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DHS COVID-19 PROVIDER GUIDANCE // OLTL

Transition Plan to Phase Out Temporary Changes to the Community HealthChoices 1915(c) Waiver

Issued: June 25, 2020; Updated: March 25, 2021

Note:  This transition plan is intended to be used in conjunction with the March 25, 2021 Temporary Changes to the Community HealthChoices 1915(c) Waiver- (Revised) Guidance.  That guidance contains complete descriptions of the temporary changes and guidelines for implementation.
 

The Centers for Medicare & Medicaid Services (CMS) approved temporary changes to the Community HealthChoices (CHC) waiver beginning March 6, 2020 in response to the COVID-19 pandemic.  Approval of these changes is covered under Appendix K, Emergency Preparedness and Response, which states may use during emergency situations to request amendments to their approved waivers.  These changes addressed potential staffing shortages and the need for service provision not included in approved service descriptions to ensure participant health and safety needs could be accommodated for the duration of the COVID-19 statewide emergency.   As described in the Temporary Changes to the CHC Waiver (Revised) Guidance, the changes were not intended to apply to all participants nor to be considered across-the-board changes that must be implemented for each participant.  These flexibilities were to be evaluated on a case-by-case basis in coordination with the CHC Managed Care Organizations (MCOs).   CMS recently approved an amendment to Appendix K which allows some flexibilities to continue until six months after the end of the federal public health emergency, or another date determined by the Office of Long-Term Living.

As the number of COVID-19 cases in each county continues to fluctuate, the temporary waiver changes can be phased out in some cases, provided participants can be safely served and providers and service coordinators are taking proper precautions; however, in other cases the temporary waiver changes may need to continue based on the circumstances present.  The chart below provides guidance to the CHC-MCOs on the flexibilities that are still available.  This guidance replaces and rescinds the Appendix K transition plan guidance issued on January 4, 2021.  

The following flexibilities are available until six months after the end of the federal public health emergency, or another date determined by OLTL.  The federal public health emergency is set to expire on April 21, 2021; however, it's possible the federal government will decide to extend the emergency beyond April.

Appendix K FlexibilityGuidance
Personal Protective Equipment (PPE)PPE such as gloves, gowns and masks for participant use can be obtained as Specialized Medical Equipment and Supplies if no other source is available. PPE may be added to a participant's person-centered service plan (PCSP) without the need for a comprehensive needs assessment or a physician's prescription.
Service LimitationsAdult Daily Living – Long-Term or Continuous Nursing may be provided temporarily as a separate service at the same time that Adult Daily Living Services are provided to ensure participant health and safety needs can be met.  This flexibility can be implemented with prior approval of the CHC-MCO if the need for long-term or continuous nursing is a result of COVID-19.     
Residential Habilitation – Long-Term or Continuous Nursing may be provided temporarily as a separate service at the same time that Residential Habilitation is provided to ensure participant health and safety needs can be met.  This flexibility can be implemented with prior approval of the CHC-MCO if the need for long-term or continuous nursing is a result of COVID-19 and with prior approval of the CHC-MCO.  
RespiteRespite in a licensed facility may be extended beyond 29 consecutive days with prior approval of the CHC-MCO.  The need for additional Respite must be a result of COVID-19 and necessary to meet the participant's health and safety needs.
Personal Assistance Services (Agency and Participant-Directed) and Participant-Directed Community Supports –
 
On a case by case basis, spouses, legal guardians, and persons with power of attorney may serve as paid direct care workers.
These situations must be reviewed and approved by OLTL on a case by case basis.
This flexibility is only available when scheduled workers are not available due to COVID-19 and the participant's emergency backup plan cannot be implemented. Spouses, legal guardians and persons with power of attorney will be allowed to serve as paid direct care workers only until a replacement direct care worker is in place and in no case beyond the duration of the COVID-19 emergency declaration. 
 
This temporary flexibility does not apply in circumstances where a participant or their representative refuses services due to COVID-19 safety concerns despite the direct care worker(s) being available to provide services.  
 
Expanded Settings Where Services May Be Provided

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Residential Habilitation and Structured Day Habilitation Services may be provided to participants by Residential Habilitation and Structured Day Habilitation staff in private homes.

When services are provided in the Residential Habilitation or Structured Day setting, providers are required to evaluate the setting's space  considerations, participant and staff numbers, work flow and develop a plan to support social distancing, arrivals and departures, lunch, activities space, and any other considerations unique to the space or program activities for individuals and staff at all times when present at the setting.  Based on the evaluation, providers must develop a plan for transitioning participants back to Residential Habilitation and Structured Day Habilitation settings.  Examples of the elements to be included in the plan are as follows:

    • Alternating days for participants
    • Alternating arrival and departure times
    • Reducing the number of participants
    • Re-arranging program space so that participants are a minimum 6 feet apart
    • Erecting barriers, tape, or other visual indicators to support social distancing measures

Providers must adhere to the cleaning and disinfecting guidelines issued by the Centers for Disease Control and Prevention (CDC).  In addition, Residential Habilitation providers should continue to monitor and adhere to the guidance issued by the Office of Long-Term Living (OLTL) which pertains to Personal Care Homes and Assisted Living Residences as well as the CDC guidance around congregate settings and direct service providers.

**New flexibility as of 12/7/2020**
 
Adult Daily Living Services may be provided to participants by Adult Daily Living staff in private homes.

When services are provided in the Adult Daily Living setting, providers should follow the guidance for reopening and operating Older Adult Daily Living Centers during COVID-19 issued by the Department of Aging and the guidance for temporary closure of older adult daily living centers issued by the Office of Developmental Programs.

** New flexibility as of 12/7/2020**
 
Adult Daily Living Services may be provided remotely using phone or video conferencing. 

Additional guidance can be found in the January 4, 2021 Temporary Changes to the Community HealthChoices 1915(c) Waiver (Revised) Guidance.

Structured Day Habilitation may be provided remotely using phone or video conferencing to new participants and participants who received the services face-to-face prior to the COVID emergency declaration.

Structured Day Habilitation services may transition to face-to-face whenever possible.  When services are provided in the  Structured Day Habilitation setting, Structured Day Habilitation providers are required to evaluate the setting's space considerations, participant and staff numbers, work flow and develop a plan to support social distancing, arrivals and departures, lunch, activities space, and any other considerations unique to the space or program activities for individuals and staff at all times when present at the setting.  Based on the evaluation, providers must develop a plan for transitioning participants back to Structured Day Habilitation settings.  Examples of the elements to be included in the plan are as follows:

    • Alternating days for participants
    • Alternating arrival and departure times
    • Reducing the number of participants
    • Re-arranging program space so that participants are a minimum 6 feet apart
    • Erecting barriers, tape, or other visual indicators to support social distancing measures

Providers must adhere to the cleaning and disinfecting guidelines as well as the general guidelines for businesses and employers and direct service providers issued by the CDC.

Cognitive Rehabilitation and Behavior Therapy may be provided remotely using phone or video conferencing to new participants and participants who received the services face-to-face prior to the COVID-19 emergency declaration.  Participants may receive services remotely via phone or video conferencing for the purpose of social distancing within an outpatient setting AND when it has been determined that the participant can actively participate and benefit from receiving the service remotely.

Cognitive Rehabilitation and Behavior Therapy may transition to face-to-face sessions where possible.  Providers must follow and maintain safe behavioral practices as defined by the CDC and the Department of Health when doing so.

Counseling Services may be provided remotely using phone or video conferencing.  Participants may receive services remotely via phone or video conferencing for the purpose of social distancing within an outpatient setting AND when it has been determined that the participant can actively participate and benefit from receiving the service remotely. 

Counseling Services may transition to face-to-face sessions where possible.  Providers must follow and maintain safe behavioral practices as defined by the CDC and the Department of Health when doing so.

Modification of Worker QualificationsResidential Habilitation, Structured Day Habilitation Services, Adult Daily Living, and Personal Assistance Services – Individual staff members who are qualified to provide any one of these services may be reassigned to provide Residential Habilitation, Structured Day Habilitation Services, Adult Daily Living, and Personal Assistance Services.
Initial Level of Care Assessments

Assessors must receive education and training from the Independent Assessment Entity on how to evaluate individual risk factors and protect themselves from potential exposure according to the guidance issued by the CDC and the Department of Health

Initial level of care assessments using the FED that take place in the participant's home should be conducted face-to-face when possible.  Assessments may be conducted remotely using phone or video conferencing at the participant's choice or when risk factors may be present in the participant's home.  Assessors must follow the guidance issued by the Independent Assessment Entity for resuming face-to-face assessments and maintain safe behavioral practices as defined by the CDC and the Department of Health when doing so.

Initial level of care assessments using the FED that take place in nursing facilities should be conducted remotely using phone or video conferencing.  Assessors should follow guidance around visitation in nursing facilities that is issued by the CDC and the Department of Health.

Needs Assessments/ Reassessments

Service Coordinators must receive education and training from the CHC-MCOs on how to evaluate individual risk factors and protect themselves from potential exposure according to the guidance issued by the CDC and the Department of Health.

Annual Reassessments, including the needs assessment, may be conducted face-to-face when possible.  Service Coordinators should maintain safe behavioral practices as defined by the CDC and the Department of Health when doing so.

Reassessments may be conducted remotely using phone or video conferencing at the participant's choice or when the CHC-MCO and/or participant identifies that risk factors may be present.  

Annual reassessments, including the needs assessment, that were delayed beyond the 365th-day must be completed no later than December 31, 2020, which is 6 months after the issuance of the June 26, 2020 transition plan.

Comprehensive Needs Reassessments that are conducted when a participant's needs change, when the participant requests a reassessment or following trigger events may be conducted face-to-face when possible.  Service Coordinators should maintain safe behavioral practices as defined by the CDC and the Department of Health when doing so.

Reassessments may be conducted remotely using phone or video conferencing when the CHC-MCO and/or participant identifies that risk factors may be present.  

Person-Centered Service Planning/Service Coordination

Service Coordinators should monitor participants and PCSPs through face-to-face contacts when possible.  Service Coordinators should maintain safe behavioral practices as defined by the CDC and the Department of Health when doing so. 

When risk factors may be present in the participant's home, Service Coordinators may monitor participants and PCSPs remotely by telephone where face-to-face contacts are usually required. Service Coordinators are encouraged to contact participants frequently to ensure participants' needs are being met during the COVID-19 emergency declaration.

Person-Centered Planning Team (PCPT) meetings and PCSP development should be conducted face-to-face if possible.  PCPT meetings and PCSP development may be conducted remotely using telecommunications when risk factors may be present in the participant's home.  Members of the PCPT, determined at the discretion of the participant, may also participate remotely using phone or video conferencing.  Service Coordinators and any other members of the PCSP team should maintain safe behavioral practices as defined by the CDC and the Department of Health when doing so.
Retainer Payments to Address Emergency Related IssuesDuring the COVID-19 emergency, retainer payments to direct care workers providing Personal Assistance Services in both the agency and participant-directed models may be made when the participant is hospitalized, absent from their home, or in isolation and unable to receive services due to COVID-19. Personal Assistance Services retainer payments may not exceed 15 days – the number of days for which OLTL authorizes a payment for "bed-hold" in nursing facilities.

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