B. Individual Service Plan (ISP)

1. Service Plans address all participants' assessed needs (including health and safety risk factors) and personal goals, either by the provision of waiver services or through other means.

Activities:
  1. The RRDS meets every potential waiver participant prior to the development of the ISP. This provides the RRDS with information regarding the potential waiver participant's unique strengths and needs. This information is used when the reviews the Initial SP. The information acquired by the RRDS during this interview is documented on a standardized Intake Form which is shared with the selected SC and used to develop the ISP.
  2. The SC works with the waiver participant to establish the ISP, RSP and any Addenda (refer to Appendix C – form C.15). The SP includes the range of services needed by the waiver participant including waiver and non-waiver services. It combines all services needed to address the waiver participant's health and welfare, personal goals, preferences and cultural traditions.
  3. The waiver participant's signature on the SP signifies that he/she has read it or it has been read to him/her and they understand its contents and purpose.
  4. A Plan of Protective Oversight (PPO) (refer to Appendix C – form C.4) is completed with the waiver participant by the SC during the development of the ISP and at each RSP.
  5. The PPO is reviewed with the participant by the SC during the development of an Addendum. Any changes in the PPO will result in the completion of a new PPO for submission to the RRDS with the Addendum. If no changes are indicated, the PPO is signed indicating the contents remain the same and attached to the Addendum.
  6. All SPs are forwarded to the RRDS for final review and approval. The RRDS conducts a comprehensive review of 100% of all SPs assuring the waiver participant's goals and preferences are recognized and the plan meets his/her health and welfare needs.
  7. If the RRDS finds the SP does not reflect the waiver participant's needs and goals, support health and welfare or follow the program's policies, immediate corrective action must be requested from the SC and completed before the SP can be resubmitted to the RRDS for re-review.
  8. If a SP exceeds $300/day, the RRDS sends it to the QMS for review before approval.
  9. Waiver Service providers assess waiver participant satisfaction by conducting annual Participant Satisfaction Surveys and by investigating all complaints/grievances received. These surveys and complaints/grievances investigations will be viewed by DOH during the survey process.
  10. Any calls received regarding the SP by DOH WMS, directly or through the NHTD Complaint Line, or issues raised to DOH WMS during the annual Regional Forums regarding waiver participant SPs, will be directed by DOH WMS to the RRDS. If the issues are of significant concerns and constitutes ad SRI, it must be referred to the QMS for follow up. As a result of the investigation, changes may be required to the SP.
  11. The QMS assures Participant Satisfaction Surveys are conducted annually, analyzing data for waiver provider performance, SP implementation and regional trends. The outcomes of these surveys must be provided to DOH WMS. When individual issues arise as a result of these interviews, the QMS informs the RRDS to assure action is taken to remedy the situation.
  12. During annual random retrospective record review conducted by the QMS and DOH WMS, all approved SPs will be reviewed at a rate of at least five-percent (5%) in Year One of the waiver, two-percent (2%) in Year Two, and one-percent (1%) in Year Three.
  13. The data gathered regarding this assurance must be included in the RRDS and/or QMS Quarterly Reports for review by DOH Waiver Management staff. That staff, in consultation with the QMS and RRDS will evaluate the need to change and/or improve policies/procedures.

2. The state monitors Service Plan development in accordance with its policies and procedures and takes appropriate action when it identifies inadequacies in Service Plan development.

Activities:
  1. The RRDS is responsible to review 100% of all SPs to assure the plans are developed in accordance with waiver participant needs and goals, meet health and welfare, and reflect the policies and procedures of the waiver program. Any discrepancies in the SP must be referred back to the SC by the RRDS for further assessment and/or modification before re-review by the RRDS for approval.
  2. Each SP submitted to the RRDS for review and approval must be signed by the waiver participant to assure the waiver participant has read it or it has been read to him/her and that he/she understand its contents and purpose.
  3. The RRDS assures all SPs over $300/day are reviewed by QMS prior to final approval.
  4. The RRDS examines all SRIs in relationship to the SP to understand if a change in the type or amount of service is needed and works with the SC to assure any immediate needed changes in the SP are made at the waiver provider level.
  5. The SC is responsible to assure that a safe and effective SP is established with the waiver participant's involvement and support. Plans are formulated initially and revised at least every six months or with more frequent Addenda, as needed. The SC must have a tracking system in place to guarantee the timeliness of SPs.
  6. The SC is responsible for facilitating Team Meetings with the waiver participant and all key parties to review the SP for revisions, to ensure the waiver participant is involved and the waiver participant's preferences are reflected in the SP.
  7. The SC submits the SP to the RRDS for review as specified in this Program Manual (refer to Section V- The Service Plan) to assure the SP is appropriate and to avoid any lapse in service coverage.
  8. DOH WMS monitor NHTD Complaint Line calls, data from the Regional Forums, complaints and annual Participant Satisfaction Surveys for trends or issues related to the SP. They will initiate an investigation to obtain further information regarding any identified issues.
  9. DOH WMS may place restrictions on waiver providers for late submission of RSPs and/or Individual Service Reports (ISR) (refer to Appendix C – form C.16). Restrictions may include the discontinuance of the waiver provider agreement or a vendor hold, which prevents the waiver provider from accepting new waiver participants until the RSP and/or ISR is submitted and approved by the RRDS. In addition, the waiver provider may have to submit a plan of action if the submission of late SPs is an ongoing problem.
  10. Where inadequacies in the SP development process are identified, DOH WMS request a review by the RRDS or QMS and/or a DOH survey of any waiver provider.
  11. DOH WMS and QMS conduct annual random retrospective reviews of five-percent (5%) of all SPs in Year One of the waiver, two-percent (2%) in Year Two, and one-percent (1%) in Year Three. DOH WMS reserve the right to review SPs at any time.
  12. The data gathered regarding this assurance must be included in the RRDS and/or QMS Quarterly Reports for review by DOH WMS. That staff, in consultation with the QMS and RRDS evaluates the need to change and/or improve policies/procedures.

3. Service Plans are updated/revised at least annually or when warranted by changes in the waiver participant's needs. In the (6) months.

Activities:
  1. The SC must assure Team Meetings are held at least every six months with the waiver participant, key parties and anyone the waiver participant requests for the purpose of reviewing the SP for needed revisions and development of an RSP.
  2. An Addendum is used when there is a need for minor adjustments in the SP. The Addendum is a short form the RRDS can review and approve quickly. An RSP is used when there are major changes in the types and amounts of waiver services needed to assure health and welfare.
  3. All RSPs and Addenda must be reviewed and approved by the RRDS assuring waiver participant needs, goals, and health and welfare are met.
  4. A waiver participant may request a review of his/her SP at any time and the SC must comply with this request. If needed, a Team Meeting will be held with all appropriate persons in attendance.
  5. In the event the outcome of an investigation of an SRI, Recordable Incident or complaint leads to an Addenda or revisions in the SP, the RRDS assures changes are implemented in a timely manner by waiver providers.
  6. The SC and RRDS track the submission and review of all SPs according to policy and procedure.
  7. In the event SPs are delinquent, RRDS notifies DOH WMS. (refer to Section V – The Service Plan).
  8. The data gathered regarding this assurance must be included in the RRDS and/or QMS Quarterly Reports for review by DOH Waiver Management staff. That staff in consultation with the QMS and RRDS evaluates the need to change and/or improve policies/procedures.

4. Services are delivered in accordance with the Service Plan, including in the type, scope, amount, duration, and frequency specified in the Service Plan.

Activities:
  1. The SC maintains regular contact with the waiver participant to discuss the delivery of services as approved in his/her SP.
  2. Discrepancies between SPs and actual service utilization may be discovered through a range of methods including a random retrospective review by DOH WMS of SPs against claims data acquired through eMedNY, OMIG audits of waiver providers, DOH surveys and audits of waiver providers, Line calls, waiver provider Participant Satisfaction Surveys, QMS Participant Satisfaction Surveys and Regional Forums regarding waiver participant experiences with provision of services. If problems are discovered, further investigation will be pursued. If it is found services are not being delivered in accordance with the SP, DOH WMS will take appropriate action which may include a Vendor Hold or termination of the Provider Agreement.
  3. The data gathered regarding this assurance must be included in the RRDS and/or QMS Quarterly Reports for review by DOH WMS. That staff, in consultation with the QMS and RRDS will evaluate the need to change and/or improve policies/procedures.

5. Participants are afforded choice between waiver services and institutional care.

Activities:
  1. The RRDC staff is responsible for outreach and community education regarding the NHTD Waiver.
  2. The RRDS interviews all potential waiver participants and offers them informed choice between community-based services versus institutional care. The RRDS tracks the number of potential waiver participants interviewed and the number of potential waiver participants who chose waiver services instead of institutionalization.
  3. The RRDS documents that potential waiver participants are offered choice by having the potential waiver participant sign the Freedom of Choice form (refer to Appendix B – form B.4) during the initial phase of the application process.
  4. The QMS and DOH WMS conducts an annual random retrospective review of five-percent (5%) of waiver participant records in Year One of the waiver, two-percent (2%) in Year Two, and one-percent (1%) in Year Three to assure that the Freedom of Choice form was completed and included in the Application Packet.
  5. DOH WMS conducts annual visits to the RRDC. These visits include review of Freedom of Choice forms.
  6. Potential waiver participants may contact the NHTD Complaint Line to express concerns about Freedom of Choice. DOH WMS will monitor the NHTD Complaint Line and take appropriate action to assure all potential waiver participants are offered the choice between community based services, including waiver services and institutional care.
  7. The QMS conducts an annual Participant Satisfaction Survey to assure waiver participants continue to be afforded choice between community services and institutional care. DOH WMS monitors these Surveys for trends related to freedom of choice and issues corrective action as necessary for remediation and improvement.
  8. The data gathered regarding this assurance must be included in the RRDS and/or QMS Quarterly Reports for review by DOH WMS. That staff, in consultation with the QMS and RRDS will evaluate the need to change and/or improve policies/procedures.

6. Participants are afforded choice between/among waiver services and providers.

Activities:
  1. In the intake interview with the potential waiver participant, the RRDS explains the use of waiver services.
  2. During the intake interview, the RRDS assures individuals are offered choice in selection of SC by providing a list of available SC agencies. The potential waiver participant is encouraged to interview SCs prior to making a selection. Upon selection of a SC by the waiver participant, the RRDS assures the Service Coordination Selection form (refer to Appendix B – form B.4) is completed and signed by the waiver participant and maintained in his/her record.
  3. The waiver participant is informed during the initial interview with the RRDS and again by the SC that at any time he/she may request a change in waiver providers, including SCs and complete a Change of Provider Request form (refer to Appendix C – form C.18). The SC assures each waiver participant is given a list of available qualified waiver service providers for selection which is attached to the Change of Provider Request form. Upon selection of waiver service provider(s), the SC will assure the agency can accept the waiver participant. The SC maintains the completed and signed Change of Provider Request form in the participant's record.
  4. The SC assures the waiver participant signs the SP indicating his/her acceptance of waiver providers and waiver services.
  5. On an annual basis, the SC assures the waiver participant reviews and signs a Waiver Participant Rights and Responsibilities form (refer to Appendix C – form C.5) which includes information regarding a waiver participant's right to choose between/among waiver services/providers. A copy is kept in the waiver participant's record and is given to the waiver participant.
  6. During data collection from annual QMS Participant Satisfaction Surveys, DOH WMS and QMS will note any negative responses regarding a waiver participant's right to choose waiver services and waiver providers. QMS initiates action to further investigate any response and report findings to DOH WMS. DOH WMS imposes penalties on waiver providers as necessary.
  7. All waiver providers are responsible for conducting annual Participant Satisfaction Surveys containing questions about "choice". These surveys can be reviewed during DOH surveys and upon request by the RRDS, QMS and DOH WMS.
  8. DOH WMS and the QMS will conduct annual random retrospective review of at least five-percent (5%) of waiver participant records in Year One of the waiver, two-percent (2%) in Year Two, and one-percent (1%) in Year Three to assure Provider Selection forms have been appropriately completed and to monitor trends that warrant changes in protocol.
  9. During annual Regional Forums DOH WMS collects feedback from waiver participants regarding their choice of waiver services. That staff analyzes the information to determine if agency specific or system-wide improvements are needed.
  10. The data gathered regarding this assurance must be included in the RRDS and/or QMS Quarterly Reports for review by DOH WMS. That staff, in consultation with the QMS and RRDS will evaluate the need to change and/or improve policies/procedures.