This information bulletin addresses the Department of Human Services (DHS), Division of Developmental Disabilities (DDD) amendment to the process of requesting funding for additional staff support for individuals who receive Community Integrated Living Arrangement (CILA) and Developmental Training services. Providers that need to request additional staff support for individuals who exhibit temporary, long-term exceptional, extraordinary medical, physical, or behavioral needs will be required to use this new process.
When authorized by DDD, the additional staff supports will be delivered by a trained staff person on a one-to-one basis for specific tasks, duties and responsibilities required by the individual. All additional staff supports should be considered time-limited in duration. DDD-funded one-to-one staff supports are not to supplement staffing levels within the (CILA) or Developmental Training services.
Additional staff support requests shall be submitted in an abbreviated request process for short term duration, temporary conditions that are likely to improve or end. If necessary, an abbreviated request can be submitted prior to a detailed request for long term duration of additional staff support needs.
This information bulletin will outline the requirements and process for a service provider to request, deliver, record, report and renew, if necessary, additional staff supports for people who receive Community Integrated Living Arrangement (Program 60D-CILA) or Developmental Training (Programs 31A or 31U - DT) services.
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Definition of the Need for Additional Staff Supports for CILA and Day Training
The DDD may award residential and/or developmental training additional staff supports to eligible individuals who are authorized for, enrolled in, and receive services under the DHS' bill codes of 60D CILA and/or 31A or 31U DT services and who have short term, temporary condition that is likely to improve or end, or long-term exceptional and/or extraordinary medical and/or behavioral conditions or issues that require additional staff supports for an extended period of time. All additional staff supports are to be delivered on a one-to-one basis.
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Initial and Long-Term Provider Applications for Additional Staff Supports for CILA and Developmental Training
Beginning July 1, 2012, service providers may make an initial request for short term or time-limited duration additional staff supports by submitting a brief explanation of the individual's medical, physical, and/or behavioral needs that require one-to-one staff supports. The narrative should be concise in explanation of the individual's need and specify the duties and responsibilities the additional staff will be performing. Initial requests should be no longer than one typed page.
An initial request can also be submitted for the immediate staff supports needed for long term or extended time duration needs of an individual to assist the individual while a provider is collecting and compiling the required information for a long term / extended duration additional staff support request.
All additional staff support requests (initial and long-term) are submitted to the appropriate network facilitator or Bureau of Transition Services (BTS) representative. CILA and Developmental Training additional staff support hours are to assist service providers to meet the needs of individuals who experience temporary or long-term exceptional or extraordinary medical, physical or behavioral issues.
The CILA and Developmental Training provider can apply to the DDD for additional staff supports for long-term exceptional and/or extraordinary medical and/or behavioral conditions or issues by submitting one of the below:
- The Determination of Medical Needs Questionnaire (doc) with required supporting documentation for an individual's Medical or physical issues
- The Determination of Behavioral Needs Questionnaire (doc) with required supporting documentation for an individual's behavioral issues.
Both questionnaires require support documentation and synthesized data to substantiate the individual's long-term exceptional or extraordinary medical or behavioral need in order to be considered a complete request.
Note: Any request submitted with un-synthesized data will be determined as incomplete. Incomplete requests shall be returned to the requesting service provider. Once the required information is obtained, the requesting service provider may resubmit the request to the Network Facilitator or BTS Representative.
The DDD shall evaluate all complete and properly submitted requests and respond with a written award or denial letter to the requesting service provider.
After an initial request and prior to submitting an additional staff support request for an individual's long-term exceptional and/or extraordinary behavioral needs, the service provider will be required to work with the local Clinical and Administrative Review Team (CART) and/or Service Support Team (SST) to develop a behavior plan that includes strategies to resolve the issues before requesting further additional staff supports.
After an initial request and prior to submitting an additional staff support request for an individual's long-term exceptional and extraordinary behavioral needs, initiation of psychiatric and behavior analyst services is expected.
Additional staff support requests for behavioral issues also require the submission of synthesized data to show evidence of increased frequency and severity of the maladaptive behaviors within the recent six-month period despite psychiatric or behavioral treatments. Requests which do not include documentation of psychiatric or behavior analyst services or synthesized data will not be processed and will be returned to the service provider as incomplete.
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Eligibility Criteria for Additional Staff Supports for CILA and Developmental Training
An individual can be considered eligible for additional staff supports when the individual has a temporary or long-term exceptional or extraordinary medical, physical or behavioral issues.
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Medical Issues could include, but are not limited to:
- Short-term duration, temporary condition that is likely to improve or end
- Recovery and rehabilitation from major bone fractures (e.g. hip, pelvis, spine, femur, tibia, fibula) that require additional personal assistance
- Post hospital or convalescent care discharge
- Post surgical convalescent care within the CILA
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Long-term duration, chronic condition that is unlikely to improve or end:
- End stage COPD
- Hospice care
- Diabetes requiring insulin use
- Severe medical complications of diabetes, dementia/Alzheimer's
- Kidney failure requiring dialysis
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Required one-to-one staff duties for medical issues are limited to:
- Monitoring a severe medical condition
- Monitoring a person who requires sedation prior to or following medical appointments, treatments, and procedures
- Interactions with outside medical personnel and professionals
- Taking the individual to a high number of medical visits or treatments
- Frequent or complicated medical treatments
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Physical issues could include, but are not limited to:
- Individuals with hearing or vision impairment who communicate through sign or by using tactile language skills
- Individuals with cerebral palsy or severe physical limitations who require hand-over-hand assistance
- Individuals who are totally dependent for another person's assistance with physical transfers, toileting/incontinence, bathing, feeding, and/or mobility
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Required one-to-one staff duties for physical issues are limited to:
- Aiding individual in communication program
- Following recommendations for therapy activities given by PT, OT; ST
- Performing daily self-care for individuals who are unable to assist
- Ensuring skin integrity through adherence to repositioning schedule for individuals unable to move themselves
- Assisting individual to maintain adequate nutrition and hydration for those dependent on staff for this duty
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Behavioral Issues could include, but are not limited to the following:
- Individuals with severe SIB who need intense monitoring or interventions to prevent harm
- Individuals with a history of inappropriate sexual advances toward others
- Individuals with physical aggression who require immediate interventions to prevent harm
- Individuals with elopement who live around busy traffic areas
- Individuals with Pica
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Required one-to-one staff duties for behavioral issues are limited to:
- Implementation of appropriate behavior management interventions as set forth in individual's behavior intervention plan
- Training of individual to utilize positive replacement behaviors in accordance with behavior intervention plan
- Prevention of inappropriate reinforcement of maladaptive behaviors by others who may not be adhering to current behavior intervention plan.
After an initial request and prior to submitting a additional staff support request for an individual's long-term exceptional or extraordinary behavioral needs, initiation of psychiatric or behavior analyst services is expected prior to submitting a request for additional staff supports for behavioral issues.
Additional staff support requests for behavioral issues also require the submission of synthesized data to show evidence of increased frequency and severity of the behavior within the recent six-month period, despite psychiatric or behavioral treatments.
After an initial request, the service provider will be required to work in partnership with the local Clinical and Administrative Review Team (CART) or Service Support Team (SST) to develop a behavior plan, which includes strategies to resolve the issues prior to requesting further additional staff supports.
Requests that do not include documentation of psychology or behavior analyst services, synthesized data, CART or SST involvement, will not be processed and will be returned to the service provider as incomplete.
The DDD will consider funding of CILA or Developmental Training additional staff supports when the request is determined to be necessary for the individual or other individual's safety and well being.
When authorized, additional staff supports for CILA or Developmental Training requests must be:
- Provided by a trained staff person who is specifically assigned to the individual approved for one-to-one staff supports.
- Assigned one-to-one staff person cannot have or perform other duties or responsibilities beyond the one-to-one for any time which is to be billed for one-to-one supports.
- Assigned one-to-one staff person must document the completion of assigned one-to-one duties and responsibilities in the individual's record for any amount of time that is billed for one-to-one supports.
- One-to-one supports are to be delivered within arm's length for the individual with temporary or long-term exceptional or extraordinary needs as specified above.
The DDD will NOT fund CILA and Developmental Training additional staff support when the staff's responsibilities are to:
- Be available for "what if" scenarios, conditions and issues
- Keep the individual engaged in activities of daily living and community integration
- Supplement the staffing levels funded by the DDD or scheduled by the service provider within the Community Integrated Living Arrangement (CILA) or Developmental Training services
- Perform routine tasks or complete duties expected of direct care staff to accomplish in the provision of CILA or Developmental Training services.
- Perform general or regular staff assistance with the individual to complete or document:
- goals and objectives
- run assigned programs
- activities of daily living
- community integration
- take or administer medication
- routine daily activities
- duties and responsibilities in the individual's ISP
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Evaluation of CILA or Developmental Training Additional Staff Support Requests
The DDD's review of an initial or long-term CILA or Developmental Training additional staff support request shall entail evaluating the following:
- Exceptional, extraordinary medical, physical, or behavioral needs of the individual served.
- Frequency and severity of the individual's temporary or long-term exceptional or extraordinary needs.
- Projected continuation of the individual's exceptional or extraordinary needs.
- Assessments, evaluations, reports, test results or recommendations by professional staff and/or consultants.
- Interventions and programming previously implemented by the service provider to address the individual's exceptional or extraordinary needs.
- The individual's response to programming previously implemented by the service provider to address the individual's exceptional or extraordinary needs.
- Recommendations of the CART or SST
- Duties and responsibilities assigned to the CILA or Developmental Training one-to-one staff support person.
- Time-of-day the additional staff support person will be required to provide one-to-one support services.
When reviewing a request for long term additional staff supports, the DDD will evaluate the service provider's delineation of specific duties, responsibilities and time-of-day for one-to-one staff supports and assess whether the DSPs duties and responsibilities are quantifiable and measurable in detail.
The DDD will not count or give credit when calculating the award of additional 53R/D long term staff support hours when One-to-one staff support duties, responsibilities or time-of-day that do not specify a quantifiable or measurable tasks.
The DDD will also assess the service providers psych and/or behavior analyst services, synthesized data showing evidence of increased frequency and severity of the behavior within the recent six-month period despite psychiatric or behavioral treatments and the service providers work with the local Clinical and Administrative Review Team (CART) or Service Support Team (SST) to develop and implement a Behavior Plan.
The DDD will also assess the strategies to resolve the issues prior to requesting further additional staff supports. Requests which are determined to have not satisfactorily met the above evaluation criteria will not be processed and will be returned to the service provider as incomplete.
Upon approval by the DDD of either initial and/or long term one-to-one staff support, the service provider will be responsible to ensure documentation is recorded to verify the provision of one-to-one support services. The DDD shall also review initial and/or long term one-to-one staff support through, but not limited to, individual progress notes, staff schedules, agency payroll records, follow-up reports from professionals, consultants, ISSA, CART, and SST.
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Calculating and Awarding of CILA or Developmental Training Additional Staff Supports
When approved, the DDD will issue awards for initial staff support requests of up to 500 hours for 53R and/or 53D up to 115 hours.
The DDD will no longer incorporate additional staff support hours into an individual's CILA 60D or Developmental Training 31A/U rate. Individuals whose CILA and/or Developmental Training additional staff support hours have previously been included in their 60D or 31A/U rate will have those additional staff support hours switched to the Purchase-of-Service 53R/D authorization and billing process as of July 1, 2012.
A review date will also be established to at the time the additional staff support hours are switched. It will be the service provider's responsibility to complete and submit a request for long term staff supports per the process detailed in this information bulletin to their network facilitator or BTS representative to continue additional staff supports after the scheduled review date.
The DDD will calculate long term one-to-one staff supports by evaluating approvable individual staff support hours as requested and detailed by the service provider. Approved individual staff support hours as determined by the DDD will be added together to determine the person's total long-term individual staff support need.
An individual in CILA may have available individual staff support hours already funded in their CILA rate as determined by the CILA Model. The CILA Model currently calculates a number of staff support hours for an individual for Prime, Non-Prime, and Night shift.
The Prime, Non-Prime, and Night shift time periods consist of funding for base staff support coverage and individual staff support time to meet the needs of the individual. The base staff level in a CILA is 1,733 DSP hours for any person being served in a CILA site with a capacity of four or greater. The individual's DSP staff hours as determined by the CILA Model above the base staff level are the individual staff support hours already included in the individual's CILA funding.
If the approvable individual staff support hours exceed the individual staff supports already funded through the CILA Model the additional staff support hours will be awarded through the 53R bill code process. Additional staff support hours will only be awarded when the approved individual staff support hours exceed the individual staff supports funded through the CILA Model. Approvable additional staff support hours determined to be at or below the individual staff supports funded through the CILA Model will be considered already funded.
Example: An individual is determined by the DDD as needing 600 individual support staff hours based on the request for long-term additional staff supports submitted by the provider agency. The person lives in a four-person CILA with an ICAP of 36. The CILA Model calculates 2,597 DSP staff hours for Prime, Non-Prime, and Night Shift staff as this person's CILA funding. This person's portion of base staff coverage is 1,733 DSP hours. This leaves 864 DSP hours (2,597-1,733=864) available for approvable individual staff supports. In this example the CILA Model funding shows the individual support staff needs of this person are already funded by the CILA Model and no additional staff supports would be awarded.
The maximum award for all additional staff supports for an individual in 31A/U DT services cannot exceed 1,100 hours in any State fiscal year. Individuals who are authorized for 31U DT services as a part of their Home-Based Support Services (HBS) must document in their HBS service AND financial plans the utilization of 53D supports prior to the DDD awarding 53D supports or a service provider delivering or billing 53D supports.
When approved by the DDD, long term additional CILA or Developmental Training one-to-one staff support hours will be:
- Awarded through the 53R/D bill code process only.
- The approval for long term 53R/D hours will be set to cover a minimum period of time.
- Approved 53R/D hours will reset at the end of the State fiscal year.
The DDD will not award additional CILA or Developmental Training long term one-to-one staff support hours if the service provider uses or bills the approved 53R/D hours before the minimum time period expires.
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Service Reporting and Billing CILA or Developmenal Training Additional Staff
Billing for CILA or Developmental Training additional staff support hours can be entered in ROCS via 53R/D after the service has been provided to the individual. Billing for additional staff support prior to the delivery of the services will be rejected.
Providers billing for 53R/D hours must develop and maintain a unique four (4) digit identifier for the CILA or Developmental Training additional staff support staff to identify the person who delivered the service. This unique four (4) digit identifier must be entered in ROCS when billing 53R/D. ROCS will reject 53R/D billing for all hours that do not have the CILA and/or Developmental Training one-to-one staff support staff identifier entered at the time of data submission.
The individual must be reported as "P" for present in CILA for 53R hours to be accepted in the ROCS billing system. Billed 53R hours on a reported bed hold or day absent in 60D CILA will result in the 53R billing being rejected for the whole month. The provider will have to review its billing, correct any mistakes, and rebill all the 53R for the month.
The individual must have reported 31A or 31U hours for 53D hours to be accepted in the ROCS billing system. Billed 53D hours cannot exceed the billed 31A/U hours for any given day. Billed 53D hours over the reported 31A/31U hours will result in the 53D to be rejected for the whole month. The provider will have to review its billing, correct any mistakes, and rebill all the 53D hours for the month. The provider cannot bill for 53R/D hours until after the one-to-one support has been provide for the individual.
A service provider delivering 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 assure to not bill more 53D staff supports than are documented in the individual's HBS service AND financial plans.
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Monitoring of CILA or Developmental Training Additional Staff
The DDD shall systemically evaluate billing of 53R/D. The evaluation of 53R/D billing could require service providers to supply documentation of the provision of CILA and/or Developmental Training one-to-one staff support services.
The service provider will be responsible to ensure documentation of one-to-one staff support is recorded to verify the provision of individual staff support service. The DDD may evaluate one-to-one staff support 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
Service providers found inappropriately billing 53R/D will result in the DDD recovering payments for undocumented one-to-one staff support hours. A service provider who inappropriately bills for 53R/D may also be sanctioned by the DDD. Sanctions may range from prohibited future billing of 53R/D to revocation of the service provider's CILA license, DT certification, and/or contract with the Department of Human Services.
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Expiration and renewal of CILA or Developmental Training Long-Term Additional Staff Supports
The award of CILA and/or Developmental Training additional staff support is limited to the number of billable hours as specified on the DDD award as specified on their rate sheet and/or award memorandum. Awarded additional staff support hours either expire at the end of the state's Fiscal Year or when all available 53R/D hours have been billed by the provider, whichever occurs first.
Before the end of the award period the service provider believes the individual continues to require CILA or Developmental Training additional staff support services it is incumbent upon the service provider to apply to the DDD's Network Facilitator or Bureau of Transition Services (BTS) Representative for any long term additional staff support services. It is strongly recommended the service provider have their completed request submitted to the Network Facilitator or the BTS Representative 60 days prior to the end of the award period. The DDD will not be responsible for backdating effective dates or any lapse in funding of additional staff supports while a request is being processed.
Individuals whose CILA or Developmental Training additional staff support hours have previously been included in their 60D or 31A/U rate will have those additional staff support hours switched to the Purchase-of-Service 53R/D authorization and billing process as of January 1, 2013.
An expiration date for the additional staff supports will also be established at the time the additional staff support hours are switched to the 53R/D bill process. It will be the service provider's responsibility to complete and submit a request for long term staff supports to their network facilitator or BTS representative to continue additional staff supports after the scheduled expiration date.
The DDD will not award additional CILA and/or Developmental Training staff support hours if the service provider uses or bills the approved 53R/D hours before the minimum time period expires.
Effective immediately.
