DEPARTMENT OF CHILDREN AND FAMILY SERVICES
Agency for Persons with DisabilitiesRULE NO: RULE TITLE
65G-1.010: Definitions
65G-1.046: Crisis Determination Procedure
65G-1.047: Crisis Status CriteriaNOTICE OF CHANGE
Notice is hereby given that the following changes have been made to the proposed rule in accordance with subparagraph 120.54(3)(d)1., F.S., published in Vol. 33 No. 25, June 22, 2007 issue of the Florida Administrative Weekly.
65G-1.010 Definitions.
In this chapter, terms and phrases shall have the meanings defined in Chapter 393, F.S., or this section.
(1) “Area Office” is the local office responsible for managing one of the Agency’s 14 service areas.
(2) “Central Office” is the Agency’s headquarters located at 4030 Esplanade Way, Suite 380, Tallahassee, FL, 32399-0950; main phone number (850)488-4257.
(3) “Crisis enrollment” is expedited enrollment on an Agency-operated Medicaid waiver regardless of an applicant’s date of application for the waiver or placement on the Agency’s waitlist.
(4) “Handbook” is the Florida Medicaid Developmental Disabilities Waiver Services Coverage and Limitations Handbook, October 2003, incorporated by reference in Agency for Health Care Administration (AHCA) subsection 59G-13.080(12), F.A.C. The Handbook is available at: http://floridamedicaid.acs-inc.com/index.jsp.
(5) “Protective Services” means the program in the Department of Children and Family Services that responds to reports made to the department’s central abuse hotline alleging abuse, abandonment, neglect, or exploitation, pursuant to Chapter 39 or 415, F.S.
(6) “Wait list” is the list maintained by the Central Office of persons requesting and waiting for waiver services.
(7) “Waiver” is a Home and Community-Based Services (HCBS) waiver authorized by 42 U.S.C. 1396n(c) of the federal Social Security Act and s. 409.906, F.S., that provides a package of Medicaid-funded home and community-based supports and services to eligible persons with developmental disabilities who live at home or in a home-like setting. The Agency currently operates two HCBS waivers:
(a) The Developmental Disabilities Home and Community-Based Services (DD) waiver that provides home and community-based supports and services without a dollar cap to eligible persons with developmental disabilities who are able to live at home or in a home-like setting; and
(b) The Family and Supported Living (FSL) waiver that provides limited home and community-based supports and services with an annual dollar cap to eligible persons with developmental disabilities who are able to live in their own home or family home.
Specific Authority 393.501(1), 393.065 FS. Law Implemented 393.065 FS. History–New ________.
65G-1.046 Crisis Determination Procedure.
(1) Subject to funding availability, the Agency will accept oral or written requests for crisis enrollment in a HCBS waiver by the applicant or the applicant’s family, guardian, guardian advocate, or support coordinator.
(2) The applicant or applicant’s representative shall request crisis enrollment through the Area Office in the service area where the applicant resides. The Agency may not enroll an applicant on the waiver unless the Agency has determined that the applicant has a developmental disability, as defined at Section 393.063(9), F.S., and also meets the following waiver eligibility requirements listed in the Handbook, Chapter 2 “Requirements to Receive Services”:
(a) The recipient’s intelligence quotient (IQ) is 59 or less; or
(b) The recipient’s IQ is 60-69 inclusive and the recipient has a secondary handicapping condition that includes:
1. Cerebral palsy, spina bifida, Prader-Willi syndrome, epilepsy, autism, or
2. Ambulation, sensory, chronic health, and behavioral problems;
(c) The recipient’s IQ is 60-69 inclusive and the recipient has severe functional limitations in at least three of the following major life activities:
1. Self-care,
2. Learning,
3. Mobility,
4. Self-direction,
5. Understanding and use of language,
6. Capacity for independent living; or
(d) The recipient is eligible under a primary disability of autism, cerebral palsy, spina bifida, or Prader-Willi syndrome and the condition results in substantial functional limitations in three or more major life activities listed at paragraph (c), above.
(3) The Area Office will collect pertinent information and supporting documentation relevant to a crisis determination and conduct a preliminary assessment based on the crisis status criteria specified in Rule 65G-1.047, F.A.C.
(a) If the Area Office concludes that the applicant does not meet crisis status or that the services needed are available from other agencies or programs or covered by other third-party payors, the Area Office will deny the crisis enrollment request and provide written notification of the denial to the applicant or applicant’s representative.
(b) If the Area Office concludes that the applicant may meet crisis status and does not have access to insurance, other agencies or programs for needed services, or concludes that programs in which the applicant is participating cannot meet the applicant’s service needs, the Area Office will submit its initial assessment and supporting documentation to the Central Office for review and final determination of whether the applicant meets crisis status. The applicant or the applicant’s representative may, upon request, review the initial assessment and supporting documentation to ensure that all necessary information is included.
(4) The Central Office will notify the Area Offices of deadlines for submission of crisis enrollment requests to the Central Office for periodic review. Following review of the submissions, the Central Office will notify the Area Office whether it has approved or denied each submission. The Area Office is responsible for notifying the applicant or applicant’s representative of the Central Office’s final crisis determination.
(a) APPROVAL.
1. If funding is available and the applicant is approved for crisis enrollment, the applicant will be offered placement on the FSL waiver, unless that waiver cannot reasonably meet the applicant’s specific service needs for addressing the crisis. In such instances, the person will be offered placement on the DD waiver. In determining the appropriate waiver placement, the Central Office will consider the availability of services necessary to resolve the crisis situation that are not provided under the FSL waiver, including the need for residential habilitation services, nursing services beyond the coverage provided through the Medicaid State Plan, or placement in a residential facility.
2. After the Central Office determines the appropriate waiver placement, the Area Office will provide written notice of placement to the applicant or applicant’s representative. If the applicant is not already a client of the Agency or is not already on the waitlist, the Agency will provide a full determination of the applicant’s eligibility for services within 45 days of the crisis eligibility determination, as provided in Section 393.065(2), F.S. Eligibility for Medicaid waiver services is contingent upon eligibility for the state Medicaid services, such as Supplemental Security Income (SSI), MEDS-AD, or TANF provided by the Department of Children and Families, as required by the Handbook, Chapter 2, “Requirements to Receive Services.” If the applicant is not enrolled in a state Medicaid program, the Area Office will refer the applicant to the local Department of Children and Families for submission of a Request for Assistance (RFA). If the applicant is deemed eligible for state Medicaid, the Area Office will complete the waiver enrollment. If the applicant is not Medicaid-eligible, the Area office will rescind the approval for crisis enrollment on the Medicaid waiver.
(b) DENIAL. The Area Office will notify the applicant or applicant’s representative in writing of a denial of crisis enrollment. If the Agency denied the application based on lack of documentation and additional documentation becomes available, or a change in the applicant’s situation may affect the applicant’s status for crisis determination, the applicant may reapply to the Area Office for crisis consideration.
Specific Authority 393.501(1), 393.065 FS. Law Implemented 393.065 FS. History–New ________.
65G-1.047 Crisis Status Criteria.
(1) Individuals determined to be in crisis will be prioritized for available waiver placements in order of the severity of crisis, with the severity determined by risk to the health, safety, and welfare of each applicant relative to that of the other applicants, as indicated by the applicable criteria for each crisis category met by the applicant.
(2) If several crises status applicants fall within the same crisis category, they will be prioritized within that category by consideration of the intensity of services needed.
“Intensity of services needed” prioritizes the following service needs in intensity from greatest to least:
(a) Residential placement with need of residential habilitation, nursing, or behavioral services, including supported living with required supports;
(b) Residential placement without need of residential habilitation, nursing, or behavioral services, including supported living with some supports;
(c) Behavioral intervention services;
(d) Other therapies to avoid or reduce disability;
(e) Meaningful day activity needs;
(f) Durable medical equipment needs;
(g) Environmental accessibility adaptations;
(h) Consumable medical supplies.
(3) If an applicant falls within more than one category of crises, the applicant will be considered within the higher priority of crisis category. After prioritization based on crisis category and intensity of services, applicants will be further prioritized if necessary based on the chronological order of crisis determination, with the earlier dates of determination having higher priority.
(4) “First priority” crisis category: The applicant is currently homeless, living in a homeless shelter, or living with relatives in an unsafe environment. In such cases, the following indicia, supported by credible evidence, are relevant to a crisis determination in this category:
(a) Without immediate provision of waiver services, the health and safety of the applicant are at risk;
(b) The applicant has no shelter available and needs emergency placement by the Agency or another state agency;
(c) Alternative funding is not available for other placement and services to the applicant;
(d) The applicant temporarily is staying with friends or relatives but residence is not expected to last more than several weeks;
(e) The applicant’s caregiver has no legal obligation to provide shelter to the applicant and the caregiver’s commitment to shelter the applicant is low;
(f) Factors affecting the applicant’s safety in the current setting include risk of physical abuse of the applicant or risk of insufficient supervision and support;
(g) The home has insufficient room to shelter the applicant, or the applicant must share a room in an inappropriate living arrangement, based on the ages, genders, and conditions of the persons sharing the room;
(h) The applicant’s desire for placement creates a reasonable expectation that the applicant will be cooperative with placement;
(i) Violence or illegal activities within the applicant’s current living environment by the applicant or others has required the intervention of local or state law enforcement authorities;
(j) Complaints of neglect, exploitation, or abuse of the applicant to Protective Services, or other adverse environmental conditions affecting the applicant, have been investigated and confirmed pursuant to Chapter 39, Part II, or Section 415.104, F.S.;
(k) The applicant requires services of greater intensity.
(5) “Second priority” crisis category: The applicant exhibits behaviors that, without provision of immediate waiver services, may create a life-threatening situation for the applicant or others, or that may result in bodily harm to the applicant or others requiring emergency medical care from a physician. In such cases, the following indicia supported by credible evidence are relevant to a determination of crisis under this category:
(a) Without immediate waiver services, the health and safety of the applicant or others in the household is at risk;
(b) The applicant’s injury to self or others is frequent or intense;
(c) The applicant or others are at risk for serious injury or permanent damage;
(d) There is documentation of medical treatment for the applicant’s injury to self or others;
(e) No other supports are available to address the applicant’s behaviors;
(f) Other attempted behavioral assessments and interventions have proven ineffective;
(g) The relative ages, sexes, and sizes of the aggressor and the subjects of aggression place the subjects of aggression at risk of injury;
(h) The caregiver has insufficient ability to control the applicant;
(i) The ages or disabilities of the applicant or caregiver exacerbate the problems;
(j) Violence or illegal activity within the applicant’s current living environment by the applicant or others has required the intervention of local or state law enforcement authorities;
(k) Complaints of neglect, exploitation, or abuse of the applicant, or other adverse environmental conditions affecting the applicant have been investigated by Protective Services and confirmed pursuant to Chapter 39, Part II, or Section 415.104, F.S.;
(l) The applicant requires services of greater intensity.
(6) “Third priority” crisis category: The applicant’s current caregiver is in extreme duress and is no longer able to provide for the applicant’s health and safety because of illness, injury, or advanced age. The applicant needs immediate waiver services to remain living with the caregiver or to relocate to an alternative living arrangement. In such cases, the following indicia, supported by credible evidence, are relevant to a determination of crisis in this category:
(a) Without immediate provision of waiver services, the applicant’s health and safety are at imminent risk;
(c) Other potential caregivers, such as another parent, stepparent, brother, sister or other relative or person, are unavailable or are unwilling or unable to provide care;
(d) The caregiver’s physical or mental condition prevents the provision of adequate care;
(e) The caregiver is deceased, about to expire, or permanently disabled;
(f) The caregiver’s age impairs the caregiver’s ability to provide sufficient care to the applicant;
(g) The caregiver cannot provide sufficient care because of the age or size of the applicant, or the physical, functional, or behavioral demands of the applicant;
(h) The services provided by the caregiver are limited in amount, duration, or frequency, rendering the applicant semi-dependent or totally dependent;
(i) The caregiver’s economic situation is unstable and unlikely to improve as a result of the care-giving demands of the applicant;
(j) The caregiver’s obligations to the needs of other dependents prevent the caregiver from providing the applicant with adequate care, or the caregiver’s obligation of care to the applicant places other dependents at risk of insufficient care;
(k) Violence or illegal activities within the applicant’s current living environment by the applicant or others has required intervention by local or state law enforcement authorities;
(l) Complaints of neglect, exploitation, or abuse of the applicant, or other adverse environmental conditions affecting the applicant have been investigated by Protective Services and confirmed pursuant to Chapter 39, Part II, or Section 415.104, F.S.;
(m) The individual requires services of greater intensity.
Specific Authority 393.501(1), 393.065 FS. Law Implemented 393.065 FS. History–New________.
