††††† 907 KAR 3:090. Acquired brain injury waiver services.

 

††††† RELATES TO: KRS 205.5605, 205.5606, 205.5607, 205.8451, 205.8477, 42 C.F.R. 441.300 - 310, 42 C.F.R. 455.100 - 106, 42 U.S.C. 1396a, b, d, n

††††† STATUTORY AUTHORITY: KRS 194A.010(1), 194A.030(2), 194A.050(1), 205.520(3)

††††† NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and Family Services, Department for Medicaid Services, has responsibility to administer the Medicaid Program. KRS 205.520(3) authorizes the cabinet, by administrative regulation, to comply with any requirement that may be imposed, or opportunity presented, by federal law for the provision of medical assistance to Kentuckyís indigent citizenry. KRS 205.5606(1) requires the cabinet to promulgate administrative regulations to establish a consumer-directed services program to provide an option for the home and community-based services waivers. This administrative regulation establishes the coverage provisions relating to home- and community-based waiver services provided to an individual with an acquired brain injury as an alternative to nursing facility services and including a consumer-directed services program pursuant to KRS 205.5606.

 

††††† Section 1. Definitions. (1) "ABI" means an acquired brain injury.

††††† (2) "ABI provider" means an entity that meets the criteria established in Section 2 of this administrative regulation.

††††† (3) "ABI recipient" means an individual who meets the criteria established in Section 3 of this administrative regulation.

††††† (4) "Acquired Brain Injury Branch" or "ABIB" means the Acquired Brain Injury Branch of the Department for Medicaid Services, Division of Community Alternatives.

††††† (5) "Acquired brain injury waiver service" or "ABI waiver service" means a home and community based waiver service provided to a Medicaid eligible individual who has acquired a brain injury.

††††† (6) "Advanced practice registered nurse" is defined by KRS 314.l011(7).

††††† (7) "Assessment" or "reassessment" means a comprehensive evaluation of abilities, needs, and services that is:

††††† (a) Completed on a MAP-351;

††††† (b) Submitted to the department:

††††† 1. For a level of care determination; and

††††† 2. No less than every twelve (12) months thereafter.

††††† (8) "Behavior intervention committee" or "BIC" means a group of individuals established to evaluate the technical adequacy of a proposed behavior intervention for an ABI recipient.

††††† (9) "Blended services" means a nonduplicative combination of ABI waiver services identified in Section 4 of this administrative regulation and CDO services identified in Section 8 of this administrative regulation provided pursuant to a recipient's approved plan of care.

††††† (10) "Board certified behavior analyst" means an independent practitioner who is certified by the Behavior Analyst Certification Board, Inc.

††††† (11) "Budget allowance" is defined by KRS 205.5605(1).

††††† (12) "Case manager" means an individual who manages the overall development and monitoring of a recipientís plan of care.

††††† (13) "Consumer" is defined by KRS 205.5605(2).

††††† (14) "Consumer directed option" or "CDO" means an option established by KRS 205.5606 within the home and community based services waiver that allows recipients to:

††††† (a) Assist with the design of their programs;

††††† (b) Choose their providers of services; and

††††† (c) Direct the delivery of services to meet their needs.

††††† (15) "Covered services and supports" is defined by KRS 205.5605(3).

††††† (16) "Crisis prevention and response plan" means a plan developed by an interdisciplinary team to identify any potential risk to a recipient and to detail a strategy to minimize the risk.

††††† (17) "DCBS" means the Department for Community Based Services.

††††† (18) "Department" means the Department for Medicaid Services or its designee.

††††† (19) "Good cause" means a circumstance beyond the control of an individual that affects the individual's ability to access funding or services, including:

††††† (a) Illness or hospitalization of the individual which is expected to last sixty (60) days or less;

††††† (b) Death or incapacitation of the primary caregiver;

††††† (c) Required paperwork and documentation for processing in accordance with Section 3 of this administrative regulation that has not been completed but is expected to be completed in two (2) weeks or less; or

††††† (d) The individual or his or her legal representative has made diligent contact with a potential provider to secure placement or access services but has not been accepted within the sixty (60) day time period.

††††† (20) "Human rights committee" or "HRC" means a group of individuals established to protect the rights and welfare of an ABI recipient.

††††† (21) "Interdisciplinary team" means a group of individuals that assist in the development and implementation of an ABI recipientís plan of care consisting of:

††††† (a) The ABI recipient and legal representative if appointed;

††††† (b) A chosen ABI service provider;

††††† (c) A case manager; and

††††† (d) Others as designated by the ABI recipient.

††††† (22) "Level of care certification" means verification, by the department, of ABI program eligibility for:

††††† (a) An individual; and

††††† (b) A specific period of time.

††††† (23) "Licensed marriage and family therapist" or "LMFT" is defined by KRS 335.300(2).

††††† (24) "Licensed professional clinical counselor" is defined by KRS 335.500(3).

††††† (25) "Medically necessary" or "medical necessity" means that a covered benefit is determined to be needed in accordance with 907 KAR 3:130.

††††† (26) "Occupational therapist" is defined by KRS 319A.010(3).

††††† (27) "Occupational therapy assistant" is defined by KRS 319A.010(4).

††††† (28) "Patient liability" means the financial amount, determined by the department, that an individual is required to contribute towards cost of care in order to maintain Medicaid eligibility.

††††† (29) "Personal services agency" is defined by KRS 216.710(8).

††††† (30) "Psychologist" is defined by KRS 319.010(9).

††††† (31) "Psychologist with autonomous functioning" means an individual who is licensed in accordance with KRS 319.056.

††††† (32) "Qualified mental health professional" is defined by KRS 202A.011(12).

††††† (33) "Representative" is defined by KRS 205.5605(6).

††††† (34) "Speech-language pathologist" is defined by KRS 334A.020(3).

††††† (35) "Support broker" means an individual designated by the department to:

††††† (a) Provide training, technical assistance, and support to a consumer; and

††††† (b) Assist a consumer in any other aspects of CDO.

††††† (36) "Support spending plan" means a plan for a consumer that identifies the:

††††† (a) CDO services requested;

††††† (b) Employee name;

††††† (c) Hourly wage;

††††† (d) Hours per month;

††††† (e) Monthly pay;

††††† (f) Taxes; and

††††† (g) Budget allowance.

††††† (37) "Transition plan" means a plan that is developed by an interdisciplinary team to aid an ABI recipient in exiting from the ABI program into the community.

 

††††† Section 2. Non-CDO Provider Participation. (1) In order to provide an ABI waiver service in accordance with Section 4 of this administrative regulation, excluding a consumer-directed option service, an ABI provider shall:

††††† (a) Be enrolled as a Medicaid provider in accordance with 907 KAR 1:671;

††††† (b) Be certified by the department prior to the initiation of the service;

††††† (c) Be recertified at least annually by the department;

††††† (d) Have an office within the Commonwealth of Kentucky; and

††††† (e) Complete and submit a MAP-4100a to the department.

††††† (2) An ABI provider shall comply with:

††††† (a) 907 KAR 1:672;

††††† (b) 907 KAR 1:673; and

††††† (c) 902 KAR 20:078.

††††† (3) An ABI provider shall have a governing body that shall be:

††††† (a) A legally-constituted entity within the Commonwealth of Kentucky; and

††††† (b) Responsible for the overall operation of the organization including establishing policy that complies with this administrative regulation concerning the operation of the agency and the health, safety and welfare of an ABI recipient served by the agency.

††††† (4) An ABI provider shall:

††††† (a) Unless participating in the CDO program, ensure that an ABI waiver service is not provided to an ABI recipient by a staff member of the ABI provider who has one (1) of the following blood relationships to the ABI recipient:

††††† 1. Child;

††††† 2. Parent;

††††† 3. Sibling; or

††††† 4. Spouse;

††††† (b) Not enroll an ABI recipient for whom the ABI provider cannot meet the service needs; and

††††† (c) Have and follow written criteria that complies with this administrative regulation for determining the eligibility of an individual for admission to services.

††††† (5) An ABI provider shall comply with the requirements of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, 42 U.S.C. 1320d to 1320d-8.

††††† (6) An ABI provider shall meet the following requirements if responsible for the management of an ABI recipient's funds:

††††† (a) Separate accounting shall be maintained for each ABI recipient or for his or her interest in a common trust or special account;

††††† (b) Account balance and records of transactions shall be provided to the ABI recipient or legal representative on a quarterly basis; and

††††† (c) The ABI recipient or legal representative shall be notified when a large balance is accrued that may affect Medicaid eligibility.

††††† (7) An ABI provider shall have a written statement of its mission and values.

††††† (8) An ABI provider shall have written policy and procedures for communication and interaction with a family and legal representative of an ABI recipient which shall:

††††† (a) Require a timely response to an inquiry;

††††† (b) Require the opportunity for interaction with direct care staff;

††††† (c) Require prompt notification of any unusual incident;

††††† (d) Permit visitation with the ABI recipient at a reasonable time and with due regard for the ABI recipient's right of privacy;

††††† (e) Require involvement of the legal representative in decision-making regarding the selection and direction of the service provided; and

††††† (f) Consider the cultural, educational, language and socioeconomic characteristics of the ABI recipient.

††††† (9) An ABI provider shall ensure the rights of an ABI recipient by:

††††† (a) Making available a description of the rights and the means by which the rights may be exercised, including:

††††† 1. The right to time, space, and opportunity for personal privacy;

††††† 2. The right to retain and use personal possessions; and

††††† 3. For a supervised residential care, personal care, companion or respite provider, the right to communicate, associate and meet privately with a person of the ABI recipientís choice, including:

††††† a. The right to send and receive unopened mail; and

††††† b. The right to private, accessible use of the telephone;

††††† (b) Maintaining a grievance and appeals system;

††††† (c) Complying with the Americans with Disabilities Act (28 C.F.R. Part 35); and

††††† (d) Prohibiting the use of:

††††† 1. Prone or supine restraint;

††††† 2. Corporal punishment;

††††† 3. Seclusion;

††††† 4. Verbal abuse; or

††††† 5. Any procedure which denies private communication, requisite sleep, shelter, bedding, food, drink, or use of a bathroom facility.

††††† (10) An ABI provider shall maintain fiscal and service records and incident reports for a minimum of six (6) years from the date that a covered service is provided and all the records and reports shall be made available to the:

††††† (a) Department;

††††† (b) ABI recipientís selected case manager;

††††† (c) Cabinet for Health and Family Services, Office of Inspector General or its designee;

††††† (d) General Accounting Office or its designee;

††††† (e) Office of the Auditor of Public Accounts or its designee;

††††† (f) Office of the Attorney General or its designee; or

††††† (g) Centers for Medicare and Medicaid Services.

††††† (11) An ABI provider shall cooperate with monitoring visits from monitoring agents.

††††† (12) An ABI provider shall maintain a record for each ABI recipient served that shall:

††††† (a) Be recorded in permanent ink;

††††† (b) Be free from correction fluid;

††††† (c) Have a strike through each error which is initialed and dated; and

††††† (d) Contain no blank lines between each entry.

††††† (13) A record of each ABI recipient who is served shall:

††††† (a) Be cumulative;

††††† (b) Be readily available;

††††† (c) Contain a legend that identifies any symbol or abbreviation used in making a record entry; and

††††† (d) Contain the following specific information:

††††† 1. The ABI recipient's name and Medical Assistance Identification Number (MAID);

††††† 2. An assessment summary relevant to the service area;

††††† 3. The MAP-109;

††††† 4. The crisis prevention and response plan that shall include:

††††† a. A list containing emergency contact telephone numbers; and

††††† b. The ABI recipientís history of any allergies with appropriate allergy alerts for severe allergies;

††††† 5. The transition plan that shall include:

††††† a. Skills to be obtained from the ABI waiver program;

††††† b. A listing of the on-going formal and informal community services available to be accessed; and

††††† c. A listing of additional resources needed;

††††† 6. The training objective for any service which provides skills training to the ABI recipient;

††††† 7. The ABI recipient's medication record, including a copy of the prescription or the signed physicianís order and the medication log if medication is administered at the service site;

††††† 8. Legally-adequate consent for the provision of services or other treatment including a consent for emergency attention which shall be located at each service site;

††††† 9. The Long Term Care Facilities and Home and Community Based Program Certification form, MAP-350, updated at recertification; and

††††† 10. Current level of care certification;

††††† (e) Be maintained by the provider in a manner to ensure the confidentiality of the ABI recipient's record and other personal information and to allow the ABI recipient or legal representative to determine when to share the information as provided by law;

††††† (f) Be secured against loss, destruction or use by an unauthorized person ensured by the provider; and

††††† (g) Be available to the ABI recipient or legal guardian according to the provider's written policy and procedures which shall address the availability of the record.

††††† (14) An ABI provider shall:

††††† (a)1. Ensure that each new staff person or volunteer performing direct care or a supervisory function has had a tuberculosis (TB) risk assessment performed by a licensed medical professional and, if indicated, a TB skin test with a negative result within the past twelve (12) months as documented on test results received by the provider;

††††† 2. Maintain, for existing staff, documentation of each staff personís or, if a volunteer performs direct care or a supervisory function, the volunteerís annual TB risk assessment or negative tuberculosis test required by subparagraph 1 of this paragraph;

††††† 3. Ensure that an employee or volunteer who tests positive for TB or has a history of a positive TB skin test shall be assessed annually by a licensed medical professional for signs or symptoms of active disease;

††††† 4. Before allowing a staff person or volunteer determined to have signs or symptoms of active disease to work, ensure that follow-up testing is administered by a physician with the test results indicating the person does not have active TB disease; and

††††† 5. Maintain annual documentation for an employee or volunteer with a positive TB test to ensure no active disease symptoms are present;

††††† (b)1. For each potential employee or volunteer expected to perform direct care or a supervisory function, obtain prior to the date of hire or date of service as a volunteer, the results of:

††††† a. A criminal record check from the Administrative Office of the Courts or equivalent out-of-state agency if the individual resided, worked, or volunteered outside Kentucky during the year prior to employment or volunteer service; and

††††† b. A nurse aide abuse registry check as described in 906 KAR 1:100;

††††† 2. Obtain, within thirty (30) days of the date of hire or date of service as a volunteer, the results of a central registry check as described in 922 KAR 1:470; and

††††† 3. Annually, for twenty-five (25) percent of employees randomly selected, obtain the results of a criminal record check from the Kentucky Administrative Office of the Courts or equivalent out-of-state agency if the individual resided or worked outside of Kentucky during the year prior to employment; and

††††† (c) Not employ or permit an individual to serve as a volunteer performing direct care or a supervisory function if the individual has a prior conviction of an offense delineated in KRS 17.165(1) through (3) or prior felony conviction;

††††† (d) Not permit an employee or volunteer to transport an ABI recipient if the employee or volunteer:

††††† 1. Does not possess a valid operator's license issued pursuant to KRS 186.410; or

††††† 2. Has a conviction of Driving Under the Influence (DUI) during the past year;

††††† (e) Not employ or permit an individual to serve as a volunteer performing direct care or a supervisory function if the individual has a conviction of trafficking, manufacturing, or possession of an illegal drug during the past five (5) years;

††††† (f) Not employ or permit an individual to serve as a volunteer performing direct care or a supervisory function if the individual has a conviction of abuse, neglect or exploitation;

††††† (g) Not employ or permit an individual to serve as a volunteer performing direct care or a supervisory function if the individual has a Cabinet for Health and Family Services finding of child abuse or neglect pursuant to the central registry;

††††† (h) Not employ or permit an individual to serve as a volunteer performing direct care or a supervisory function if the individual is listed on the nurse aide abuse registry;

††††† (i) Evaluate and document the performance of each employee upon completion of the agencyís designated probationary period and at a minimum of annually thereafter; and

††††† (j) Conduct and document periodic and regularly-scheduled supervisory visits of all professional and paraprofessional direct-service staff at the service site in order to ensure that high quality, appropriate services are provided to the ABI recipient.

††††† (15) An ABI provider shall:

††††† (a) Have an executive director who:

††††† 1. Is qualified with a bachelorís degree from an accredited institution in administration or a human services field; and

††††† 2. Has a minimum of one (1) year of administrative responsibility in an organization which served an individual with a disability; and

††††† (b) Have adequate direct-contact staff who:

††††† 1. Is eighteen (18) years of age or older;

††††† 2. Has a high school diploma or GED; and

††††† 3.a. Has a minimum of two (2) years experience in providing a service to an individual with a disability; or

††††† b. Has successfully completed a formalized training program such as nursing facility nurse aide training.

††††† (16) An ABI provider shall establish written guidelines that address the health, safety and welfare of an ABI recipient, which shall include:

††††† (a) Ensuring the health, safety and welfare of the ABI recipient;

††††† (b) Maintenance of sanitary conditions;

††††† (c) Ensuring each site operated by the provider is equipped with:

††††† 1. Operational smoke detectors placed in strategic locations; and

††††† 2. A minimum of two (2) correctly-charged fire extinguishers placed in strategic locations, one (1) of which shall be capable of extinguishing a grease fire and have a rating of 1A10BC;

††††† (d) For a supervised residential care or adult day training provider, ensuring the availability of an ample supply of hot and cold running water with the water temperature at a tap used by the ABI recipient not exceeding 120 degrees Fahrenheit;

††††† (e) Ensuring that the nutritional needs of the ABI recipient are met in accordance with the current recommended dietary allowance of the Food and Nutrition Board of the National Research Council or as specified by a physician;

††††† (f) Ensuring that staff who supervise medication administration:

††††† 1. Unless the employee is a licensed or registered nurse, have specific training provided by a licensed medical professional (a nurse, pharmacist, or medical doctor) and documented competency on cause and effect and proper administration and storage of medication; and

††††† 2. Document all medication administered, including self-administered, over-the-counter drugs, on a medication log, with the date, time, and initials of the person who administered the medication and ensure that the medication shall:

††††† a. Be kept in a locked container;

††††† b. If a controlled substance, be kept under double lock;

††††† c. Be carried in a proper container labeled with medication, dosage, time of administration, and the recipientís name if administered to the ABI recipient or self-administered at a program site other than his or her residence; and

††††† d. Be documented on a medication administration form and properly disposed of if discontinued; and

††††† (g) Establish policies and procedures for on-going monitoring of medication administration as approved by the department.

††††† (17) An ABI provider shall establish and follow written guidelines for handling an emergency or a disaster which shall:

††††† (a) Be readily accessible on site;

††††† (b) Include an evacuation drill:

††††† 1. To be conducted and documented at least quarterly; and

††††† 2. For a residential setting, scheduled to include a time overnight when an ABI recipient is typically asleep;

††††† (c) Mandate that:

††††† 1. The result of an evacuation drill be evaluated and modified as needed; and

††††† 2. Results of the prior yearís evacuation drill be maintained on site.

††††† (18) An ABI provider shall:

††††† (a) Provide orientation for each new employee which shall include the mission, goals, organization and policy of the agency;

††††† (b) Require documentation of all training which shall include:

††††† 1. The type of training provided;

††††† 2. The name and title of the trainer;

††††† 3. The length of the training;

††††† 4. The date of completion; and

††††† 5. The signature of the trainee verifying completion;

††††† (c) Ensure that each employee complete ABI training consistent with the curriculum that has been approved by the department prior to working independently with an ABI recipient which shall include:

††††† 1. Required orientation in brain injury;

††††† 2. Identifying and reporting abuse, neglect and exploitation;

††††† 3. Unless the employee is a licensed or registered nurse, first aid, which shall be provided by an individual certified as a trainer by the American Red Cross or other nationally-accredited organization; and

††††† 4. Coronary pulmonary resuscitation which shall be provided by an individual certified as a trainer by the American Red Cross or other nationally-accredited organization;

††††† (d) Ensure that each employee completes at least six (6) hours of continuing education in brain injury annually;

††††† (e) Not be required to receive the training specified in paragraph (c)1 of this subsection if the provider is a professional who has, within the prior five (5) years, 2,000 hours of experience in serving a person with a primary diagnosis of a brain injury including:

††††† 1. An occupational therapist or occupational therapy assistant providing occupational therapy;

††††† 2. A psychologist or psychologist with autonomous functioning providing psychological services;

††††† 3. A speech-language pathologist providing speech therapy; or

††††† 4. A board certified behavior analyst; and

††††† (f) Ensure that prior to the date of service as a volunteer, an individual receives training which shall include:

††††† 1. Required orientation in brain injury as specified in paragraph (c)1, 2, 3, and 4 of this subsection;

††††† 2. Orientation to the agency;

††††† 3. A confidentiality statement; and

††††† 4. Individualized instruction on the needs of the ABI recipient to whom the volunteer will provide services.

††††† (19) An ABI provider shall provide information to a case manager necessary for completion of a Mayo-Portland Adaptability Inventory-4 for each ABI recipient served by the provider.

††††† (20) A case management provider shall:

††††† (a) Establish a human rights committee which shall:

††††† 1. Include an:

††††† a. Individual with a brain injury or a family member of an individual with a brain injury;

††††† b. Individual not affiliated with the ABI provider; and

††††† c. Individual who has knowledge and experience in human rights issues;

††††† 2. Review and approve each plan of care with human rights restrictions at a minimum of every six (6) months;

††††† 3. Review and approve, in conjunction with the ABI recipientís team, behavior intervention plans that contain human rights restrictions; and

††††† 4. Review the use of a psychotropic medication by an ABI recipient without an Axis I diagnosis; and

††††† (b) Establish a behavior intervention committee which shall:

††††† 1. Include one (1) individual who has expertise in behavior intervention and is not the behavior specialist who wrote the behavior intervention plan;

††††† 2. Be separate from the human rights committee; and

††††† 3. Review and approve, prior to implementation and at a minimum of every six (6) months in conjunction with the ABI recipient's team, an intervention plan that includes highly restrictive procedures or contain human rights restrictions; and

††††† (c) Complete and submit a Mayo-Portland Adaptability Inventory-4 to the department for each ABI recipient:

††††† 1. Within thirty (30) days of the recipient's admission into the ABI program;

††††† 2. Annually thereafter; and

††††† 3. Upon discharge from the ABI waiver program.

 

††††† Section 3. ABI Recipient Eligibility, Enrollment and Termination. (1) To be eligible to receive a service in the ABI program:

††††† (a) An individual shall:

††††† 1. Be at least eighteen (18) years of age;

††††† 2. Have acquired a brain injury of the following nature, to the central nervous system:

††††† a. An injury from physical trauma;

††††† b. Damage from anoxia or from a hypoxic episode; or

††††† c. Damage from an allergic condition, toxic substance, or another acute medical incident; and

††††† 3. Apply to be placed on the ABI waiting list in accordance with Section 7 of this administrative regulation;

††††† (b) A case manager or support broker, on behalf of an applicant, shall submit a certification packet to the department containing the following:

††††† 1. A copy of the allocation letter;

††††† 2. A Medicaid Waiver Assessment, MAP-351;

††††† 3. A statement for the need for ABI waiver services which shall be signed and dated by a physician on a MAP-10, Waiver Services Ė Physicianís Recommendation;

††††† 4. A Long Term Care Facilities and Home and Community Based Program Certification form, MAP-350;

††††† 5. A MAP-109; and

††††† 6. The MAP 24C, Admittance, Discharge or Transfer of an Individual in the ABI/SCL Program;

††††† (c) An individual shall receive notification of potential funding allocated for ABI services for the individual;

††††† (d) An individual shall meet the patient status criteria for nursing facility services established in 907 KAR 1:022 including nursing facility services for a brain injury;

††††† (e) An individual shall meet the following conditions:

††††† 1. Have a primary diagnosis that indicates an ABI with structural, nondegenerative brain injury;

††††† 2. Be medically stable;

††††† 3. Meet Medicaid eligibility requirements established in 907 KAR 20:010;

††††† 4. Exhibit cognitive, behavioral, motor or sensory damage with an indication for rehabilitation and retraining potential; and

††††† 5. Have a rating of at least four (4) on the Family Guide to the Rancho Levels of Cognitive Functioning; and

††††† (f) An individual shall receive notification of approval from the department.

††††† (2) An individual shall not remain in the ABI waiver program for an indefinite period of time.

††††† (3) The basis of an eligibility determination for participation in the ABI waiver program shall be:

††††† (a) The presenting problem;

††††† (b) The plan of care goal;

††††† (c) The expected benefit of the admission;

††††† (d) The expected outcome;

††††† (e) The service required; and

††††† (f) The cost effectiveness of service delivery as an alternative to nursing facility and nursing facility brain injury services.

††††† (4) An ABI waiver service shall not be furnished to an individual if the individual is:

††††† (a) An inpatient of a hospital, nursing facility or an intermediate care facility for individuals with mental retardation or a developmental disability; or

††††† (b) Receiving a service in another home and community based waiver program.

††††† (5) The department shall make:

††††† (a) An initial evaluation to determine if an individual meets the nursing facility patient status criteria established in 907 KAR 1:022; and

††††† (b) A determination of whether to admit an individual into the ABI waiver program.

††††† (6) To maintain eligibility as an ABI recipient:

††††† (a) An individual shall maintain Medicaid eligibility requirements established in 907 KAR 20:010; and

††††† (b) A reevaluation shall be conducted at least once every twelve (12) months to determine if the individual continues to meet the patient status criteria for nursing facility services established in 907 KAR 1:022.

††††† (7) An ABI case management provider shall notify the local DCBS office, ABIB, and the department via a MAP 24C, Admittance, Discharge or Transfer of an Individual in the ABI/SCL Program, if the ABI recipient is:

††††† (a) Admitted to the ABI waiver program;

††††† (b) Discharged from the ABI waiver program;

††††† (c) Temporarily discharged from the ABI waiver program;

††††† (d) Readmitted from a temporary discharge;

††††† (e) Admitted to a nursing facility;

††††† (f) Changing the primary provider; or

††††† (g) Changing the case management agency.

††††† (8) The department may exclude an individual from receiving ABI waiver services if the projected cost of ABI waiver services for the individual is reasonably expected to exceed the cost of nursing facility services for the individual.

††††† (9) Involuntary termination and loss of an ABI waiver program placement shall be in accordance with 907 KAR 1:563 and shall be initiated if:

††††† (a) An individual fails to initiate an ABI waiver service within sixty (60) days of notification of potential funding without good cause shown. The individual or legal representative shall have the burden of providing documentation of good cause, including:

††††† 1. A statement signed by the recipient or legal representative;

††††† 2. Copies of letters to providers; and

††††† 3. Copies of letters from providers;

††††† (b) An ABI recipient or legal representative fails to access the required service as outlined in the plan of care for a period greater than sixty (60) consecutive days without good cause shown.

††††† 1. The recipient or legal representative shall have the burden of providing documentation of good cause including:

††††† a. A statement signed by the recipient or legal representative;

††††† b. Copies of letters to providers; and

††††† c. Copies of letters from providers; and

††††† 2. Upon receipt of documentation of good cause, the department shall grant one (1) extension in writing which shall be:

††††† a. Sixty (60) days for an individual who does not reside in a facility; and

††††† b. For an individual who resides in a facility, the length of the transition plan and contingent upon continued active participation in the transition plan;

††††† (c) An ABI recipient changes residence outside the Commonwealth of Kentucky;

††††† (d) An ABI recipient does not meet the patient status criteria for nursing facility services established in 907 KAR 1:022;

††††† (e) An ABI recipient is no longer able to be safely served in the community;

††††† (f) The ABI recipient has reached maximum rehabilitation potential; or

††††† (g) The ABI recipient is no longer actively participating in services within the approved plan of care as determined by the interdisciplinary team.

††††† (10) Involuntary termination of a service to an ABI recipient by an ABI provider shall require:

††††† (a) Simultaneous notice to the department, the ABI recipient or legal representative and the case manager at least thirty (30) days prior to the effective date of the action, which shall include:

††††† 1. A statement of the intended action;

††††† 2. The basis for the intended action;

††††† 3. The authority by which the action is taken; and

††††† 4. The ABI recipientís right to appeal the intended action through the providerís appeal or grievance process; and

††††† (b) The case manager in conjunction with the provider to:

††††† 1. Provide the ABI recipient with the name, address and telephone number of each current ABI provider in the state;

††††† 2. Provide assistance to the ABI recipient in making contact with another ABI provider;

††††† 3. Arrange transportation for a requested visit to an ABI provider site;

††††† 4. Provide a copy of pertinent information to the ABI recipient or legal representative;

††††† 5. Ensure the health, safety and welfare of the ABI recipient until an appropriate placement is secured;

††††† 6. Continue to provide supports until alternative services or another placement is secured; and

††††† 7. Provide assistance to ensure a safe and effective service transition.

††††† (11) Voluntary termination and loss of an ABI waiver program placement shall be initiated if an ABI recipient or legal representative submits a written notice of intent to discontinue services to the service provider and to the department.

††††† (a) An action to terminate services shall not be initiated until thirty (30) calendar days from the date of the notice; and

††††† (b) The ABI recipient or legal representative may reconsider and revoke the notice in writing during the thirty (30) calendar day period.

 

††††† Section 4. Covered Services. (1) An ABI waiver service shall:

††††† (a) Be prior-authorized by the department; and

††††† (b) Be provided pursuant to the plan of care.

††††† (2) The following services shall be provided to an ABI recipient by an ABI waiver provider:

††††† (a) Case management services, which shall:

††††† 1. Include initiation, coordination, implementation, and monitoring of the assessment or reassessment, evaluation, intake, and eligibility process;

††††† 2. Assist an ABI recipient in the identification, coordination, and facilitation of the interdisciplinary team and interdisciplinary team meetings;

††††† 3. Assist an ABI recipient and the interdisciplinary team to develop an individualized plan of care and update it as necessary based on changes in the recipient's medical condition and supports;

††††† 4. Include monitoring of the delivery of services and the effectiveness of the plan of care, which shall:

††††† a. Be initially developed with the ABI recipient and legal representative if appointed prior to the level of care determination;

††††† b. Be updated within the first thirty (30) days of service and as changes or recertification occurs; and

††††† c. Include the MAP-109 being sent to the department or its designee prior to the implementation of the effective date the change occurs with the ABI recipient;

††††† 5. Include a transition plan that shall be developed within the first thirty (30) days of service, updated as changes or recertification occurs, updated thirty (30) days prior to discharge, and shall include:

††††† a. The skills or service obtained from the ABI waiver program upon transition into the community; and

††††† b. A listing of the community supports available upon the transition;

††††† 6. Assist an ABI recipient in obtaining a needed service outside those available by the ABI waiver;

††††† 7. Be provided by a case manager who:

††††† a.(i) Is a registered nurse;

††††† (ii) Is a licensed practical nurse;

††††† (iii) Is an individual who has a bachelorís or masterís degree in a human services field who meets all applicable requirements of his or her particular field including a degree in psychology, sociology, social work, rehabilitation counseling, or occupational therapy;

††††† (iv) Is an independent case manager; or

††††† (v) Is employed by a free-standing case management agency;

††††† b. Has completed case management training that is consistent with the curriculum that has been approved by the department prior to providing case management services;

††††† c. Shall provide an ABI recipient and legal representative with a listing of each available ABI provider in the service area;

††††† d. Shall maintain documentation signed by an ABI recipient or legal representative of informed choice of an ABI provider and of any change to the selection of an ABI provider and the reason for the change;

††††† e. Shall provide a distribution of the crisis prevention and response plan, transition plan, plan of care, and other documents within the first thirty (30) days of the service to the chosen ABI service provider and as information is updated;

††††† f. Shall provide twenty-four (24) hour telephone access to an ABI recipient and chosen ABI provider;

††††† g. Shall work in conjunction with an ABI provider selected by an ABI recipient to develop a crisis prevention and response plan which shall be:

††††† (i) Individual-specific; and

††††† (ii) Updated as a change occurs and at each recertification;

††††† h. Shall assist an ABI recipient in planning resource use and assuring protection of resources;

††††† i.(i) Shall conduct two (2) face-to-face meetings with an ABI recipient within a calendar month occurring at a covered service site no more than fourteen (14) days apart, with one (1) visit quarterly at the ABI recipientís residence; and

††††† (ii) For an ABI recipient receiving supervised residential care, shall conduct at least one (1) of the two (2) monthly visits at the ABI recipientís supervised residential care provider site;

††††† j. Shall ensure twenty-four (24) hour availability of services; and

††††† k. Shall ensure that the ABI recipientís health, welfare, and safety needs are met; and

††††† 8. Be documented by a detailed staff note which shall include:

††††† a. The ABI recipientís health, safety and welfare;

††††† b. Progress toward outcomes identified in the approved plan of care;

††††† c. The date of the service;

††††† d. Beginning and ending time;

††††† e. The signature and title of the individual providing the service; and

††††† f. A quarterly summary which shall include:

††††† (i) Documentation of monthly contact with each chosen ABI provider; and

††††† (ii) Evidence of monitoring of the delivery of services approved in the recipientís plan of care and of the effectiveness of the plan of care;

††††† (b) Behavior programming services which shall:

††††† 1. Be the systematic application of techniques and methods to influence or change a behavior in a desired way;

††††† 2. Include a functional analysis of the ABI recipient's behavior which shall include:

††††† a. An evaluation of the impact of an ABI on cognition and behavior;

††††† b. An analysis of potential communicative intent of the behavior;

††††† c. The history of reinforcement for the behavior;

††††† d. Critical variables that precede the behavior;

††††† e. Effects of different situations on the behavior; and

††††† f. A hypothesis regarding the motivation, purpose and factors which maintain the behavior;

††††† 3. Include the development of a behavioral support plan which shall:

††††† a. Be developed by the behavioral specialist;

††††† b. Not be implemented by the behavior specialist who wrote the plan;

††††† c. Be revised as necessary;

††††† d. Define the techniques and procedures used;

††††† e. Include the hierarchy of behavior interventions ranging from the least to the most restrictive;

††††† f. Reflect the use of positive approaches; and

††††† g. Prohibit the use of prone or supine restraint, corporal punishment, seclusion, verbal abuse, and any procedure which denies private communication, requisite sleep, shelter, bedding, food, drink, or use of a bathroom facility;

††††† 4. Include the provision of training to other ABI providers concerning implementation of the behavioral intervention plan;

††††† 5. Include the monitoring of an ABI recipient's progress which shall be accomplished through:

††††† a. The analysis of data concerning the frequency, intensity, and duration of a behavior;

††††† b. Reports involved in implementing the behavioral service plan; and

††††† c. A monthly summary which assesses the participantís status related to the plan of care;

††††† 6. Be provided by a behavior specialist who shall:

††††† a.(i) Be a psychologist;

††††† (ii) Be a psychologist with autonomous functioning;

††††† (iii) Be a licensed psychological associate;

††††† (iv) Be a psychiatrist;

††††† (v) Be a licensed clinical social worker;

††††† (vi) Be a clinical nurse specialist with a masterís degree in psychiatric nursing or rehabilitation nursing;

††††† (vii) Be an advanced practice registered nurse (APRN);

††††† (viii) Be a board certified behavior analyst; or

††††† (ix) Be a licensed professional clinical counselor; and

††††† b. Have at least one (1) year of behavior specialist experience or provide documentation of completed coursework regarding learning and behavior principles and techniques; and

††††† 7. Be documented by a detailed staff note which shall include:

††††† a. The date of the service;

††††† b. The beginning and ending time; and

††††† c. The signature and title of the behavioral specialist;

††††† (c) Companion services which shall:

††††† 1. Include a nonmedical service, supervision or socialization as indicated in the recipient's plan of care;

††††† 2. Include assisting with but not performing meal preparation, laundry and shopping;

††††† 3. Include light housekeeping tasks which are incidental to the care and supervision of an ABI waiver service recipient;

††††† 4. Include services provided according to the approved plan of care which are therapeutic and not diversional in nature;

††††† 5. Include accompanying and assisting an ABI recipient while utilizing transportation services;

††††† 6. Include documentation by a detailed staff note which shall include:

††††† a. Progress toward goal and objectives identified in the approved plan of care;

††††† b. The date of the service;

††††† c. Beginning and ending time; and

††††† d. The signature and title of the individual providing the service;

††††† 7. Not be provided to an ABI recipient who receives supervised residential care; and

††††† 8. Be provided by:

††††† a. A home health agency licensed and operating in accordance with 902 KAR 20:081;

††††† b. A community mental health center licensed and operating in accordance with 902 KAR 20:091 and certified at least annually by the department;

††††† c. A community habilitation program certified by the department; or

††††† d. A supervised residential care provider;

††††† (d) Supervised residential care level I services, which:

††††† 1. Shall be provided by:

††††† a. A community mental health center licensed and operating in accordance with 902 KAR 20:091 and certified at least annually by the department; or

††††† b. An ABI provider;

††††† 2. Shall not be provided to an ABI recipient unless the recipient has been authorized to receive residential care by the departmentís residential review committee which shall:

††††† a. Consider applications for residential care in the order in which the applications are received;

††††† b. Base residential care decisions on the following factors:

††††† (i) Whether the applicant resides with a caregiver or not;

††††† (ii) Whether the applicant resides with a caregiver but demonstrates maladaptive behavior which places the applicant at significant risk of injury or jeopardy if the caregiver is unable to effectively manage the applicantís behavior or the risk it poses, resulting in the need for removal from the home to a more structured setting; or

††††† (iii) Whether the applicant demonstrates behavior which may result in potential legal problems if not ameliorated;

††††† c. Be comprised of three (3) Cabinet for Health and Family Services employees:

††††† (i) With professional or personal experience with brain injury or other cognitive disabilities; and

††††† (ii) None of whom shall be supervised by the manager of the acquired brain injury branch; and

††††† d. Only consider applications at a monthly committee meeting if the applications were received at least three (3) business days before the committee convenes;

††††† 3. Shall not have more than three (3) ABI recipients simultaneously in a residence rented or owned by the ABI provider;

††††† 4. Shall provide twenty-four (24) hours of supervision daily unless the provider implements, pursuant to subparagraph 5 of this paragraph, an individualized plan allowing for up to five (5) unsupervised hours per day;

††††† 5. May include the provision of up to five (5) unsupervised hours per day per recipient if the provider develops an individualized plan for the recipient to promote increased independence. The plan shall:

††††† a. Contain provisions necessary to ensure the recipientís health, safety, and welfare;

††††† b. Be approved by the recipientís treatment team, with the approval documented by the provider; and

††††† c. Contain periodic reviews and updates based on changes, if any, in the recipientís status;

††††† 6. Shall include assistance and training with daily living skills including:

††††† a. Ambulating;

††††† b. Dressing;

††††† c. Grooming;

††††† d. Eating;

††††† e. Toileting;

††††† f. Bathing;

††††† g. Meal planning;

††††† h. Grocery shopping;

††††† i. Meal preparation;

††††† j. Laundry;

††††† k. Budgeting and financial matters;

††††† l. Home care and cleaning;

††††† m. Leisure skill instruction; or

††††† n. Self-medication instruction;

††††† 7. Shall include social skills training including the reduction or elimination of maladaptive behaviors in accordance with the individualís plan of care;

††††† 8. Shall include provision or arrangement of transportation to services, activities, or medical appointments as needed;

††††† 9. Shall include accompanying or assisting an ABI recipient while the recipient utilizes transportation services as specified in the recipientís plan of care;

††††† 10. Shall include participation in medical appointments or follow-up care as directed by the medical staff;

††††† 11. Shall be documented by a detailed staff note which shall document:

††††† a. Progress toward goals and objectives identified in the approved plan of care;

††††† b. The date of the service;

††††† c. The beginning and ending time of the service; and

††††† d. The signature and title of the individual providing the service;

††††† 12. Shall not include the cost of room and board;

††††† 13. Shall be provided to an ABI recipient who:

††††† a. Does not reside with a caregiver;

††††† b. Is residing with a caregiver but demonstrates maladaptive behavior that places him or her at significant risk of injury or jeopardy if the caregiver is unable to effectively manage the behavior or the risk it presents, resulting in the need for removal from the home to a more structured setting; or

††††† c. Demonstrates behavior that may result in potential legal problems if not ameliorated;

††††† 14. May utilize a modular home only if the:

††††† a. Wheels are removed;

††††† b. Home is anchored to a permanent foundation; and

††††† c. Windows are of adequate size for an adult to use as an exit in an emergency;

††††† 15. Shall not utilize a motor home;

††††† 16. Shall provide a sleeping room which ensures that an ABI recipient:

††††† a. Does not share a room with an individual of the opposite gender who is not the ABI recipient's spouse;

††††† b. Does not share a room with an individual who presents a potential threat; and

††††† c. Has a separate bed equipped with substantial springs, a clean and comfortable mattress, and clean bed linens as required for the ABI recipient's health and comfort; and

††††† 17. Shall provide service and training to obtain the outcomes for the ABI recipient as identified in the approved plan of care;

††††† (e) Supervised residential care level II services, which:

††††† 1. Shall be provided by:

††††† a. A community mental health center licensed and operating in accordance with 902 KAR 20:091 and certified at least annually by the department; or

††††† b. An ABI provider;

††††† 2. Shall not be provided to an ABI recipient unless the recipient has been authorized to receive residential care by the departmentís residential review committee which shall:

††††† a. Consider applications for residential care in the order in which the applications are received;

††††† b. Base residential care decisions on the following factors:

††††† (i) Whether the applicant resides with a caregiver or not;

††††† (ii) Whether the applicant resides with a caregiver but demonstrates maladaptive behavior which places the applicant at significant risk of injury or jeopardy if the caregiver is unable to effectively manage the applicantís behavior or the risk it poses, resulting in the need for removal from the home to a more structured setting; or

††††† (iii) Whether the applicant demonstrates behavior which may result in potential legal problems if not ameliorated;

††††† c. Be comprised of three (3) Cabinet for Health and Family Services employees:

††††† (i) With professional or personal experience with brain injury or other cognitive disabilities; and

††††† (ii) None of whom shall be supervised by the manager of the acquired brain injury branch; and

††††† d. Only consider applications at a monthly committee meeting if the applications were received at least three (3) business days before the committee convenes;

††††† 3. Shall not have more than three (3) ABI recipients simultaneously in a residence rented or owned by the ABI provider;

††††† 4. Shall provide twelve (12) to eighteen (18) hours of daily supervision, the amount of which shall:

††††† a. Be based on the recipientís needs;

††††† b. Be approved by the recipientís treatment team; and

††††† c. Be documented in the recipientís plan of care which shall also contain periodic reviews and updates based on changes, if any, in the recipientís status;

††††† 5. Shall include assistance and training with daily living skills including:

††††† a. Ambulating;

††††† b. Dressing;

††††† c. Grooming;

††††† d. Eating;

††††† e. Toileting;

††††† f. Bathing;

††††† g. Meal planning;

††††† h. Grocery shopping;

††††† i. Meal preparation;

††††† j. Laundry;

††††† k. Budgeting and financial matters;

††††† l. Home care and cleaning;

††††† m. Leisure skill instruction; or

††††† n. Self-medication instruction;

††††† 6. Shall include social skills training including the reduction or elimination of maladaptive behaviors in accordance with the individualís plan of care;

††††† 7. Shall include provision or arrangement of transportation to services, activities, or medical appointments as needed;

††††† 8. Shall include accompanying or assisting an ABI recipient while the recipient utilizes transportation services as specified in the recipientís plan of care;

††††† 9. Shall include participation in medical appointments or follow-up care as directed by the medical staff;

††††† 10. Shall include provision of twenty-four (24) hour on-call support;

††††† 11. Shall be documented by a detailed staff note which shall document:

††††† a. Progress toward goals and objectives identified in the approved plan of care;

††††† b. The date of the service;

††††† c. The beginning and ending time of the service; and

††††† d. The signature and title of the individual providing the service;

††††† 12. Shall not include the cost of room and board;

††††† 13. Shall be provided to an ABI recipient who:

††††† a. Does not reside with a caregiver;

††††† b. Is residing with a caregiver but demonstrates maladaptive behavior that places him or her at significant risk of injury or jeopardy if the caregiver is unable to effectively manage the behavior or the risk it presents, resulting in the need for removal from the home to a more structured setting; or

††††† c. Demonstrates behavior that may result in potential legal problems if not ameliorated;

††††† 14. May utilize a modular home only if the:

††††† a. Wheels are removed;

††††† b. Home is anchored to a permanent foundation; and

††††† c. Windows are of adequate size for an adult to use as an exit in an emergency;

††††† 15. Shall not utilize a motor home;

††††† 16. Shall provide a sleeping room which ensures that an ABI recipient:

††††† a. Does not share a room with an individual of the opposite gender who is not the ABI recipient's spouse;

††††† b. Does not share a room with an individual who presents a potential threat; and

††††† c. Has a separate bed equipped with substantial springs, a clean and comfortable mattress, and clean bed linens as required for the ABI recipient's health and comfort; and

††††† 17. Shall provide service and training to obtain the outcomes for the ABI recipient as identified in the approved plan of care;

††††† (f) Supervised residential care level III services, which:

††††† 1. Shall be provided by:

††††† a. A community mental health center licensed and operating in accordance with 902 KAR 20:091 and certified at least annually by the department; or

††††† b. An ABI provider;

††††† 2. Shall not be provided to an ABI recipient unless the recipient has been authorized to receive residential care by the departmentís residential review committee which shall:

††††† a. Consider applications for residential care in the order in which the applications are received;

††††† b. Base residential care decisions on the following factors:

††††† (i) Whether the applicant resides with a caregiver or not;

††††† (ii) Whether the applicant resides with a caregiver but demonstrates maladaptive behavior which places the applicant at significant risk of injury or jeopardy if the caregiver is unable to effectively manage the applicantís behavior or the risk it poses, resulting in the need for removal from the home to a more structured setting; or

††††† (iii) Whether the applicant demonstrates behavior which may result in potential legal problems if not ameliorated;

††††† c. Be comprised of three (3) Cabinet for Health and Family Services employees:

††††† (i) With professional or personal experience with brain injury or other cognitive disabilities; and

††††† (ii) None of whom shall be supervised by the manager of the acquired brain injury branch; and

††††† d. Only consider applications at a monthly committee meeting if the applications were received at least three (3) business days before the committee convenes;

††††† 3. Shall be provided in a single family home, duplex or apartment building to an ABI recipient who lives alone or with an unrelated roommate;

††††† 4. Shall not be provided to more than two (2) ABI recipients simultaneously in one (1) apartment or home;

††††† 5. Shall not be provided in more than two (2) apartments in one (1) building;

††††† 6. Shall, if provided in an apartment building, have staff:

††††† a. Available twenty-four (24) hours per day and seven (7) days per week; and

††††† b. Who do not reside in a dwelling occupied by an ABI recipient;

††††† 7. Shall provide less than twelve (12) hours of supervision or support in the residence based on an individualized plan developed by the provider to promote increased independence which shall:

††††† a. Contain provisions necessary to ensure the recipientís health, safety, and welfare;

††††† b. Be approved by the recipientís treatment team, with the approval documented by the provider; and

††††† c. Contain periodic reviews and updates based on changes, if any, in the recipientís status;

††††† 8. Shall include assistance and training with daily living skills including:

††††† a. Ambulating;

††††† b. Dressing;

††††† c. Grooming;

††††† d. Eating;

††††† e. Toileting;

††††† f. Bathing;

††††† g. Meal planning;

††††† h. Grocery shopping;

††††† i. Meal preparation;

††††† j. Laundry;

††††† k. Budgeting and financial matters;

††††† l. Home care and cleaning;

††††† m. Leisure skill instruction; or

††††† n. Self-medication instruction;

††††† 9. Shall include social skills training including the reduction or elimination of maladaptive behaviors in accordance with the individualís plan of care;

††††† 10. Shall include provision or arrangement of transportation to services, activities, or medical appointments as needed;

††††† 11. Shall include accompanying or assisting an ABI recipient while the recipient utilizes transportation services as specified in the recipientís plan of care;

††††† 12. Shall include participation in medical appointments or follow-up care as directed by the medical staff;

††††† 13. Shall be documented by a detailed staff note which shall document:

††††† a. Progress toward goals and objectives identified in the approved plan of care;

††††† b. The date of the service;

††††† c. The beginning and ending time of the service;

††††† d. The signature and title of the individual providing the service; and

††††† e. Evidence of at least one (1) daily face-to-face contact with the ABI recipient;

††††† 14. Shall not include the cost of room and board;

††††† 15. Shall be provided to an ABI recipient who:

††††† a. Does not reside with a caregiver;

††††† b. Is residing with a caregiver but demonstrates maladaptive behavior that places him or her at significant risk of injury or jeopardy if the caregiver is unable to effectively manage the behavior or the risk it presents, resulting in the need for removal from the home to a more structured setting; or

††††† c. Demonstrates behavior that may result in potential legal problems if not ameliorated;

††††† 16. May utilize a modular home only if the:

††††† a. Wheels are removed;

††††† b. Home is anchored to a permanent foundation; and

††††† c. Windows are of adequate size for an adult to use as an exit in an emergency;

††††† 17. Shall not utilize a motor home;

††††† 18. Shall provide a sleeping room which ensures that an ABI recipient:

††††† a. Does not share a room with an individual of the opposite gender who is not the ABI recipient's spouse;

††††† b. Does not share a room with an individual who presents a potential threat; and

††††† c. Has a separate bed equipped with substantial springs, a clean and comfortable mattress, and clean bed linens as required for the ABI recipient's health and comfort; and

††††† 19. Shall provide service and training to obtain the outcomes for the ABI recipient as identified in the approved plan of care;

††††† (g) Counseling services which:

††††† 1. Shall be designed to help an ABI waiver service recipient resolve personal issues or interpersonal problems resulting from his or her ABI;

††††† 2. Shall assist a family member in implementing an ABI waiver service recipientís approved plan of care;

††††† 3. In a severe case, shall be provided as an adjunct to behavioral programming;

††††† 4. Shall include substance abuse or chemical dependency treatment, if needed;

††††† 5. Shall include building and maintaining healthy relationships;

††††† 6. Shall develop social skills or the skills to cope with and adjust to the brain injury;

††††† 7. Shall increase knowledge and awareness of the effects of an ABI;

††††† 8. May include a group therapy service if the service is:

††††† a. Provided to a minimum of two (2) and a maximum of eight (8) ABI recipients; and

††††† b. Included in the recipientís approved plan of care for:

††††† (i) Substance abuse or chemical dependency treatment, if needed;

††††† (ii) Building and maintaining healthy relationships;

††††† (iii) Developing social skills;

††††† (iv) Developing skills to cope with and adjust to a brain injury, including the use of cognitive remediation strategies consisting of the development of compensatory memory and problem solving strategies, and the management of impulsivity; and

††††† (v) Increasing knowledge and awareness of the effects of the acquired brain injury upon the ABI recipientís functioning and social interactions;

††††† 9. Shall be provided by:

††††† a. A psychiatrist;

††††† b. A psychologist;

††††† c. A psychologist with autonomous functioning;

††††† d. A licensed psychological associate;

††††† e. A licensed clinical social worker;

††††† f. A clinical nurse specialist with a masterís degree in psychiatric nursing;

††††† g. An advanced practice registered nurse (APRN); or

††††† h. A certified alcohol and drug counselor;

††††† i. A licensed marriage and family therapist; or

††††† j. A licensed professional clinical counselor; and

††††† 10. Shall be documented by a detailed staff note which shall include:

††††† a. Progress toward the goals and objectives established in the plan of care;

††††† b. The date of the service;

††††† c. The beginning and ending time; and

††††† d. The signature and title of the individual providing the service;

††††† (h) Occupational therapy which shall be:

††††† 1. A physician-ordered evaluation of an ABI recipientís level of functioning by applying diagnostic and prognostic tests;

††††† 2. Physician-ordered services in a specified amount and duration to guide an ABI recipient in the use of therapeutic, creative, and self-care activities to assist the ABI recipient in obtaining the highest possible level of functioning;

††††† 3. Exclusive of maintenance or the prevention of regression;

††††† 4. Provided by an occupational therapist or an occupational therapy assistant if supervised by an occupation therapist in accordance with 201 KAR 28:130; and

††††† 5. Documented by a detailed staff note which shall include:

††††† a. Progress toward goal and objectives identified in the approved plan of care;

††††† b. The date of the service;

††††† c. Beginning and ending time; and

††††† d. The signature and title of the individual providing the service;

††††† (i) Personal care services which shall:

††††† 1. Include the retraining of an ABI waiver service recipient in the performance of an activity of daily living by using repetitive, consistent and ongoing instruction and guidance;

††††† 2. Be provided by:

††††† a. An adult day health care center licensed and operating in accordance with 902 KAR 20:066;

††††† b. A home health agency licensed and operating in accordance with 902 KAR 20:081;

††††† c. A personal services agency; or

††††† d. Another ABI provider;

††††† 3. Include the following activities of daily living:

††††† a. Eating, bathing, dressing or personal hygiene;

††††† b. Meal preparation; and

††††† c. Housekeeping chores including bed-making, dusting and vacuuming;

††††† 4. Be documented by a detailed staff note which shall include:

††††† a. Progress toward goal and objectives identified in the approved plan of care;

††††† b. The date of the service;

††††† c. Beginning and ending time; and

††††† d. The signature and title of the individual providing the service; and

††††† 5. Not be provided to an ABI recipient who receives supervised residential care

††††† (j) A respite service which shall:

††††† 1. Be provided only to an ABI recipient unable to administer self-care;

††††† 2. Be provided by a:

††††† a. Nursing facility;

††††† b. Community mental health center;

††††† c. Home health agency;

††††† d. Supervised residential care provider; or

††††† e. Community habilitation program;

††††† 3. Be provided on a short-term basis due to absence or need for relief of an individual providing care to an ABI recipient;

††††† 4. Be limited to 336 hours in a twelve (12) month period unless an individual's normal caregiver is unable to provide care due to a:

††††† a. Death in the family;

††††† b. Serious illness; or

††††† c. Hospitalization;

††††† 5. Not be provided to an ABI recipient who receives supervised residential care;

††††† 6. Not include the cost of room and board if provided in a nursing facility; and

††††† 7. Be documented by a detailed staff note which shall include:

††††† a. Progress toward goals and objectives identified in the approved plan of care;

††††† b. The date of the service;

††††† c. The beginning and ending time; and

††††† d. The signature and title of the individual providing the service;

††††† (k) Speech, hearing and language services which shall be:

††††† 1. A physician-ordered evaluation of an ABI recipient with a speech, hearing or language disorder;

††††† 2. A physician-ordered habilitative service in a specified amount and duration to assist an ABI recipient with a speech and language disability in obtaining the highest possible level of functioning;

††††† 3. Exclusive of maintenance or the prevention of regression;

††††† 4. Provided by a speech language pathologist; and

††††† 5. Documented by a detailed staff note which shall include:

††††† a. Progress toward goals and objectives identified in the approved plan of care;

††††† b. The date of the service;

††††† c. The beginning and ending time; and

††††† d. The signature and title of the individual providing the service;

††††† (l) Adult day training services which shall:

††††† 1. Be provided by:

††††† a. An adult day health care center which is certified by the department and licensed and operating in accordance with 902 KAR 20:066;

††††† b. An outpatient rehabilitation facility which is certified by the department and licensed and operating in accordance with 902 KAR 20:190;

††††† c. A community mental health center licensed and operating in accordance with 902 KAR 20:091;

††††† d. A community habilitation program;

††††† e. A sheltered employment program; or

††††† f. A therapeutic rehabilitation program;

††††† 2. Rehabilitate, retrain and reintegrate an individual into the community;

††††† 3. Not exceed a staffing ratio of five (5) ABI recipients per one (1) staff person, unless an ABI recipient requires individualized special service;

††††† 4. Include the following services:

††††† a. Social skills training related to problematic behaviors identified in the recipient's plan of care;

††††† b. Sensory or motor development;

††††† c. Reduction or elimination of a maladaptive behavior;

††††† d. Prevocational; or

††††† e. Teaching concepts and skills to promote independence including:

††††† (i) Following instructions;

††††† (ii) Attendance and punctuality;

††††† (iii) Task completion;

††††† (iv) Budgeting and money management;

††††† (v) Problem solving; or

††††† (vi) Safety;

††††† 5. Be provided in a nonresidential setting;

††††† 6. Be developed in accordance with an ABI waiver service recipientís overall approved plan of care;

††††† 7. Reflect the recommendations of an ABI waiver service recipientís interdisciplinary team;

††††† 8. Be appropriate:

††††† a. Given an ABI waiver service recipientís age, level of cognitive and behavioral function and interest;

††††† b. Given an ABI waiver service recipientís ability prior to and since his or her injury; and

††††† c. According to the approved plan of care and be therapeutic in nature and not diversional;

††††† 9. Be coordinated with occupational, speech, or other rehabilitation therapy included in an ABI waiver service recipientís plan of care;

††††† 10. Provide an ABI waiver service recipient with an organized framework within which to function in his or her daily activities;

††††† 11. Entail frequent assessments of an ABI waiver service recipientís progress and be appropriately revised as necessary; and

††††† 12. Be documented by a detailed staff note which shall include:

††††† a. Progress toward goal and objectives identified in the approved plan of care;

††††† b. The date of the service;

††††† c. The beginning and ending time;

††††† d. The signature and title of the individual providing the service; and

††††† e. A monthly summary that assesses the participantís status related to the approved plan of care;

††††† (m) Supported employment services which shall be:

††††† 1. Intensive, ongoing services for an ABI recipient to maintain paid employment in an environment in which an individual without a disability is employed;

††††† 2. Provided by a:

††††† a. Supported employment provider;

††††† b. Sheltered employment provider; or

††††† c. Structured day program provider;

††††† 3. Provided one-on-one;

††††† 4. Unavailable under a program funded by either the Rehabilitation Act of 1973 (29 U.S.C. Chapter 16) or Pub.L. 99-457 (34 C.F.R. Parts 300 to 399), proof of which shall be documented in the ABI recipient's file;

††††† 5. Limited to forty (40) hours per week alone or in combination with structured day services;

††††† 6. An activity needed to sustain paid work by an ABI recipient receiving waiver services including supervision and training;

††††† 7. Exclusive of work performed directly for the supported employment provider; and

††††† 8. Documented by a time and attendance record which shall include:

††††† a. Progress towards the goals and objectives identified in the plan of care;

††††† b. The date of service;

††††† c. The beginning and ending time; and

††††† d. The signature and title of the individual providing the service;

††††† (n) Specialized medical equipment and supplies which shall:

††††† 1. Include durable and nondurable medical equipment, devices, controls, appliances or ancillary supplies;

††††† 2. Enable an ABI recipient to increase his or her ability to perform daily living activities or to perceive, control or communicate with the environment;

††††† 3. Be ordered by a physician and submitted on a Request for Equipment form, MAP-95, and include three (3) estimates for vision and hearing;

††††† 4. Include equipment necessary to the proper functioning of specialized items;

††††† 5. Not be available through the departmentís durable medical equipment, vision or hearing programs;

††††† 6. Not be necessary for life support;

††††† 7. Meet applicable standards of manufacture, design and installation; and

††††† 8. Exclude those items which are not of direct medical or remedial benefit to an ABI recipient;

††††† (o) Environmental modifications which shall:

††††† 1. Be provided in accordance with applicable state and local building codes;

††††† 2. Be provided to an ABI recipient if:

††††† a. Ordered by a physician;

††††† b. Prior-authorized by the department;

††††† c. Submitted on a Request for Equipment form, MAP-95, by a case manager or support broker;

††††† d. Specified in an ABI recipientís approved plan of care;

††††† e. Necessary to enable an ABI recipient to function with greater independence within his or her home; and

††††† f. Without the modification, the ABI recipient would require institutionalization;

††††† 3. Not include a vehicle modification;

††††† 4. Be limited to no more than $2,000 for an ABI recipient in a twelve (12) month period; and

††††† 5. If entailing:

††††† a. Electrical work, be provided by a licensed electrician; or

††††† b. Plumbing work, be provided by a licensed plumber;

††††† (p) An assessment which shall:

††††† 1. Be a comprehensive assessment which shall identify:

††††† a. An ABI waiver recipientís needs; and

††††† b. Services that an ABI recipientís family cannot manage or arrange for the recipient;

††††† 2. Evaluate an ABI waiver recipientís physical health, mental health, social supports, and environment;

††††† 3. Be requested by:

††††† a. An individual requesting ABI waiver services;

††††† b. A family member of the individual requesting ABI services; or

††††† c. A legal representative of the individual requesting ABI services;

††††† 4. Be conducted:

††††† a. By an ABI case manager or support broker; and

††††† b. Within seven (7) calendar days of receipt of the request for an assessment;

††††† 5. Include at least one (1) face-to-face contact in the ABI waiver recipientís home between the assessor, the ABI waiver recipient, and, if appropriate, the recipientís family;

††††† 6. Not be reimbursable if the individual no longer meets ABI program eligibility requirements; or

††††† (q) A reassessment, which shall:

††††† 1. Be performed at least once every twelve (12) months;

††††† 2. Be conducted:

††††† a. Using the same procedures as for an assessment; and

††††† b. By an ABI case manager or support broker;

††††† 3. Be timely conducted to enable the results to be submitted to the department within three (3) weeks prior to the expiration of the current level of care certification to ensure that certification is consecutive;

††††† 4. Not be reimbursable if the individual no longer meets ABI program eligibility requirements; and

††††† 5. Not be retroactive.

 

††††† Section 5. Exclusions of the Acquired Brain Injury Waiver Program. A condition included in the following list shall not be considered an acquired brain injury requiring specialized rehabilitation:

††††† (1) A stroke treatable in a nursing facility providing routine rehabilitation services;

††††† (2) A spinal cord injury for which there is no known or obvious injury to the intracranial central nervous system;

††††† (3) Progressive dementia or another condition related to mental impairment that is of a chronic degenerative nature, including senile dementia, organic brain disorder, Alzheimerís Disease, alcoholism or another addiction;

††††† (4) A depression or a psychiatric disorder in which there is no known or obvious central nervous system damage;

††††† (5) A birth defect;

††††† (6) Mental retardation without an etiology to an acquired brain injury;

††††† (7) A condition which causes an individual to pose a level of danger or an aggression which is unable to be managed and treated in a community; or

††††† (8) Determination that the recipient has met his or her maximum rehabilitation potential.

 

††††† Section 6. Incident Reporting Process. (1) An incident shall be documented on an Incident Report form.

††††† (2) There shall be three (3) classes of incidents as follows:

††††† (a) A Class I incident which shall:

††††† 1. Be minor in nature and not create a serious consequence;

††††† 2. Not require an investigation by the provider agency;

††††† 3. Be reported to the case manager or support broker within twenty-four (24) hours;

††††† 4. Be reported to the guardian as directed by the guardian; and

††††† 5. Be retained on file at the provider and case management or support brokerage agency;

††††† (b) A Class II incident which shall:

††††† 1.a. Be serious in nature; or

††††† b. Include a medication error;

††††† 2. Require an investigation which shall be initiated by the provider agency within twenty-four (24) hours of discovery and shall involve the case manager or support broker; and

††††† 3. Be reported to the following by the provider agency:

††††† a. The case manager or support broker within twenty-four (24) hours of discovery;

††††† b. The guardian within twenty-four (24) hours of discovery; and

††††† c. BISB within twenty-four (24) hours of discovery followed by a complete written report of the incident investigation and follow-up within ten (10) calendar days of discovery; and

††††† (c) A Class III incident which shall:

††††† 1.a. Be grave in nature;

††††† b. Involve suspected abuse, neglect or exploitation;

††††† c. Involve a medication error which requires a medical intervention or hospitalization;

††††† d. Be an admission to an acute or psychiatric hospital;

††††† e. Involve the use of a chemical or physical restraint; or

††††† f. Be a death;

††††† 2. Be Immediately investigated by the provider agency, and the investigation shall involve the case manager or support broker; and

††††† 3. Be reported by the provider agency to:

††††† a. The case manager or support broker within eight (8) hours of discovery;

††††† b. DCBS, immediately upon discovery, if involving suspected abuse, neglect, or exploitation in accordance with KRS Chapter 209;

††††† c. The guardian within eight (8) hours of discovery; and

††††† d. BISB, within eight (8) hours of discovery, followed by a complete written report of the incident investigation and follow-up within seven (7) calendar days of discovery. If an incident occurs after 5 p.m. EST on a weekday or occurs on a weekend or holiday, notification to BISB shall occur on the following business day.

††††† (3) The following documentation with a complete written report shall be submitted for a death:

††††† (a) The plan of care in effect at the time of death;

††††† (b) The list of prescribed medications, including PRN medications, in effect at the time of death;

††††† (c) The crisis plan in effect at the time of death;

††††† (d) Medication administration review (MAR) forms for the current and previous month;

††††† (e) Staff notes from the current and previous month including details of physician and emergency room visits;

††††† (f) Any additional information requested by the department;

††††† (g) A coroner's report; and

††††† (h) If performed, an autopsy report.

 

††††† Section 7. ABI Waiting List. (1) An individual of age eighteen (18) years or older applying for an ABI waiver service shall be placed on a statewide waiting list which shall be maintained by the department.

††††† (2) In order to be placed on the ABI waiting list, an individual shall submit to the department a completed MAP-26, Program Application Kentucky Medicaid Program Acquired Brain Injury (ABI) Waiver Services Program, and a completed MAP-10, Waiver Services Ė Physicianís Recommendation.

††††† (3) The order of placement on the ABI waiting list shall be determined by chronological date of receipt of the completed MAP-10, Waiver Services Ė Physicianís Recommendation, and by category of need.

††††† (4) The ABI waiting list categories of need shall be emergency or nonemergency.

††††† (5) To be placed in the emergency category of need, an individual shall be determined by the emergency review committee to meet the emergency category criteria established in subsection (8) of this section.

††††† (6) The emergency review committee shall:

††††† (a) Be comprised of three (3) individuals from the department:

††††† 1. Who shall each have professional or personal experience with brain injury or cognitive disabilities; and

††††† 2. None of whom shall be supervised by the branch manager of the departmentís acquired brain injury branch;

††††† (b) Meet during the fourth (4th) week of each month to review and consider applications for the acquired brain injury waiver program to determine if applicants meet the emergency category of need criteria established in subsection (8) of this subsection.

††††† (7) A completed MAP-26, Program Application Kentucky Medicaid Program Acquired Brain Injury (ABI) Waiver Services Program, and a completed MAP-10, Waiver Services Ė Physicianís Recommendation for an ABI waiting list applicant shall be submitted to the department no later than three (3) business days prior to the fourth (4th) week of each month in order to be considered by the emergency review committee during that monthís emergency review committee meeting.

††††† (8) An applicant shall meet the emergency category of need criteria if the applicant is currently demonstrating behavior related to his or her acquired brain injury:

††††† (a) That places the individual, caregiver, or others at risk of significant harm; or

††††† (b) Which has resulted in the applicant being arrested.

††††† (9) An applicant who does not meet the emergency category of need criteria established in subsection (8) of this subsection shall be considered to be in the nonemergency category of need.

††††† (10) In determining chronological status of an applicant, the original date of receipt of the MAP-26, Program Application Kentucky Medicaid Program Acquired Brain Injury (ABI) Waiver Services Program, and the MAP-10, Waiver Services Ė Physicianís Recommendation, shall be maintained and not change if an individual is moved from one (1) category of need to another.

††††† (11) A written statement by a physician or other qualified mental health professional shall be required to support the validation of risk of significant harm to a recipient or caregiver.

††††† (12) Written documentation by law enforcement or court personnel shall be required to support the validation of a history of arrest.

††††† (13) If multiple applications are received on the same date, a lottery shall be held to determine placement on the waiting list within each category of need.

††††† (14) A written notification of placement on the waiting list shall be mailed to the individual or his or her legal representative and case management provider if identified.

††††† (15) Maintenance of the ABI waiting list shall occur as follows:

††††† (a) The department shall, at a minimum, annually update the waiting list during the birth month of an individual;

††††† (b) If an individual is removed from the ABI waiting list, written notification shall be mailed by the department to the individual and his or her legal representative and also the ABI case manager; and

††††† (c) The requested data shall be received by the department within thirty (30) days from the date on the written notice required by subsection (14) of this section.

††††† (16) Reassignment of an applicantís category of need shall be completed based on the updated information and validation process.

††††† (17) An individual or legal representative may submit a request for consideration of movement from one category of need to another at any time that an individualís status changes.

††††† (18) An individual shall be removed from the ABI waiting list if:

††††† (a) After a documented attempt, the department is unable to locate the individual or his or her legal representative;

††††† (b) The individual is deceased;

††††† (c) The individual or individualís legal representative refuses the offer of ABI placement for services and does not request to be maintained on the waiting list; or

††††† (d) An ABI placement for services offer is refused by the individual or legal representative and he or she does not, without good cause, complete the Acquired Brain Injury Waiver Services Program Application form, MAP-26, within sixty (60) days of the placement allocation date.

††††† 1. The individual or individualís legal representative shall have the burden of providing documentation of good cause including:

††††† a. A signed statement by the individual or the legal representative;

††††† b. Copies of letters to providers; and

††††† c. Copies of letters from providers.

††††† 2. Upon receipt of documentation of good cause, the department shall grant one (1) sixty (60) day extension in writing.

††††† (19) If an individual is removed from the ABI waiting list, written notification shall be mailed by the department to the individual or individualís legal representative and the ABI case manager.

††††† (20) The removal of an individual from the ABI waiting list shall not prevent the submittal of a new application at a later date.

††††† (21) Potential funding allocated for services for an individual shall be based upon:

††††† (a) The individualís category of need; and

††††† (b) The individualís chronological date of placement on the waiting list.

 

††††† Section 8. Consumer Directed Option. (1) Covered services and supports provided to an ABI recipient participating in CDO shall include:

††††† (a) Home and community support services;

††††† (b) Community day support services;

††††† (c) Goods or services; or

††††† (d) Financial management.

††††† (2) A home and community support service shall:

††††† (a) Be available only under the consumer directed option;

††††† (b) Be provided in the consumerís home or in the community;

††††† (c) Be based upon therapeutic goals;

††††† (d) Not be diversional in nature;

††††† (e) Not be provided to an individual if the same or similar service is being provided to the individual via non-CDO ABI services; and

††††† (f)1. Be respite for the primary caregiver; or

††††† 2. Be supports and assistance related to chosen outcomes to facilitate independence and promote integration into the community for an individual residing in his or her own home or the home of a family member and may include:

††††† a. Routine household tasks and maintenance;

††††† b. Activities of daily living;

††††† c. Personal hygiene;

††††† d. Shopping;

††††† e. Money management;

††††† f. Medication management;

††††† g. Socialization;

††††† h. Relationship building;

††††† i. Meal planning;

††††† j. Meal preparation;

††††† k. Grocery shopping; or

††††† l. Participation in community activities.

††††† (3) A community day support service shall:

††††† (a) Be available only under the consumer-directed option;

††††† (b) Be provided in a community setting;

††††† (c) Be based upon therapeutic goals;

††††† (d) Not be diversional in nature;

††††† (e) Be tailored to the consumerís specific personal outcomes related to the acquisition, improvement, and retention of skills and abilities to prepare and support the consumer for:

††††† 1. Work;

††††† 2. Community activities;

††††† 3. Socialization;

††††† 4. Leisure; or

††††† 5. Retirement activities; and

††††† (f) Not be provided to an individual if the same or similar service is being provided to the individual via non-CDO ABI services.

††††† (4) Goods or services shall:

††††† (a) Be individualized;

††††† (b) Be utilized to:

††††† 1. Reduce the need for personal care; or

††††† 2. Enhance independence within the consumerís home or community;

††††† (c) Not include experimental goods or services; and

††††† (d) Not include chemical or physical restraints.

††††† (5) To be covered, a CDO service shall be specified in a consumerís plan of care.

††††† (6) Reimbursement for a CDO service shall not exceed the departmentís allowed reimbursement for the same or a similar service provided in a non-CDO ABI setting.

††††† (7) A consumer, including a married consumer, shall choose providers and the choice of CDO provider shall be documented in his or her plan of care.

††††† (8) A consumer may designate a representative to act on the consumer's behalf. The CDO representative shall:

††††† (a) Be twenty-one (21) years of age or older;

††††† (b) Not be monetarily compensated for acting as the CDO representative or providing a CDO service; and

††††† (c) Be appointed by the consumer on a MAP-2000 form.

††††† (9) A consumer may voluntarily terminate CDO services by completing a MAP-2000 and submitting it to the support broker.

††††† (10) The department shall immediately terminate a consumer from CDO services if:

††††† (a) Imminent danger to the consumerís health, safety, or welfare exists;

††††† (b) The recipientís plan of care indicates he or she requires more hours of service than the program can provide, thus jeopardizing the recipientís safety or welfare due to being left alone without a caregiver present; or

††††† (c) The recipient, caregiver, family member, or guardian threatens or intimidates a support broker or other CDO staff.

††††† (11) The department may terminate a consumer from CDO services if it determines that the consumerís CDO provider has not adhered to the plan of care.

††††† (12) Prior to a consumerís termination from CDO services, the support broker shall:

††††† (a) Notify the assessment or reassessment service provider of potential termination;

††††† (b) Assist the consumer in developing a resolution and prevention plan;

††††† (c) Allow at least thirty (30), but no more than ninety (90), days for the consumer to resolve the issue, develop and implement a prevention plan, or designate a CDO representative;

††††† (d) Complete and submit to the department a MAP-2000 form terminating the consumer from CDO services if the consumer fails to meet the requirements in paragraph (c) of this subsection; and

††††† (e) Assist the consumer in transitioning back to traditional ABI services.

††††† (13) Upon an involuntary termination of CDO services, the department shall:

††††† (a) Notify a consumer in writing of its decision to terminate the consumerís CDO participation; and

††††† (b) Inform the consumer of the right to appeal the departmentís decision in accordance with Section 10 of this administrative regulation.

††††† (14) A CDO provider:

††††† (a) Shall be selected by the consumer;

††††† (b) Shall submit a completed Kentucky Consumer Directed Option Employee Provider Contract to the support broker;

††††† (c) Shall be eighteen (18) years of age or older;

††††† (d) Shall be a citizen of the United States with a valid Social Security number or possess a valid work permit if not a U.S. citizen;

††††† (e) Shall be able to communicate effectively with the consumer, consumer representative, or family;

††††† (f) Shall be able to understand and carry out instructions;

††††† (g) Shall be able to keep records as required by the consumer;

††††† (h) Shall submit to a criminal background check conducted by the Administrative Office of the Courts if the individual is a Kentucky resident or equivalent out-of-state agency if the individual resided or worked outside Kentucky during the year prior to selection as a provider of CDO services;

††††† (i) Shall submit to a check of the central registry maintained in accordance with 922 KAR 1:470 and not be found on the registry:

††††† 1. A consumer may employ a provider prior to a central registry check result being obtained for up to thirty (30) days; and

††††† 2. If a consumer does not obtain a central registry check result within thirty (30) days of employing a provider, the consumer shall cease employment of the provider until a favorable result is obtained;

††††† (j) Shall submit to a check of the nurse aide abuse registry maintained in accordance with 906 KAR 1:100 and not be found on the registry;

††††† (k) Shall not have pled guilty or been convicted of committing a sex crime or violent crime as defined in KRS 17.165 (1) through (3);

††††† (l) Shall complete training on the reporting of abuse, neglect or exploitation in accordance with KRS 209.030 or 620.030 and on the needs of the consumer;

††††† (m) Shall be approved by the department;

††††† (n) Shall maintain and submit timesheets documenting hours worked; and

††††† (o) Shall be a friend, spouse, parent, family member, other relative, employee of a provider agency, or other person hired by the consumer.

††††† (15) A parent, parents combined, or a spouse shall not provide more than forty (40) hours of services in a calendar week (Sunday through Saturday) regardless of the number of family members who receive waiver services.

††††† (16)(a) The department shall establish a budget for a consumer based on the individualís historical costs minus five (5) percent to cover costs associated with administering the consumer directed option. If no historical cost exists for the consumer, the consumer's budget shall equal the average per capita historical costs of ABI recipients minus five (5) percent.

††††† (b) Cost of services authorized by the department for the individual's prior year plan of care but not utilized may be added to the budget if necessary to meet the individual's needs.

††††† (c) The department may adjust a consumer's budget based on the consumer's needs and in accordance with paragraphs (d) and (e) of this subsection.

††††† (d) A consumer's budget shall not be adjusted to a level higher than established in paragraph (a) of this subsection unless:

††††† 1. The consumer's support broker requests an adjustment to a level higher than established in paragraph (a) of this subsection; and

††††† 2. The department approves the adjustment.

††††† (e) The department shall consider the following factors in determining whether to allow for a budget adjustment:

††††† 1. If the proposed services are necessary to prevent imminent institutionalization;

††††† 2. The cost effectiveness of the proposed services;

††††† 3. Protection of the consumer's health, safety, and welfare; and

††††† 4. If a significant change has occurred in the recipientís:

††††† a. Physical condition resulting in additional loss of function or limitations to activities of daily living and instrumental activities of daily living;

††††† b. Natural support system; or

††††† c. Environmental living arrangement resulting in the recipientís relocation.

††††† (f) A consumerís budget shall not exceed the average per capita cost of services provided to individuals with a brain injury in a nursing facility.

††††† (17) Unless approved by the department pursuant to subsection (16)(b) through (e) of this section, if a CDO service is expanded to a point in which expansion necessitates a budget allowance increase, the entire service shall only be covered via a traditional (non-CDO) waiver service provider.

††††† (18) A support broker shall:

††††† (a) Provide needed assistance to a consumer with any aspect of CDO or blended services;

††††† (b) Be available to a consumer by phone or in person:

††††† 1. Twenty-four (24) hours per day, seven (7) days per week; and

††††† 2. To assist the consumer in obtaining community resources as needed;

††††† (c) Comply with applicable federal and state laws and requirements;

††††† (d) Continually monitor a consumer's health, safety, and welfare; and

††††† (e) Complete or revise a plan of care using the Person Centered Planning: Guiding Principles.

††††† (19) For a CDO participant, a support broker may conduct an assessment or reassessment.

††††† (20) Financial management shall:

††††† (a) Include managing, directing, or dispersing a consumerís funds identified in the consumerís approved CDO budget;

††††† (b) Include payroll processing associated with the individual hired by a consumer or the consumerís representative;

††††† (c) Include:

††††† 1. Withholding local, state, and federal taxes; and

††††† 2. Making payments to appropriate tax authorities on behalf of a consumer;

††††† (d) Be performed by an entity that:

††††† 1. Is enrolled as a Medicaid provider in accordance with 907 KAR 1:672;

††††† 2. Is currently compliant with 907 KAR 1:671;

††††† 3. Has at least two (2) years of experience working with individuals with an acquired brain injury; and

††††† (e) Include preparation of fiscal accounting and expenditure reports for:

††††† 1. A consumer or consumerís representative; and

††††† 2. The department.

 

††††† Section 9. Electronic Signature Usage. (1) The creation, transmission, storage, or other use of electronic signatures and documents shall comply with the requirements established in KRS 369.101 to 369.120.

††††† (2) An ABI provider which chooses to use electronic signatures shall:

††††† (a) Develop and implement a written security policy which shall:

††††† 1. Be adhered to by each of the provider's employees, officers, agents, and contractors;

††††† 2. Identify each electronic signature for which an individual has access; and

††††† 3. Ensure that each electronic signature is created, transmitted, and stored in a secure fashion;

††††† (b) Develop a consent form which shall:

††††† 1. Be completed and executed by each individual using an electronic signature;

††††† 2.Attest to the signature's authenticity; and

††††† 3. Include a statement indicating that the individual has been notified of his or her responsibility in allowing the use of the electronic signature; and

††††† (c) Provide the department, immediately upon request, with:

††††† 1. A copy of the provider's electronic signature policy;

††††† 2. The signed consent form; and

††††† 3. The original filed signature.

 

††††† Section 10. Appeal Rights. (1) An appeal of a department decision regarding a recipient or applicant based upon an application of this administrative regulation shall be in accordance with 907 KAR 1:563.

††††† (2) An appeal of a department decision regarding Medicaid eligibility of an individual based upon an application of this administrative regulation shall be in accordance with 907 KAR 1:560.

††††† (3) An appeal of a department decision regarding a provider based upon an application of this administrative regulation shall be in accordance with 907 KAR 1:671.

 

††††† Section 11. Incorporation by Reference. (1) The following material is incorporated by reference:

††††† (a) "MAP-109, Prior Authorization for Waiver Services", July 2008 edition;

††††† (b) "MAP 24C, Admittance, Discharge or Transfer of an Individual in the ABI/SCL Program", August 2010 edition;

††††† (c) "MAP-26, Program Application Kentucky Medicaid Program Acquired Brain Injury (ABI) Waiver Services ProgramĒ, July 2008 edition;

††††† (d) "MAP-95, Request for Equipment Form", May 2010 edition;

††††† (e) "MAP-10, Waiver Services Ė Physicianís Recommendation", August 2010 edition;

††††† (f) "Incident Report", July 2008 edition;

††††† (g) "MAP-2000, Initiation/Termination of Consumer Directed Option (CDO)", July 2008 edition;

††††† (h) "MAP-350, Long Term Care Facilities and Home and Community Based Program Certification Form", July 2008 edition;

††††† (i) "Family Guide to the Rancho Levels of Cognitive Functioning", August 2006 edition;

††††† (j) "MAP-351, Medicaid Waiver Assessment", July 2008 edition;

††††† (k) "Mayo-Portland Adaptability Inventory-4", March 2003 edition;

††††† (l) "Person Centered Planning: Guiding Principles", March 2005 edition;

††††† (m) "MAP-4100a", September 2010 edition; and

††††† (n) ďKentucky Consumer Directed Option Employee Provider ContractĒ, May 4, 2007 edition.

††††† (2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Department for Medicaid Services, 275 East Main Street, Frankfort, Kentucky 40621, Monday through Friday, 8 a.m. to 4:30 p.m. (25 Ky.R. 2993; Am. 26 Ky.R. 400; eff. 8-16-99; 28 Ky.R. 1244; 1878; eff. 2-7-2002; 30 Ky.R. 1970; 2042; eff. 3-18-04; 31 Ky.R. 471; 720; eff. 11-5-04; 34 Ky.R. 460; 1050;1480; eff. 1-4-2008; 37 Ky.R. 585; Am. 1301; Am. 1460; eff. 12-1-2010; TAm eff. 9-30-2013.)