Home and Community Based Services Manual


4.15 Assessment Process

Introduction

The Home and Community Based Services (HCBS) assessment process determines the current level of independent support and unmet needs necessary to enable the potential or current participant to remain in the least restrictive environment.

Purpose

The purpose of the assessment shall: • Establish eligibility or continued eligibility for HCBS • Ensure adequacy in the development of the Person-Centered Care Plan (PCCP) • Offer the appropriate services available • Identify and facilitate referrals outside of the HCBS program • Inform the participant of qualified HCBS providers in the participant’s area • Coordinate HCBS with the selected HCBS provider to ensure delivery of services

Legal Representative/Confidentiality

For potential or current participants who have a legal representative (e.g., guardian, or someone with a Durable Power of Attorney (DPOA) in effect), it is required the legal guardian be informed of the assessment, sign necessary documents (e.g., Participant Choice Statement) and approve the authorization of services. In addition, if there is a signed Authorization for Disclosure of Consumer/Medical Health Information in effect, the person listed shall be informed. Additional information may be needed to complete the assessment. Care should be taken to ensure the confidentiality of the potential or current participant is not compromised. When assistance from a third party is necessary to complete the assessment process, this information shall be thoroughly documented in case record of the participant’s electronic case record.

InterRAI HC Assessment

The InterRAI HC guides comprehensive care and service planning in community-based settings. It focuses on the person’s functioning and quality of life by assessing needs, strengths, and preferences. Completion of the InterRAI HC shall be done at initial referral of services and at each annual reassessment. Based on the information gathered from the completed assessment, algorithms within the electronic case record system determine the participant’s nursing facility level of care for eligibility purposes. Additional guidance for facilitating an accurate and uniform assessment with the InterRAI HC is available in the InterRAI HC manual.

Scheduling An Assessment/Reassessment

Initial Assessment

Upon receipt of a request for an initial referral for HCBS, the Division of Senior and Disability (DSDS) staff shall schedule and complete a face-to-face visit with the potential participant for an initial assessment. The scheduling and completion of all initial assessments must be completed within fifteen (15) business days of the date the referral was received.

To schedule an initial assessment, DSDS staff shall:

  • Make a minimum of one (1) attempt by phone to contact the participant and/or legal guardian
  • Leave a message and include their contact information, and the date the initial referral will be closed if attempts to contact are unsuccessful
    • The closing date of the referral shall be at least ten (10) calendar days from the day the message was left.

NOTE: If the closing date is on a State Holiday or weekend, the next business day shall be considered the date to close the referral (e.g., if the 10th calendar day ends on Saturday, the next business day is Monday).

If a message cannot be left, DSDS staff shall:

  • Send the Participant Contact Letter, outlining a response date
    • The response date shall be at least ten (10) calendar days from the day the letter is sent.

DSDS staff shall close the case if no response is received by the date provided in the letter. The participant must initiate a new referral through the initial referral process.

The HCBS provider and/or the referring entity shall be notified of DSDS staff's attempts to contact the potential participant and informed of the closing date of the referral if no contact has been made. This provides an opportunity for the provider to assist with locating the potential participant.

If the participant and/or legal guardian contacts DSDS within the ten (10) calendar days, an assessment shall be scheduled. However, if the participant fails to attend the scheduled appointment as agreed upon, the HCBS referral will be closed on the same day. DSDS staff will send the Participant Contact Letter with the “Initial Missed Appointment” reason for closing. The participant must initiate a new referral if there is still a need for services.

Reassessment

All participants authorized for HCBS shall have a reassessment completed within 365 days from the last level of care determination. DSDS staff shall attempt to schedule a face-to-face reassessment; however, in certain instances, a reassessment may be performed by telephone.

To schedule a reassessment, DSDS staff shall:

  • Make a minimum of one (1) attempt to contact the participant and/or legal guardian by phone
  • Leave a message and include their contact information along with a response date if attempts are unsuccessful
    • The response date shall be at least ten (10) calendar days from the day the message was left.
    • An adverse action shall be sent if there is no response by the date outlined in the phone message. The participant and/or legal guardian have at least 10 calendar days to respond to the adverse action. If they fail to respond, the care plan and case shall be closed.
      NOTE: If the 10th calendar day is a weekend or holiday, the next business day shall be considered the response date (e.g., if the 10th calendar day ends on Saturday, the next business day is Monday).
  • If a message cannot be left, DSDS staff shall send an adverse action. The adverse action shall include the reason for contact.
    • The participant and/or legal guardian have at least ten (10) calendar days to respond from the day it was sent. If no response, the case shall be closed.

NOTE: The current care plan shall only be reauthorized if the closing date on the adverse action exceeds the end of the current authorization date.

If the participant and/or legal guardian contacts DSDS before the closing date on either of the above adverse actions, an assessment shall be scheduled. However, if the participant fails to attend the scheduled appointment as agreed upon, DSDS will initiate an adverse action. The participant and/or legal guardian must contact DSDS within ten (10) calendar days of the adverse action to reschedule the assessment.

If the assessment is rescheduled and the participant fails to attend the second appointment, DSDS will close the case based on the closing date of the original adverse action. No other contact attempts are needed. The participant must initiate a new referral if there is still a need for services.

NOTE: DSDS staff shall contact the HCBS provider to ensure the provider is aware of the attempt to contact the participant and assist in locating them.

Participant Contact Letter

The Participant Contact Letter shall include at a minimum, the following information:

  • DSDS staff's inability to contact the participant to schedule an HCBS face-to-face (re)assessment visit
  • The date the participant and/or legal guardian is to respond by
  • The legal reference
  • A DSDS staff contact number

The ten (10) calendar days shall begin the first business day after the Participant Contact Letter is mailed. If the 10th calendar day ends on a weekend or State Holiday, the next business day shall be considered the 10th day (e.g., if the 10th calendar day ends on Saturday, the next business day is Monday).

Assessment/Reassessment Process

The (re)assessment process provides a basis in establishing a PCCP and the decisions regarding HCBS authorization. A complete thorough assessment to include information and related documentation obtained during the assessment process will establish an appropriate PCCP.

Initial Assessments

Upon receipt, all initial referrals shall be prioritized by the immediacy of the need for an initial assessment and HCBS. The following are examples of high priority referrals:

  • Immediate discharge from a hospital or nursing facility
  • Significant breakdown of current support system
  • Catastrophic event
  • Adult Protective Services request to assist with the participant’s safety and well-being
  • Family Support Division referrals requesting Home and Community Based Medicaid (HCB) Medicaid, Qualified Income Trust (QIT) and Division of Assets

The assessment and all PCCP activities, including completion of the following, shall be completed as soon as possible, but not to exceed fifteen (15) business days from the receipt of the referral.

If the potential participant does not meet the necessary level of care for HCBS, DSDS staff shall initiate an adverse action. The case shall be closed with the appropriate action and date upon completion of the Adverse Action process.

Reassessments

A participant shall have a reassessment completed by DSDS staff or its designee to establish continued eligibility for services. The end date, which reflects the last full month within 365 days from the previous level of care determination, will be indicated as the due date for the reassessment. (The month the current care plan authorization expires.)

DSDS staff shall verify the participant’s Medicaid eligibility prior to a reassessment. If the participant is a Medicaid spenddown recipient, spenddown must be met at least once within the last three (3) months to remain eligible for HCBS. DSDS staff shall verify with the Family Support Division (FSD) if the participant has pending expenditures waiting to be entered before closing the case. DSDS staff shall thoroughly document contacts with FSD and any attempts for additional information in the electronic case record.

If the participant is no longer Medicaid eligible, DSDS staff or its designee shall follow the Adverse Action policy.

Individuals enrolled in certain Managed Care Health Plans are not eligible to receive HCBS authorized by DSDS staff. If HCBS cannot be authorized for the participant, DSDS staff shall send a Notice of Closure to the individual and include their Managed Care Health Plan information on it.

The InterRAI HC shall be reviewed by DSDS staff or its designee.

  • The reassessment shall reflect any change from the previous assessment.
  • All information discussed during the reassessment interview shall be thoroughly documented.
  • During the reassessment, DSDS staff, or its designee, shall determine the participant’s satisfaction with the HCBS they receive. DSDS staff or its designee shall follow the Provider Complaint protocol regarding any provider complaints.

DSDS staff or its designee shall develop a new PCCP to ensure the continuity of HCBS. All required documents shall be reviewed and completed at each reassessment including the Participant Choice Statement.

COOP Priority

Risk indicators will display on the participant screen of the participant’s electronic case record. This indicator is determined at the (re)assessment. These indicators are intended to assist the HCBS provider in prioritizing service delivery in instances such as temporary staffing shortages, natural or other disasters, and acts of terrorism.

Document the level of priority by evaluating circumstances (e.g., support system, confusion, and noncompliance) on the assessment tool. Risk indicator of one (1) shall be used when the lack of HCBS would pose a serious threat to the health, safety, and welfare of the participant. Discretion shall be used in assigning high risk. A fragile, unreliable or insufficient support system must be documented in the electronic case record justifying high risk status.

Goals

During the (re)assessment process, DSDS staff shall work with the participant to identify a personal goal. DSDS staff shall ensure the PCCP supports the goal when possible. Any barriers that may prevent the goal from being achieved shall be documented.

An appropriate goal shall reflect what the participant hopes to achieve through HCBS. DSDS staff shall encourage the participant to express a goal in their own words, which may reflect:

  • To remain in their home
  • To be able to walk again

A goal shall not be a statement of fact, such as:

  • They don’t feel well
  • They enjoy the meals they receive

Goals may come from the participant or legal representative. In the rare circumstance when a participant cannot verbalize a goal, a primary caregiver may provide the goal for the participant. Thorough case record documentation would be required in these instances. Case record documentation shall include:

  • The participant is unable to express a goal
  • Who the goal was provided by (the legal guardian or primary unpaid caregiver)
  • Name and relationship of the person providing the goal
Backup Plan

DSDS staff shall identify, in collaboration with the participant and/or legal guardian, details of a backup plan to be used in the event of an emergency, and when events such as weather or illness prevent service delivery by the HCBS provider(s). If the aide or attendant is not available, the participant and/or legal guardian shall provide a support system to ensure needs are met and continuation of services. Available assistance may vary, but all availability should be considered.

The backup plan shall identify a specific individual(s) available to assist when needed and may consist of the following:

  • Family, friends, a neighbor, collateral contacts, etc.

A brief, detailed summary of the support shall be provided and documented in the participant’s electronic case record to include:

  • The name, phone number and relationship of the individual providing the support
  • The specific tasks to be provided
  • The frequency of each task being provided (e.g., all meals prepared Monday, Wednesday and Friday, bathing on Tuesday and Thursday)

NOTE: If multiple supports are identified, DSDS staff shall ensure all contact information, specific tasks, and the frequency of each task are documented specifically for those providing the support. 911 should only be used in rare instances and as the last option for participants with no other alternatives or support system (i.e. family, neighbor, friend, etc.). If 911 is the only alternative for an emergency contact, case record documentation shall thoroughly explain there are absolutely no other options available.

Provider Selection

DSDS staff shall allow fifteen (15) calendar days following the initial assessment for the participant and/or legal guardian to select an HCBS provider. If an HCBS provider is not selected by the end of the fifteen (15) calendar days, DSDS staff shall refer to the Adverse Action policy and initiate an adverse action. DSDS staff shall close the case if a response is not received within ten (10) calendar days from the date the adverse action was sent.

If within ninety (90) calendar days of the adverse action a participant and/or legal guardian notifies DSDS staff that a provider has been selected, a new assessment does not need to be completed. The DSDS staff who completed the initial assessment shall open the case and authorize HCBS using the initial assessment. If no HCBS provider is selected within the ninety (90) calendar days of the adverse action, the case remains closed. If an HCBS provider is selected after ninety (90) calendar days, a new assessment shall be completed.

NOTE: ‘Assessment—State Designee’ is only used if no HCBS provider is available to serve the participant.

For initial assessments, DSDS staff or its designee shall contact the referring HCBS provider when the participant has chosen another provider for authorization of HCBS. DSDS staff or its designee shall inform the referring HCBS provider the authorization was processed per the request of the participant and did not result in authorization to the referring provider.

As part of the reassessment process DSDS staff or its designee shall ensure an HCBS provider is selected. If a participant has a circumstance that requires a selection of a different provider, DSDS staff shall refer to the Person Centered Care Planning and Maintenance policy.

Physician Notification Of Care Plan

Per 13 CSR 70-91.010, the participant’s primary care physician shall be informed of, and have the opportunity to be involved with the development of the PCCP.

DSDS staff shall notify the participant’s physician of the initial PCCP for HCBS via the Physician Notification of Care Plan (HCBS-11) within three (3) business days of the date of approval.

  • The associated copy of the PCCP shall be attached to the Physician Notification of Care Plan for forwarding to the physician.
  • This notification is required only at initial authorizations of all HCBS, regardless of the service authorization.
    • The Physician Notification of Care Plan informs the physician of the availability of electronically monitoring their patient’s PCCP.
  • Physicians may contact DSDS staff or their designee to discuss the PCCP and make recommendations. The PCCP shall comply with the recommendations or requests of the physician, unless sufficient justification is documented to the contrary. Any modification that adversely impacts the participant shall require notification as outlined in the Adverse Action policy.
    • Any decision not to comply with physician recommendations or requests (i.e., statutory or regulatory violation, etc.) shall be reviewed and approved by the DSDS supervisor and documented in the participant’s electronic case record. Notification to the physician shall be made, in writing, as to why the physician’s recommendation or request is not being followed. All documentation shall be maintained within the electronic case record.
    • The completed Physician Notification of Care Plan shall be scanned and attached to the participant’s electronic case record.
Case Record Documentation

All documentation, contacts and actions made regarding the (re)assessment and the development of the PCCP shall be electronically recorded in the participant’s electronic case record. This provides a summary and justification of the participant’s circumstances and provides a record of the interaction between the participant, collateral contacts and HCBS providers. The Case Record Documentation Policy and the Case Record Documentation Quick Guide shall be utilized to ensure all appropriate documentation is completed for all case actions.

NOTE: HCBS provider reassessors shall include their email address at the conclusion of each case note entered.

Finalization

HCBS (re)assessments, corresponding documentation and information shall be entered into the electronic case record. DSDS staff shall ensure the following:

  • The authorization of units and cost of the care plan does not exceed the cost maximum
  • Documentation justifies the PCCP
  • Goals and backup plans are identified and appropriate
  • An HCBS provider has been selected

All HCBS participants shall receive a copy of the completed and signed Participant Choice Statement. The completed Participant Choice Statement shall be attached to the participant’s electronic case record.

HCBS providers shall be instructed to provide the participant with a copy of the PCCP detailing the authorization of their HCBS via the electronic case record. DSDS staff shall send the PCCP upon the participant's request.

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