding smaller settings, vacancy considerations, etc.).

The CILA Rate Work Group has relied on the efforts and products of the Wage and Fringe Benefits Work Group. The reader is directed to the Wage and Fringe Benefits Work Group Interim Report available on the Division's website.The Wage and Fringe Benefits Work Group focused narrowly on the types of staff primarily utilized in the CILA model and has recommended the use of the Bureau of Labor Statistics (BLS) Wage Data on Standard Occupational Codes (SOC) hourly wage data. These May 2007 Illinois-specific average gross hourly wages (including overtime pay and shift differentials but excluding bonus or other add-on payments and also excluding fringe benefits) have been trended forward to yield the FY2009 Projected Average Hourly Wage. The Direct Support Person (DSP) wage recommendation is based upon the "Social and Human Service Assistants" SOC 21-1093 series at $14.59/Hour; the Qualified Mental Retardation Professional (QMRP) wage recommendation is based on the "Community and Social Service Occupations" SOC 21-0000 series at $22.32/Hour; and the Supervisor wage recommendation is based on the "All Community and Social Service Specialists Not Listed Separately" SOC 21-1099 series at $19.20/Hour. BLS also publishes SOC series for Registered Nurses (RNs), and for Licensed Practical Nurses (LPNs).

The Wage and Fringe Benefit Work Group has also recommended the utilization of the BLS Employer Costs for Employee Compensation data from the September 10, 2008 release of the BLS NEWS reflecting June 2008 data. Table 7, page 15 of the NEWS reflects data for the Midwest Division, North Central Region (IL, IN, MI, OH, and WI) as the data source for fringe benefit information. See release of the NEWS. This recommendation is made in recognition of current mandated benefits such as payroll taxes and other non-mandated benefits such as health and life insurance and retirement are essential to attract and retain workers. The recommended fringe benefit percentage is 29.43% to be used as a multiplier to the base wage.

Findings

The following presents the itemized findings of the CILA Rate Work Group. Each item listed identifies a single rate component reviewed by the Work Group and provides information describing the component, its current cost and the estimated "Projected Costs" of changes that have been reviewed by the Work Group. The "Current Cost" figure for each item reflects no changes to the rate calculation and reflects current utilization levels of individuals funded in CILA under the current methodology. All "Current" and "Projected" Costs are shown in millions of dollars.

There are three types of projected cost changes that may apply to the itemized findings of the Work Group and the types are listed separately in order to distinguish the distinct costs of each. Each type is described below:

  • Type 1: A Type 1 cost change is the result of a calculation formula change from the current calculation (e.g., increasing a staffing ratio). When a Type 1 change is indicated, a recommendation is being made to modify the application practices and/or formulas used to calculate a particular rate element. Not all items will have a Type 1 change. The cost projection is based only on the formula change and may be compared to the "Current" cost to determine the cost change. If the formula is related to staff wages and fringe benefits the cost is based on the current CILA model (FY2009) staff wages and 20% fringe benefits. The Type 1 cost increase is reflected in the row amount of the "Incremental Increase" column.
  • Type 2: A Type 2 cost change is a recommendation for a change in the hourly wage, if any (e.g., a DSP hourly wage change) and does not reflect any change to the current CILA model 20% fringe benefit multiplier. The wage change may be in combination with the current CILA formula for an item, in which case the Type 1 change will be "NA", or the Type 2 change may be compounded in combination with a Type 1 formula change, if figures are indicated. The Type 2 cost increase is reflected in the row amount of the "Incremental Increase" column.
  • Type 3: A Type 3 cost change is a recommendation for a change in the fringe benefit percentage. The current CILA model 20% fringe benefit percentage is increased to the recommended 29.43% fringe benefit percentage. The projected costs may be compounded in combination with a Type 1 formula change and/or in combination with a Type 2 wage change. The Type 2 cost increase is reflected in the row amount of the "Incremental Increase" column.

For any given element of the CILA methodology, there may be one or more of the three types of changes. When the changes are interrelated, as would be the case of a staffing ratio formula change in combination with a wage change and in combination with a fringe benefit change, the projected costs are progressively added to, or built upon, the calculated estimate of each previously listed Type.

The 2009 projected values used throughout this paper represent the Work Group's considerations of what makes for an adequate rate structure based on a rational approach regarding the types of costs intended to be reflected in the CILA model and objective data values, where available. The projected values provide a reasonable upper boundary that can be used as a yardstick to assess the extent to which current reimbursement values can be compared. More pragmatically, the underlying rationale and index methodology provide the means to annually update the rate methodology values in subsequent years.

Overall Recommendation

The Work Group's overall recommendations for CILA rates are to fully implement the Type 1, 2, and 3 changes displayed in the Section 1 Recommendations that follow and for the Work Group to also continue its efforts on the items in the Section 2 Additional Review and Research Recommendations.

  1. Recommendations

    This Section 1 provides the Work Group's recommendations on items the Work Group has reviewed.

    1. Increase DSP Wage

      DSPs have a primary role in the delivery of CILA services and because of their training and experience; they are critical to the quality of services provided to a person with developmental disabilities. Their importance in assisting an individual in a wide range of activities that are a part of living and working in one's community cannot be overstated. The DSP hourly wage is a key element of the ability to hire and train new workers, to retain experienced DSPs in competitive job markets, and to ensuring an adequate workforce supply. The current DSP reimbursement wage in CILA is $10.71/Hour and $12.86/Hour with 20% fringe benefits.

      Remedy: Increase the DSP hourly wage using the BLS projected wage for the Standard Occupational Classification for the series 21-1093, Social and Human Service Assistants, to $14.59/Hour. With 20% fringe, this value becomes $17.51/Hour (Type 2 change) and $18.88/Hour with 29.43% fringe (Type 3 change).

      Calculation: Based on 16,300,105 DSP staff hours @ $12.86 plus 2,770,323 substitute DSP staff hours @ $10.71 for 8,022 people in CILA.

      Projection Current
      Funding      		 Incremental
      Increase      		 Total
      Funding      		 FFP Amount
      Current $239.159 M $0.0 M $239.2 M $119.6 M
      Type 1 N/A N/A N/A
      Type 2 $94.7 M $333.9 M $166.9 M
      Type 3 $26.3 M $360.1 M $180.1 M

    2. Adopt Senate Resolution (SR) 514 Recommendations for CILA Nursing Services

      Individuals' medical needs vary from basic health monitoring up to those requiring a significant amount of nursing and/or medication administration services. The 2006 SR514 Report of the Community Integrated Living Arrangement Nursing Services Reimbursement Work Group nursing study recommended changes for base monitoring and additional services for all individuals based on the Health Risk Screening Tool assessment and medication administration record information. The complete report is available online.

      Remedy: Implement the staff and nurse changes recommended in the Report of the Community Integrated Living Arrangement Nursing Services Reimbursement Work Group nursing study for Senate Resolution 514, October 2006. BLS wage data projected to 2009 for RN's of $36.23 and LPN's of $23.92/Hour with 20% Fringe Benefit allowance (Type 2 change). A 29.43% fringe allowance results in wages of $39.08 and $25.79 respectively (Type 3 change).

      Calculation: The Health Risk Screening Tool (HRST) total score and the medication administration information for all 8,022 individuals in CILA are used with a progressive, increasing, amount of RN and LPN staff time plus base health monitoring to determine funding levels.

      Projection Current
      Funding      		 Incremental
      Increase      		 Total
      Funding      		 FFP Amount
      Current $3.5 M $0.0 M $3.5 M $1.8 M
      Type 1 $6.8 M $10.3 M $5.1 M
      Type 2 $5.1 M $15.4 M $7.7 M
      Type 3 $1.2 M $16.6 M $8.3 M

    3. Increase QMRP Wage

      QMRPs are critical to the quality of services provided to a person with developmental disabilities. Trained and experienced QMRPs are difficult to retain with the current wage allowance. Current QMRP reimbursement wage is $15.11/Hour and with fringe is $18.14/Hour.

      Remedy: Increase the QMRP hourly wage using the BLS projected wage for 2009 for the Standard Occupational Classification for the series 21-0000, Community and Social Service Occupations to $22.32/Hour. With 20% fringe, this value becomes $26.78/Hour (Type 2 change) and $28.89/Hour with 29.43% fringe (Type 3 change).

      Calculation: Based on 7,461 people in 24 Hour and Foster Care CILA at 130 hours per person (969,930 Hours) and 1,935 hours of QMRP hours included in Intermittent and Family CILA rates.

      Projection Current
      Funding      		 Incremental
      Increase      		 Total
      Funding      		 FFP Amount
      Current $17.6 M $0.0 M $17.6 M $8.8 M
      Type 1 N/A N/A N/A
      Type 2 $8.4 M $26.0 M $13.0 M
      Type 3 $2.1 M $28.1 M $14.0 M

    4. Increase Supervisor Wage

      The supervisor is also a vital staff position for any CILA site. They function as the lead worker and house manager and are often the most familiar with the people who live at the CILA site and with the staff. Experienced supervisors are difficult to retain with the current wage allowance. The current Supervisor reimbursement wage is $13.40/Hour and with fringe is $16.08/Hour.

      Remedy: Increase the Supervisor hourly wage using the BLS projected wage for the Standard Occupational Classification for the series 21-1099, All Community and Social Service Specialists Not Listed Separately to $19.20/Hour. With 20% fringe, this value becomes $23.04/Hour (Type 2 change) and $24.85/Hour with 29.43% fringe (Type 3 change).

      Calculation: Based on 7,461 people in 24 Hour and Foster Care CILA at 130 hours per person (969,930 Hours) and 1,792 Supervisor hours included in Intermittent and Family CILA rates.

      Projection Current
      Funding      		 Incremental
      Increase      		 Total
      Funding      		 FFP Amount
      Current $15.6 M $0.0 M $15.6 M $7.8 M
      Type 1 N/A N/A N/A
      Type 2 $8.4 M $26.0 M $13.0 M
      Type 3 $2.1 M $28.1 M $14.0 M

    5. Fringe Benefit Allowance

      Currently the fringe benefit allowance of 20 percent in the CILA Model for staff addresses required employer paid payroll taxes (Social Security and Medicare), state and federal unemployment taxes, and worker's compensation insurance.

      There are two distinct issues regarding the Fringe Benefit Allowance:

      • The first is that the CILA model Substitute Staff calculation currently does not have any fringe benefit allowance included in the substitute staff hours funding. Substitute staff are needed to take the place of regular workers who use accrued benefit time off (e.g., vacation and sick time). The initial CILA model assumption was that the substitute staff would be part time personnel and would not receive benefits. However, in practice, a substitute staff is an employee for whom there are required employer-paid payroll tax expenses.
      • The second issue is that the current allowance level for all staff precludes providers from funding benefits such as health, dental or vision insurance or retirement savings benefits. Providers have a difficult time recruiting and retaining staff without being able to provide competitive employer sponsored benefits.

      Remedy: 

      1. Change the formula for the calculation of fringe benefits for substitute staff from 0% to 20% (a Type 1 formula change for substitute staff).
      2. Adopt the fringe benefit allowance of 29.43% derived from the June 2008 BLS News "Employer Cost for Employee Compensation" for the Midwest Division, North Central Region (IL, IN, MI, OH, and WI) without changing the current CILA model wage rates for any staff types. In other words, at currently funded wages and staff hours for DSPs, QMRPs, Supervisors, RNs, LPNs, Minimum Wage Night Shift staff (see also item #12 below), and substitute staff, increase the current 20% fringe benefit percentage by 9.43% to 29.43%.

      Calculation: The Type 1 formula change below funds fringe benefits at 20% for 2,770,323 Substitute (Sub) Staff hours to bring this on a par with other staff types.

      The Type 3 change that follows is based on first increasing the fringe benefit percentage for the substitute staff hours to 20% (Type 1) and then further increasing all fringes to the 29.43% fringe benefit level for all currently funded staff types, wages, and hours. The Type 3 fringe benefit cost projections below are at current wage levels and this projection differs from the Type 3 (fringe benefit) cost projections in other staff item Recommendation (see items # 1, 2, 3, 4, and 12 elsewhere in this paper) because those other items' projections are based on wage rate changes and fringe benefit changes compounded together.

      Projection Current
      Funding      		 Incremental
      Increase      		 Total
      Funding      		 FFP Amount
      Current $41.7 M $0.0 M $41.7 M $20.85 M
      Type 1 (Sub) $6.0 M $47.7 M $23.85 M
      Type 2 N/A N/A N/A
      Type 3 (Sub) $16.5 M $64.2 M $32.1 M

    6. One to Four (1-4) Person CILAs Staff Coverage Calculation

      The current staffing model for smaller sized CILA homes (1 - 4 capacity) does not fund the minimum required number of DSP staff hours for at least one DSP to be "on duty" at a site that is to provide 24 hour coverage.

      Remedy: Create a minimum staffing "floor" to fund at least one DSP to be on duty in a site with a capacity of 1, 2, 3, or 4 persons.

      Calculation: Based on 1,110 people being served in 1 - 4 bed capacity homes.

      Increase
      Projection      		 Numbers of
      Individuals      		 Added
      Hours      		 Total Cost
      Type 1      		 Total Cost
      Type 2      		 Total Cost
      Type 3
      1 Bed Site 32 173,922 $2.1 M $3.0 M $3.3 M
      2 Bed Sites 152 210,361 $2.7 M $3.7 M $4.0 M
      3 Bed Sites 156 89,794 $1.1 M $1.6 M $1.7 M
      4 Bed Sites 770 143,480 $1.8 M $2.5 M $2.7 M
      Total 1,110 617,558 $7.9 M $10.8 M $11.6 M
      Projection Current
      Funding      		 Incremental
      Increase      		 Total
      Funding      		 FFP Amount
      Current $40.3 M $0.0 M $40.3 M $20.1 M
      Type 1 $7.9 M $48.2 M $24.1 M
      Type 2 $2.8 M $51.0 M $25.5 M
      Type 3 $0.8 M $51.6 M $26.3 M

    7. Housing and Urban Development (HUD) - Fair Market Rent (FMR) Allowance

      The HUD - Fair Market Rent Allowance in the CILA Model has only received periodic COLA increases since the inception of the model. These COLA increases it is believed have not kept pace with the actual cost of obtaining and operating a residential site, regardless of size. The increased cost of property values, mortgage/rent payments and utilities coupled with insufficient reimbursement is a significant deterrent to future CILA development. In addition, currently CILA 1 and 2 person settings are not funded using the HUD FMR approach so this recommendation proposes to also include these settings.

      Remedy: Update Housing Allowances based on 2008 HUD FMR tables. In addition, include CILA 1 and 2 person settings. All CILA sites would be treated equally using the same reimbursement formula and index.

      Calculation: Based on 7,461 people in 24 Hour and Foster Care (FC) CILA and 561 people in Intermittent CILA. Family CILA is excluded.

      Site
      Breakdown      		 Individual
      People      		 24 Hr.
      & FC      		 Individual
      People      		 Intermittent Individual
      People      		 Totals
      1 & 2 Bed
      Sites      		 184 $0.3 M 473 $1.3 M 657 $1.6 M
      3 & 4 Bed Sites 926 $0.5 M 59 $0.0 M 985 $0.5 M
      5 & 6 Bed Sites 2,681 $1.2 M 27 $0.0 M 2,708 $1.2 M
      7 & 8 Bed Sites 3,670 $1.3 M 2 $0.1 M 3,672 $1.4 M
      Total 7,461 $3.3 M 561 $1.4 M 8,022 $4.7 M
      Projection Current
      Funding      		 Incremental
      Increase      		 Total
      Funding      		 FFP Amount
      Current $23.9 M $0.0 M $23.9 M $0.0 M
      Type 1 $4.7 M $28.5 M $0.0 M

    8. Vehicle Mileage Allowance

      The vehicle mileage allowance in the CILA Model has only received periodic COLA increases since the inception of the model. COLAs have not kept pace with the actual cost of operating vehicles to transport individuals.

      Remedy: Adopt and adjust the vehicle mileage allowance based on the State mileage allowance established by the Governor's Travel Control Board for State employee's mileage reimbursement. The current state mileage allowance is $0.505 per mile. Update the reimbursement allowance level on a periodic basis and based on any changes made to the State mileage allowance.

      Calculation: Based on 7,461 people (1,753,253 miles) in 24 Hour and Foster Care CILA and 37,290 miles included in Intermittent & Family CILA funding.

      Projection Current
      Funding      		 Incremental
      Increase      		 Total
      Funding      		 FFP Amount
      Current $4.7 M $0.0 M $4.7 M $2.3 M
      Type 1 $1.6 M $6.2 M $3.1 M

    9. Substitute Staff for Add-on Staff

      When a staff add-on funding is determined for a person either through an individual staff add-on or a "house matrix" there is no substitute staff allowance currently included in the rate calculation to "cover" the additional staff hours. Since the staffing plan adds more DSP staff hours that will accrue and use benefit time, additional substitute staff are needed.

      Remedy: Add a Substitute Staff Allowance for Add-on Staff and include fringe benefits when calculating a staff add-on.

      Calculation: Based on 308,625 DSP hours added to residential rates for residential staff add-ons. 308,625 {Hours} / 2,080 {1 FTE} * 31 {Days} * 8 {Hrs.} = 36,800 DSP substitute staff hours.

      Projection Current
      Funding      		 Incremental
      Increase      		 Total
      Funding      		 FFP Amount
      Current $0.0 M $0.0 M $0.0 M $0.0 M
      Type 1 $0.4 M $0.4 M $0.2 M
      Type 2 $0.2 M $0.6 M $0.3 M
      Type 3 $0.1 M $0.7 M $0.3 M

    10. Adjust for 365 Days of Operation

      The current calculation for staff coverage hours is based on a 7-day week and 52-week year, which yields only 364 days of coverage. However, 365 days divided by 7 days in a week results in a shortage of 0.14286 or about 1 day per year. Consequently, staff funding for Prime, Non-Prime, Night, and Substitute staff is one day per year short, or for only 364 days/year.

      Remedy: Adjust the staff calculation multiplier to 52.14286 from the current 52.

      Calculation: Based on 7,461 people in 24 Hour and Foster Care CILA. Using existing staff levels, this change adds 16,631 Prime; 13,061 Non-Prime; 14,186 Night Shift; and 13,416 Substitute DSP Staff Hours.

      Projection Current
      Funding      		 Incremental
      Increase      		 Total
      Funding      		 FFP Amount
      Current $0.0 M $0.0 M $0.0 M $0.0 M
      Type 1 $0.7 M $0.7 M $0.4 M
      Type 2 $0.3 M $1.0 M $0.5 M
      Type 3 $0.1 M $1.1 M $0.5 M

    11. Change the deduction for day program time away from the home

      Increase the residential paid staff time to eliminate the deduction for "no paid staff" time for day program time away from the residential site from 7 hours to 5 hours. Initially it was thought that no staff would be needed for two hours each weekday while individuals were away from the CILA site for day program attendance and the travel time to and from the day program site. However, residential staff typically have responsibilities at the residential site after the residents leave for day programs and must be on duty prior to the arrival of residents back from day programs.

      Remedy: Add one hour to "Prime" time coverage Monday through Friday

      Add one hour to "Non-Prime" time coverage Monday through Friday

      Calculation: Based on 7,461 people in 24 Hour and Foster Care CILA. Change the calculation to use five instead of seven hours away time. Uses existing staffing level calculations at 52 weeks per year.

      Projection Current
      Funding      		 Incremental
      Increase      		 Total
      Funding      		 FFP Amount
      Current $0.0 M $0.0 M $0.0 M $0.0 M
      Type 1 $18.1 M $18.1 M $9.0 M
      Type 2 $6.5 M $24.6 M $12.3 M
      Type 3 $1.9 M $26.5 M $13.2 M

    12. Minimum Wage for Asleep Night Shift Staff

      The current hourly reimbursement rate for night shift "asleep" staff is $7.24, which is below the minimum wage rate for Illinois. Service providers are required by law to pay at least the minimum wage. Fringe benefits at 20% are added to this figure.

      Remedy: Adopt and adjust the Night Shift Asleep Wage Allowance to reimburse night shift "asleep" hours at the State of Illinois' minimum wage plus a fringe benefit allowance. The current (FY2009) State minimum wage is $7.75/Hour ($8.69 with 20% fringe benefits) shown as a Type 1 formula change. Update the future reimbursement allowance level based on increases to the State's minimum wage. The Illinois minimum wage will increase to $8.00/Hour on July 1, 2009 and $8.25/Hour on July 1, 2010.

      Calculation: Based on 680,350 hours of "asleep" staff hours for 986 people in 24 Hour and Foster Care CILA. Current "asleep" staff wage is $7.24/Hour with a 20% fringe benefit allowance for a total of $8.69/Hour. The hourly minimum wage change is shown below as a Type 1 formula change.

      Projection Current
      Funding      		 Incremental
      Increase      		 Total
      Funding      		 FFP Amount
      Current $5.9 M $0.0 M $5.9 M $3.0 M
      Type 1 $0.4 M $6.3 M $3.2 M
      Type 3 $0.1 M $6.4 M $3.2 M

    13. Administration Allowance

      The Administration Allowance in the CILA Model has a "fixed" or "flat" amount regardless of the type of setting or the level of needs of the individual and was originally based on 10% of the average CILA rate. Although the allowance has received periodic COLA increases since the inception of the model, this fixed amount is now only 6.75 percent of the current average CILA rates. COLA increases to the administrative allowance in CILA have not kept pace with the overall changes in the CILA rate because some rate increases have specifically been directed to staff wages (e.g., $1/hour) and there is an increasingly greater number of individuals with higher support needs in CILA. Rates have increased while administrative costs for such functions as staff recruitment, professional liability insurance, attending conferences and training, and those administrative costs that correspond with the staffing for varying needs of individuals have not kept up with increasing costs. Other DHS-funded programs' rate methodologies (e.g., Community Living Facility) have an administrative allowance of 20 percent. In addition, it is believed that there may be industry standards for what is considered a reasonable administrative allowance that could be used as a guide to changes in the CILA model. The CILA Rate Work Group continues to research this issue.

      Remedy: Revise the Administration Allowance to be determined at a reasonable industry standard level or resume using 10% of the CILA rate.

      Calculation: For example, based on the rates for 8,022 (7,461 in 24Hr./Foster Care and 561 in Intermittent/Family CILA) people currently in CILA totaling $367,537,124 (Total CILA funding minus current Administration) 10% factor is applied.

      Projection Current
      Funding      		 Incremental
      Increase      		 Total
      Funding      		 FFP Amount
      Current $26.6 M $0.0 M $26.6 M $13.3 M
      Type 1 $9.8 M $36.4 M $18.2 M

    14. Home Modifications

      An allowance of up to $15,000 for minor Home Modifications is currently allowed for existing (not newly constructed) agency controlled (owned) CILA sites. A lower limit of $7,500 is applied when the home is "new construction" and a $5,000 limit is in place for "rented" property. Fire Department requirements have increased significantly over the years requiring CILA sites to adhere to more stringent fire and life safety codes. Most often a fire sprinkler system is required. Even in a newly constructed home, where the sprinkler system can be more readily incorporated into the design and construction, the cost of installing a sprinkler system is typically $30,000. CILA providers are expected to serve individuals with more intense physical disabilities and lower levels of functioning who are not able to meet "prompt" evacuation requirements thus the local fire department or State Fire Marshal's office requires an automated fire sprinkler system.

      Remedy: Add a one-time billing code of 53F for required Fire Department Modifications such as sprinkler systems, fire doors, fire alarms, and fire windows. Eliminate the $7,500 limit for agency controlled new construction CILA sites. Changes to the Provider Waiver Manual will be needed. Make the 53F allowance a minimum $30,000 in addition to the $15,000 allowance for other home modifications.

      Calculation: Based on 50 requests submitted during FY08 for home modifications from CILA providers for required Fire Department modifications.

      Projection Current
      Funding      		 Incremental
      Increase      		 Total
      Funding      		 FFP Amount
      Current $0.0 M $0.0 M $0.0 M $0.0 M
      Type 1 $1.5 M $1.5 M $0.8 M

2. Additional Review and Research Recommendations 

This section discusses items for which additional review and research are needed. The presentation is organized broadly including topics related to staffing, transportation, and other/miscellaneous.

  1. Assessment Instruments, Services Planning, and Staffing

    Accurate, appropriate, reliable, and objective assessment tools are fundamental to establishing individualized staffing and funding levels for CILA supports and services. It is imperative that efforts are made to employ or construct or adapt diagnostic and assessment instruments that can be properly and objectively used to accurately and reliably assess or measure an individual's needs both by type (i.e., medical, personal care, behavioral, etc.) and by relative degree (i.e., health risk, degree of dependence, intensity, severity, etc.). Ideally, with such tools, the CILA rate methodology can be modified to carry out its role and function to distribute whatever funding is available in an equitable manner. In addition, with such tools, needs can be identified and a determination made of the extent to which they are or are not being addressed by current funding methods, programs, and supports. Assessment tools should complement and be in addition to person-centered planning or individualized support budgeting approaches.

    Having the instrumentation to reliably determine support needs, such as adequate staffing or additional supports for basic self-expression and joining in and being a member of one's community, as well as for addressing medical, personal care, or behavioral needs, is fundamental to evaluate, identify, and provide the type and level of resources needed for these supports.

    The Work Group has frequently discussed the need to have uniform, accurate, appropriate, reliable, and objective assessment tools and processes regarding identifying and addressing individualized needs through the rate.

    It is imperative that efforts are made to employ or construct or adapt diagnostic and assessment instruments that can be properly and objectively used to accurately and reliably assess or measure one's needs in the following areas and to determine funding the specialized supports discussed below.

    The reader is referred to the Statewide Advisory Council Rate Committee Interim Report for additional discussion regarding addressing specialized support needs including medical, behavioral, physical/personal care, ambulatory assistance, and alternative communication needs.

  2. Individual Staff Time Allowance

    For people served in CILA there are times when a 1 to 1 staff is necessary to accompany the person to appointments, complete programming goals and objectives, and involve the person in the community in which they live. The current CILA staff methodology does not factor any staff time for these activities beyond the base staff ratios corresponding to the individual's ICAP score and their Individual Services Plan.

    Remedy: Review information to determine the extent of the issue.

    Criteria: Identify threshold criteria and standardized measure to implement any recommended methodology change.

    Evaluate: Determine the cost of any recommended change to methodology.

  3. Miscellaneous Consultants

    The Miscellaneous Consultant Allowance in the CILA Model reimburses for services necessary to provide assessments and develop therapy plans. This allowance has only received periodic COLA increases since the inception of the model, which it is believed has not kept pace with the actual cost of operation.

    Remedy: Although it has been discussed that the Consultant Allowance could be updated based on raising the current annual amount by factors related to the Employment Cost Index, it is currently thought that a more definitive approach would be to identify the types of consultants being used to determine an appropriate current value and/or an index could be used to update the allowance on an annual basis.

    Review: It is recommended that the CILA Rate Work Group conduct a study or evaluation of this issue.

    Criteria: Identify threshold criteria and standardized measure to implement any recommended methodology change.

    Evaluate: Determine the cost of any recommended change to methodology.

  4. CILA Vacancies

    Currently there is no vacancy factor provision in the CILA rate methodology for unoccupied beds. The gap between when a person leaves a CILA and the replacement arrives takes time that is not funded. Some of the costs to operate the CILA site, chiefly staff, continue even though revenue has decreased due to the vacancy. The number of current CILA vacancies is not known but anecdotally it is a problem for some providers. Discussions about filling vacancies or other remedies have noted a trend for individuals to move from larger state-operated and private institutions to other, smaller settings and other services. Although some individuals may seek adult home-based or intermittent CILA services, others will seek 24-Hour CILA supports. These trends could ameliorate the vacancy issue. It has been proposed that a vacancy factor could be developed or that an adjustment to setting size could provide some relief.

    Remedy: Adopt a vacancy factor that is built in to the residential CILA rate to cover the gap.

    Review: It is recommended that the CILA Rate Work Group conduct a study or evaluation to review vacancy information to determine the extent of the issue and potential remedies.

    Criteria: Identify threshold criteria and standardized measure to implement any recommended methodology change.

    Evaluate: Determine the cost of any recommended change to methodology.

  5. Transportation-Related

    The Work Group is in agreement that the CILA rate model reimbursement for Transportation under-represents the costs for the purchase, maintenance, and operation of large and small vehicles to transport either ambulatory or non-ambulatory individuals. In addition, a significant non-reimbursed cost is incurred in the time and mileage associated with staff that travel among CILA and day program locations.

    1. Reimburse Staff Transportation

      QMRPs, Nursing staff, and supervisors/house managers typically move among different C ILA settings throughout their shift. Currently this staff time and the cost of transportation (e.g., mileage) are not reimbursed in the CILA rate methodology.

      Remedy: Develop and include an allowance for an agency to reimburse staff transportation for costs incurred by staff required to travel to, from and between CILA sites.

      Review: It is recommended that the CILA Rate Work Group continue its review of this issue and perhaps conduct a study or evaluation of this aspect of CILA staffing to determine the extent and prevalence of this issue.

      Criteria: Identify threshold criteria and standardized measure to implement any recommended methodology change.

      Evaluate: Determine the cost of any recommended change to methodology.

    2. Vehicle Purchase/Rental Allowance

      Transportation funding in CILA is currently based on an assumption about the cost of a minivan or passenger car financed over 5 years at 8% interest. In this manner, the rate methodology funds a replacement vehicle every 5 years. The rate is capped to be spread across a minimum of four persons. Assumptions about the number of passengers that can be transported have also been questioned. The discussion has revolved around how many individuals are living together, or are transported together, and whether or not everyone is ambulatory.

      Remedy: Develop and adopt different Vehicle Purchase / Rental Allowance levels depending upon the size of the CILA site (i.e., 1-4; 5-6; 7-8). Update on an annual basis the reimbursement allowance level based on the index.

      Review: It is recommended that the CILA Rate Work Group conduct a study or evaluation of this issue.

      Criteria: Identify threshold criteria and standardized measure to implement any recommended methodology change.

      Evaluate: Determine the cost of any recommended change to methodology.

    3. Vehicle Mileage Allowance

      Currently, the CILA model reimburses mileage at $0.37 per mile for 10,000 miles annually. The rate is capped to be spread across a minimum of four persons. It has been questioned whether there are differences in travel depending on the size of the CILA setting. The reader should note that this item is somewhat related to the recommendation found in Section 1, item 8 above but here the focus is on the assumptions about miles traveled and number of persons traveling.

      Remedy: Develop and adopt different Vehicle Mileage Allowances depending upon the size of the CILA site (i.e., 1-4; 5-6; 7-8). Update on an annual basis the reimbursement allowance level based on the index.

      Review: It is recommended that the CILA Rate Work Group conduct a study or evaluation of this issue to determine if it is an issue.

      Criteria: Identify threshold criteria and standardized measure to implement any recommended methodology change.

      Evaluate: Determine the cost of any recommended change to methodology.

    4. Non-Ambulatory Vehicle Lift and Modifications Allowance

      Currently, the Non-Ambulatory Vehicle Lift and Modifications Allowance is only granted in an individual's rate when that person is designated as non-ambulatory. The rate is capped to be spread across a minimum of four persons. This does not fund the cost of the modifications necessary for non-ambulatory vehicle capabilities unless everyone at the site is designated as "non-ambulatory." When only one or two individuals are non-ambulatory only a fraction of the cost of the modifications is funded.

      Remedy: Change or incorporate the "Non-Ambulatory" Calculation for everyone living at a CILA site when non-ambulatory transportation is needed.

      Review: It is recommended that the CILA Rate Work Group conduct a study or evaluation of this issue.

      Criteria: Identify threshold criteria and standardized measure to implement any recommended methodology change.

      Evaluate: Determine the cost of any recommended change to methodology.

  6. Other/Miscellaneous

    1. Telephone Allowance

      The Telephone Allowance in the CILA Model has only received periodic COLA increases since the inception of the model, which it is believed has not kept pace with the actual cost of operation. In recent years, many things have changed about telephone services in the home including the type of service (limited, local versus other plans) and the cost of services.

      Remedy: Identify and adopt a BLS Consumer Price Index (CPI) series to update the Telephone Allowance. Or, allow a basic charge monthly charge and change calculation to spread basic telephone cost between all people at the site. Update on an annual basis the reimbursement allowance level based on the index.

      Review: It is recommended that the CILA Rate Work Group conduct a study or evaluation of this issue.

      Criteria: Identify threshold criteria and standardized measure to implement any recommended methodology change.

      Evaluate: Determine the cost of any recommended change to methodology.

    2. Property and Building Insurance

      The HUD FMR system is a rental equivalence system and, as such, the HUD FMR values used in the CILA rate model already includes the landlord/owner's costs for property and building insurance to cover losses. However, the individual renting the property is not covered for personal property losses in the HUD FMR so the Property and Building Insurance Allowance in the CILA Model was developed. This allowance has only received periodic COLA increases since the inception of the model and it is not known if this has kept pace with the actual cost of renter's insurance.

      Remedy: The Property and Building Insurance Allowance could be revised to reflect more current costs of renter's insurance. In addition, this allowance should be annually updated based on an appropriate CPI series or other index.

      Review: It is recommended that the CILA Rate Work Group conduct a study or evaluation of this issue.

      Criteria: Identify threshold criteria and standardized measure to implement any recommended methodology change.

      Evaluate: Determine the cost of any recommended change to methodology.

    3. Maintenance and Housekeeping Allowance

      The Maintenance and Housekeeping Allowance in the CILA Model has only received periodic COLA increases since the inception of the model, which it is believed has not kept pace with the actual cost of operation.

      Remedy: Identify and adopt an Index to update the Maintenance Allowance. Update on an annual basis the reimbursement allowance level based on the index.

      Review: It is recommended that the CILA Rate Work Group conduct a study or evaluation of this issue.

      Criteria: Identify threshold criteria and standardized measure to implement any recommended methodology change.

      Evaluate: Determine the cost of any recommended change to methodology.

    4. Food Allowance

      The Food Allowance in the CILA Model has only received periodic COLA increases since the inception of the model, which it is believed has not kept pace with the actual cost of operation.

      Remedy: It has been proposed that the Food Allowance could be updated by adding $0.50 per meal or $1.50 per day. The new daily food allowance would be $8.88. It has also been proposed that an index series, possibly from the CPI or from the USDA Food Cost Index could be used to update on an annual basis the reimbursement allowance level.

      Review: It is recommended that the CILA Rate Work Group conduct a study or evaluation of this issue.

      Criteria: Identify threshold criteria and standardized measure to implement any recommended methodology change.

      Evaluate: Determine the cost of any recommended change to methodology.

    5. Non-Food Allowance

      The Non-Food Allowance in the CILA Model covers inedible consumable household supplies. The allowance has only received periodic COLA increases since the inception of the model, which it is believed has not kept pace with the actual cost of operation.

      Remedy: Identify and adopt an Index to update the Non-Food Allowance. Update on an annual basis the reimbursement allowance level based on the index.

      Review: It is recommended that the CILA Rate Work Group conduct a study or evaluation of this issue.

      Criteria: Identify threshold criteria and standardized measure to implement any recommended methodology change.

      Evaluate: Determine the cost of any recommended change to methodology.

    6. Other Supplies Allowance

      The Other Supplies Allowance in the CILA Model covers materials and supplies used for LI programmatic purposes. The allowance has only received periodic COLA increases since the inception of the model, which it is believed has not kept pace with the actual cost of operation.

      Remedy: Identify and adopt an Index to update the Other Supplies Allowance. Update on an annual basis the reimbursement allowance level based on the index.

      Review: It is recommended that the CILA Rate Workgroup conduct a study or evaluation of this issue.

      Criteria: Identify threshold criteria and standardized measure to implement any recommended methodology change.

      Evaluate: Determine the cost of any recommended change to methodology.

    7. Damage / Depreciation / Replacement Allowance

      Currently there is no allowance in the CILA methodology to cover Damage / Depreciation / Replacement Factor for household furnishings, equipment and appliances, furniture and household items such as sheets and towels in CILA.

      Remedy: Develop and adopt a Damage / Depreciation / Replacement allowance.

      Review: It is recommended that the CILA Rate Workgroup conduct a study or evaluation to review information to determine the extent of the issue.

      Criteria: Identify threshold criteria and standardized measure to implement any recommended methodology change.

      Evaluate: Determine the cost of any recommended change to methodology

    8. Utility Allowance

      The Utility Allowance in the CILA Model is currently used for 1 and 2 person CILA sites only. This allowance has only received periodic COLA increases since the inception of the model, which it is believed has not kept pace with the actual cost of operation.

      Remedy: Identify and adopt an Index to update the Utility Allowance for 1 & 2 bed CILA sites. Only applicable if the HUD FMR tables are not adjusted to cover 1 and 2 bed CILA sites as recommendation #7 in Section 1 above.

      Calculation: None at this time. If item #7 in the completed review findings of this paper is adopted, this item would not be applicable as the HUD FMR includes Utility Allowance.