The purpose of the proposed rules is to incorporate specific criteria for Long-Term Care Community Diversion Projects, as it applies to managed care organizations and other qualified providers. These rules are developed to comply with Section 430....

DEPARTMENT OF ELDER AFFAIRS
Division of Statewide Community Based Services

RULE NO: RULE TITLE
58N-1: Long-Term Care Community Diversion Projects
58N-1.001: Application Process
58N-1.003: Service Descriptions
58N-1.005: Service Provider Qualifications
58N-1.007: Program Standards and Operating Procedures
58N-1.009: Care and Service Standards
58N-1.011: Outcome Measures
58N-1.013: Quality Assurance Standards
58N-1.015: Utilization Review
58N-1.017: Grievance and Conflict Resolution Procedures
58N-1.019: Service Satisfaction
PURPOSE AND EFFECT: The purpose of the proposed rules is to incorporate specific criteria for Long-Term Care Community Diversion Projects, as it applies to managed care organizations and other qualified providers. These rules are developed to comply with Section 430.706, F.S., and require that all providers enrolling in, or currently enrolled in the Long-Term Care Community Diversion Project, comply with specific criteria to ensure that participants’ needs are met to attain or maintain their highest practicable mental, physical and psychosocial well being through a continuum of care.
SUBJECT AREA TO BE ADDRESSED: Application process, service descriptions, service provider qualifications, program standards and operating procedures, care and service standards, outcome measures, quality assurance program, utilization review, grievance and conflict resolution procedures, and service satisfaction.
SPECIFIC AUTHORITY: 430.08, 430.706 FS.
LAW IMPLEMENTED: 409.912(27), 430.705(2)(b)2., 430.706, 641.3155, 641.51, 641.511 FS.
A RULE DEVELOPMENT WORKSHOP WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:
DATE AND TIME: December 7, 2006, 9:30 a.m. – 12:30 p.m. EST.
PLACE: Department of Elder Affairs, 4040 Esplanade Way, Conference Room 225F, Tallahassee, FL 32399-7000
Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 72 hours before the workshop/meeting by contacting: Jim Crochet, Office of the General Counsel, Department of Elder Affairs, 4040 Esplanade Way, Tallahassee, FL 32399-7000, [phone]. Email address: [e-mail]. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT, IF AVAILABLE, IS: Jim Crochet, Office of the General Counsel, Department of Elder Affairs, 4040 Esplanade Way, Tallahassee, FL 32399-7000, [phone]. Email address: [e-mail].

THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:

58N-1.001 Application Process.

(1) Applicants who wish to apply as a provider for the Long-Term Care Community Diversion Project shall complete DOEA Form LTCD-001, Department of Elder Affairs Long-Term Care Community Diversion Pilot Project Provider Application, which is hereby incorporated by reference.

(a) The form is available from the Department of Elder Affairs, Division of Statewide Community-Based Services, Long-Term Care and Support, 4040 Esplanade Way, Tallahassee, FL 32399-7000, Telephone number [phone]. The form is also available on the department’s Web site at http://elderaffairs.state.fl.us.

(b) Applicants shall follow the instructions in completing the application and submit the application as instructed on the application cover sheet.

(2) In addition, applicants shall also enroll as Medicaid providers by completing the following forms:

(a) AHCA form 2200-0003 (December 2004), Florida Medicaid Provider Enrollment Application; and

(b) Non-Institutional MPA (Revised July 2006), Non-Institutional Medicaid Provider Agreement.

(c) These forms are hereby incorporated by reference and may be obtained from ACS State Healthcare, Provider Enrollment, P. O. Box 7070, Tallahassee, FL 32314-7070, or from the Agency for Health Care Administration Web site at http://floridamedicaid.acs-inc.com/index.jsp?display=enrollme nt.

Specific Authority 430.08, 430.706 FS. Law Implemented 430.706 FS. History–New_______.

 

58N-1.003 Service Descriptions.

In addition to the terms defined in Section 430.703, F.S., and the provider contract, the following service descriptions are included. Long-Term Care Community Diversion Project providers (hereafter referred to as “diversion providers”) are required to either arrange or provide these services, as needed, to participants enrolled in Long-Term Care Community Diversion Projects (hereafter referred to as “diversion project”) as part of their contract with the department.

(1) Adult Companion Services: Non-medical care, supervision, and socialization provided to a functionally impaired adult.

(a) Companions assist or supervise the participant with tasks such as meal preparation, laundry and shopping, but do not perform these activities as discreet services.

(b) These services include light housekeeping tasks incidental to the care and supervision of the participant.

(c) The provision of companion services does not include hands-on nursing care.

(2) Adult Day Health Services: Services provided pursuant to Chapter 429, Part VIII, F.S. Examples include services furnished in an outpatient setting, encompassing both the health and social services needed to ensure optimal functioning of a participant, including social services to assist with personal and family problems, and planned group therapeutic activities.

(a) Adult day health services include nutritional meals. Meals shall be included when the participant is at the center during meal times.

(b) Adult day health care includes medical screening, emphasizing prevention and continuity of care, including routine blood pressure checks and diabetic maintenance checks.

(c) Physical, occupational, and speech therapies indicated in the participant's plan of care are furnished as components of this service.

(d) Nursing services which include periodic evaluation, medical supervision, and supervision of self-care services directed toward activities of daily living and personal hygiene are also a component of this service.

(e) The inclusion of physical, occupational and speech therapies, and nursing services does not require the diversion provider to contract with an adult day health care provider to deliver these services when they are included in a participant’s plan of care. The diversion provider may contract with other providers qualified to deliver these services pursuant to the terms of its contract with the department.

(3) Assisted Living Services: Personal care services, homemaker services, chore services, attendant care, companion services, medication oversight, and therapeutic social and recreational programming provided in a home-like environment to a resident living in an assisted living facility licensed pursuant to Chapter 429 Part I, Florida Statutes.

(a) Assisted living services may also include: physical therapy, occupational therapy, speech therapy, medication administration, and periodic nursing evaluations.

(b) This service does not include the cost of room and board.

(c) This service includes 24-hour on-site staff response to meet scheduled or unpredictable needs in a way that promotes maximum dignity and independence, and to provide supervision, safety and security.

(d) The diversion provider may arrange for other authorized service providers to deliver care to residents in assisted living facilities in the same manner as those services would be delivered to a person in their own home. The diversion provider shall be responsible for placing participants in the appropriate assisted living facility setting.

(e) Assistive care services are covered under the diversion provider’s contract and cannot be billed separately by the assisted living facility.

(4) Case Management Services: Services that assist participants in gaining access to needed Medicaid waiver and State Plan services as well as other needed medical, social, and educational needs, regardless of the funding source. Case management services coordinate and integrate care delivery through ongoing monitoring of service provision as provided in each participant care plan.

(5) Chore Services: Services needed to maintain the participant’s home in a clean, sanitary and safe environment. This service includes heavy household chores such as washing floors, windows and walls, tacking down loose rugs and tiles, and moving heavy items of furniture in order to provide safe entry and exit.

(6) Consumable Medical Supply Services: The provision of disposable supplies used by the participant and caregiver, which are essential to adequately care for the participant’s needs. These supplies enable the participant to perform activities of daily living or stabilize or monitor a health condition.

(a) Consumable medical supplies include adult disposable diapers, tubes of ointment, cotton balls and alcohol for use with injections, medicated bandages, gauze and tape, colostomy and catheter supplies, and other consumable supplies.

(b) Items covered under Medicaid home health agency services, personal toiletries, and household items such as detergents, bleach, and paper towels, or prescription drugs are not included.

(7) Environmental Accessibility Adaptation Services: Physical adaptations to the home required under the plan of care necessary to ensure the participant’s health, welfare, and safety or enable the participant to function with greater independence in the home, without which he/she would require placement in an institutional setting.

(a) Such adaptations may include the installation of ramps and grab-bars, widening of doorways, modification of bathroom facilities, or installation of specialized electric and plumbing systems to accommodate the medical equipment and supplies required by the participant.

(b) Excluded are those adaptations or improvements to the home that are of general utility and are not of direct medical or remedial benefit to the participant, such as carpeting, roof repair, or central air conditioning. Adaptations, which add to the total square footage of the home, are not included in this benefit.

(c) All services must be provided in accordance with applicable state and local building codes.

(8) Escort Services: The provision of a personal escort for a participant to and from service providers. An escort may provide language interpretation for a participant who has hearing or speech impairments or who speaks a language different from that of the service provider. Escort providers assist participants in gaining access to services.

(9) Family Training Services: The provision of training and counseling services for the families of participants served by the diversion provider. Training includes instruction and updates about treatment regimens and use of equipment specified in the plan of care to safely maintain the participant at home.

(a) “Family” is defined as the individuals who live with or provide care to a participant served by the diversion provider and may include a parent, spouse, children, relatives, foster family, or in-laws.

(b) “Family” does not include persons who are employed to care for the participant.

(10) Financial Assessment/Risk Reduction Services: The provision of financial assessment and guidance to the caregiver and participant. This service provides instructions for and/or actual performance of routine, necessary, monetary tasks for financial management such as budgeting and bill paying.

(a) This service includes a financial assessment to prevent exploitation by sorting through financial papers and insurance policies and organizing them in a usable manner.

(b) This service also includes coaching and counseling participants to avoid financial abuse, to maintain and balance accounts that directly relate to the participants living arrangement, or to lessen the risk of nursing home placement due to inappropriate money management.

(11) Home Delivered Meals: Nutritionally sound meals delivered to the residence of a participant who has difficulty shopping for or preparing food without assistance.

(a) Each meal shall provide 1/3 of the Recommended Dietary Allowance (RDA).

(b) Home delivered meals may be hot, cold, frozen, dried, canned or a combination of these methods with a    satisfactory storage life.

(c) Religious preferences in the selection and preparation of menu items shall be accommodated.

(12) Homemaker Services: The provision of general household activities (meal preparation and routine household care) provided by a trained homemaker.

(13) Nursing Facility Services: Services furnished in a health care facility licensed under Chapters 400 and 408, Part II, F.S.

(14) Nutritional Assessment/Risk Reduction Services: A nutritional assessment, hands-on care, and guidance to caregivers and participants with respect to nutrition.

(a) This service instructs caregivers and participants to follow dietary specifications that are essential to their health and physical functioning, to prepare and eat nutritionally appropriate meals, and promote better health through improved nutrition.

(b) This service may include instructions on shopping for quality food and food preparation.

(15) Occupational Therapy: Treatment to restore, improve, or maintain impaired functions aimed at increasing or maintaining the recipient’s ability to perform tasks required for independent functioning to improve his/her capability to live safely in the home. The need for this service shall be determined through a multi-disciplinary assessment.

(16) Personal Care Services: Assistance with eating, bathing, dressing, personal hygiene, and other activities of daily living. This service includes assistance with preparation of meals, but does not include the cost of the meals. This service may also include housekeeping chores such as bed making, dusting and vacuuming, which are incidental to the care furnished, or which are essential to the health and welfare of the participant, rather than his/her family.

(17) Personal Emergency Response System (PERS): The installation and service of an electronic device, which enables participants at high risk of placement in an institutional setting to secure help in an emergency.

(a) The PERS is connected to the participant’s telephone and programmed to signal a response center once a “help” button is activated. The participant may also wear a portable “help” button to allow for mobility.

(b) PERS services are generally limited to those participants who live alone or who are alone for significant parts of the day and who would otherwise require extensive supervision.

(c) Providers of this service must have a process for verifying the functionality of the system at least weekly.

(18) Physical Therapy: Treatment to restore, improve, or maintain impaired functions by using activities and chemicals with heat, light, electricity or sound; massage; and active, resistive, or passive exercise to improve a participant’s capability to live safely in the home. The need shall be determined through a multi-disciplinary assessment.

(19) Respite Care Services: Services provided to participants on a short-term basis, who are unable to care for themselves, due to the absence or need for relief of their caregivers. Respite care does not substitute for the care usually provided by a registered nurse, a licensed practical nurse, or a therapist. Respite care is provided in the home or place of residence or a Medicaid licensed hospital, nursing facility, or assisted living facility.

(20) Speech Therapy: The identification and treatment of neurological deficiencies related to feeding problems, congenital or trauma-related maxillofacial anomalies, autism, or neurological conditions that effect oral motor functions. Services include the evaluation and treatment of problems related to an oral motor dysfunction to improve a participant’s ability to live safely in the home. The need for this service shall be determined by a multi-disciplinary assessment.

Specific Authority 430.08, 430.706 FS. Law Implemented 430.706 FS. History–New_______.

 

58N-1.005 Service Provider Qualifications.

(1) Adult Companion Services: These services shall be provided by a licensed home health agency pursuant to Chapter 400, Part IV, F.S.; or individuals having a certificate of registration issued by the Agency for Health Care Administration pursuant to Section 400.509, F. S.; or be a Community Care for the Elderly (CCE) provider as defined in Section 430.203, F.S., and registered in accordance with Section 400.509, F.S.

(2) Adult Day Health Services: These services shall be administered by providers licensed by the Agency for Health Care Administration as an adult day care center pursuant to Chapter 429, Part III, F.S., or meet the adult day care center exemption requirements in Section 429.905, F.S.

(3) Assisted Living Facility Services: These are services provided in an assisted living facility licensed in accordance with to Chapter 429 Part I, F.S.

(a) The facility shall be licensed for Limited Nursing Services (LNS) or Extended Congregate Care (ECC) Services or have a standard license and meet the staffing requirements of a LNS or ECC facility.

(b) Participants residing in standard licensed facilities prior to the effective date of this rule shall have the option to remain in the facility.

(4) Case Management Services: These services shall be provided by case managers employed by the diversion provider. Case managers shall meet at least one of the following qualifications:

(a) Have a Bachelor’s Degree in social work, sociology, psychology, gerontology or related field; or

(b) Have a Bachelor’s Degree in an unrelated field and have at least two (2) years of geriatric experience; or

(c) Be a registered nurse licensed to practice in the state; or

(d) Be a licensed practical nurse licensed to practice in the state with four (4) years of geriatric experience.

(5) Chore Services: These services shall be provided by a lead agency as defined in Section 430.203(9), F.S.; a home health agency licensed in accordance with Chapter 400, Part IV, F.S.; a pest control agency licensed pursuant to Section 482.071, F.S.; a general contractor licensed to do home repair pursuant to Section 489.131, F.S.; or a person employed by or under the direct supervision of the general contractor, who the general contractor has confirmed is qualified by training or experience to provide home repair, home modification, general construction, chore services; and who has received the following training:

(a) Safety and home accident prevention;

(b) Participant record confidentiality;

(c) Project policies and procedures;

(d) Background and purpose of the program;

(e) Emergency procedures in the event of a crisis during the course of work;

(f) House and yard cleaning and sanitation;

(g) Simple repairs and the use of related tools and equipment; and

(h) Aging process and first aid.

(6) Consumable Medical Supply Services: These services shall be provided by pharmacies meeting the requirements under Section 465.022, F.S.; home medical equipment providers licensed pursuant to Chapter 400, Part X, F.S.; or home health agencies licensed pursuant to Chapter 400, Part IV, F.S.

(7) Environmental Accessibility Adaptation Services: These services shall be provided by general contractors licensed to do home repairs pursuant to Section 489.131, F.S.; or persons employed by or under the direct supervision of general contractors, who the general contractor has confirmed is qualified by training or experience to provide home repairs, home modifications, and general construction; and who has received the following training:

(a) Safety and home accident prevention;

(b) Participant record confidentiality;

(c) Project policies and procedures;

(d) Background and purpose of the program;

(e) Emergency procedures in the event of a crisis during the course of work;

(f) House and yard cleaning and sanitation; and

(g) Simple repairs and the use of related tools and equipment.

(8) Escort Services: These services shall be provided by lead agencies as defined in Section 430.203(9), F.S.; home health agencies licensed pursuant to Chapter 400, Part IV, F.S.; or persons employed by or working under the direct supervision of the diversion provider and trained in the following areas:

(a) Dynamics of aging;

(b) Communication and assistance with hearing and visually impaired patients;

(c) Emergency procedures; and

(d) Participant confidentiality.

(9) Family Training Services: These services shall be provided by home health agencies licensed pursuant to Chapter 400, Part IV, F.S.; lead agencies as defined in Section 430.203(9), F.S.; or medical practitioners licensed under Chapters 464 or 491, F.S., and shall include training or counseling within the scope of their practice.

(10) Financial Assessment/Risk Reduction Services: These services shall be provided by home health agencies licensed pursuant to Chapter 400, Part IV, F.S.; lead agencies as defined in Section 430.203(9), F.S.; persons confirmed to be qualified to perform the service by experience and training, such as certified financial planners, bank employees, or individual bookkeepers; or qualified persons employed by or working under the direct supervision of the diversion provider.

(11) Home Delivered Meals: These services shall be provided by lead agencies as defined in Section 430.203(9), F.S.; or subcontractors who meet food service standards as defined in Chapters 500 and 509, F.S.; or Older Americans Act providers as defined in Rule Chapter 58A-1, F.A.C., Administration of Federal Aging Programs.

(12) Homemaker Service Providers: These services shall be provided by home health agencies licensed pursuant to Chapter 400, Part IV, F.S.; lead agencies as defined in Section 430.203(9), F.S.; or individuals having a certificate of registration issued by the Agency for Health Care Administration pursuant to Section 400.509, F.S.

(13) Nursing Facility Services: These services shall be provided by nursing facilities licensed under Chapters 400 or 408, Part II, F.S.

(14) Nutritional Assessment Risk Reduction Services: These services shall be provided by Registered Licensed Dietitians or other health professionals functioning in their legal scope of practice and licensed under Section 468, F.S. A dietetic technician (DTR) may, according to the American Dietetic Association, assist a dietitian and assume full responsibility under supervision of a Registered Licensed Dietitian for a wide range of duties including counseling participants on specific diets. A Registered Licensed Dietitian licensed under Section 468, F.S, must approve nutritional education materials. These services may be provided by lead agencies as defined in Section 430.203(9), F.S.

(15) Occupational, Physical, and Speech Therapy Providers: These services shall be provided by home health agencies licensed pursuant to Chapter 400, Part IV, F.S., or providers holding current registration, certification, or licenses pursuant to Chapters 468 and 486, F.S.

(16) Personal Care Providers: These services shall be provided by lead agencies as defined in Section 430.203(9), F.S.; certified nursing assistants employed by a Nurse Registry pursuant to Section 400.506, F.S.; or home health agencies licensed pursuant to Chapter 400, Part IV, F.S.

(17) Personal Emergency Response System Service Providers: This service shall be provided by providers meeting the requirements as defined in Chapter 489, Part II, F.S.

(18) Respite Care Providers: These services shall be provided by licensed home health agencies pursuant to Chapter 400, Part IV, F.S.; providers having certificates of registration issued by the Agency for Health Care Administration pursuant to Section 400.509, F.S.; lead agencies as defined in Section 430.203(9), F.S.; adult day care centers licensed pursuant to Chapter 429, Part III, F.S.; assisted living facilities licensed pursuant to Chapter 429, Part I, F.S.; or nursing facilities licensed pursuant to Chapter 400, F.S.

Specific Authority 430.08, 430.706 FS. Law Implemented 430.706 FS. History–New________.

 

58N-1.007 Program Standards and Operating Procedures.

(1) Financial Solvency: The diversion provider shall establish and maintain a restricted insolvency protection account pursuant to Section 430.705(2)(b)4., F.S.

(2) Surplus Account: The diversion provider shall establish and maintain a surplus account pursuant to Section 430.705(2)(b)5., F.S.

(3) Financial Reporting: The diversion provider shall submit unaudited financial statements to the department quarterly.

(4) Audited Financial Statements: The diversion provider shall submit an annual audited financial statement specific to the diversion program that expressly confirms that the provider satisfies the requirements in subsection (2) of this rule.

(a) The diversion provider shall also submit a signed statement from the president of the organization attesting that no assets have been pledged to secure personal loans.

(b) The diversion provider shall submit the financial statement to the department no later than four (4) months after the end of its fiscal year.

(c) The financial statement shall be prepared by an independent certified public accountant on the accrual basis of accounting in accordance with generally accepted accounting principles as established by the American Institute of Certified Public Accountants (AICPA).

1. Audits performed to meet the requirements of OMB Circular 128 shall satisfy this requirement.

2. For government owned and operated facilities that operate on a cash method of accounting, data based on such a method of accounting shall be acceptable.

(5) Financial Risk: To participate as a diversion provider, the entity shall demonstrate the capacity to assume        responsibility and financial risk for providing all acute care services and home and community-based waiver services necessary to maintain participants in a community setting. Furthermore, diversion providers shall demonstrate the capacity to integrate the administration and delivery of these services to meet individual needs in order for participants to attain or maintain their highest practical mental, physical and psychosocial well being while living in the community for as long as is safely feasible.

(6) Diversion Provider Network Requirements:

(a) Prior to the provision of any services to participants, the diversion provider shall have, at a minimum, at least two (2) subcontractors for each service described in Rules 58N-1.003 and 58N-1.005, F.A.C. The diversion provider is required to have:

(b) Two (2) subcontractors for each service for up to 99 participants.

(c) An additional subcontractor for increments of fifty (50) additional participants for each specific service utilized.

(7) Exceptions to Provider Network Requirements:

(a) The department may grant an exception to the requirement cited in paragraph (6)(c) of this rule, upon consultation with the Agency for Health Care Administration, in instances where there are no available subcontractors for the specific service(s) needed, or when the diversion provider is unable to negotiate agreements with subcontractors after demonstration of a good-faith effort.

(b) The following services are exempt from the requirement cited in paragraph (6)(c) of this rule:

1. Personal Emergency Response System;

2. Home delivered meals;

3. Financial assessment/risk reduction;

4. Nutritional assessment/risk reduction; and

5. Family training.

(8) Assisted Living and Nursing Home Facilities:

(a) The diversion provider shall make a good-faith effort to establish subcontracts with assisted living and nursing home facilities.

(b) These facilities shall be located not more than thirty (30) miles from caregivers and families to encourage frequent visiting with participants.

(9) Provider Network Prohibition: The diversion provider may not enter into exclusive contracts or arrangements with subcontractors for services that prohibit, by any means, entities from contracting with other providers for the same or similar services.

Specific Authority 430.08, 430.706 FS. Law Implemented 430.706 FS. History–New________.

 

58N-1.009 Care and Service Standards.

(1) Medicaid Waiver Services: With the exception of nursing facility services, the long-term care services included under the diversion projects are authorized under the Medicaid home and community–based waiver. The waiver services shall meet all licensure and certification requirements as specified in Rule 58N-1.003, F.A.C., the Medicaid Nursing Home Waiver Agreement, state and federal regulations, and acceptable community professional practice requirements.

(2) Assisted Living and Nursing Home Facilities: Assisted living facilities and nursing home facilities licensed under Chapters 429 and 400, F.S., respectively, shall meet all contractual requirements related to reports, policies and procedures, and quality assurance provisions of the long-term care diversion project. Additionally, these facilities shall be in compliance with federal regulations and acceptable community professional practice requirements.

(2) Acute Care Services:

(a) The following services are covered for participants based on the Medicaid state plan approved by the federal Centers for Medicare and Medicaid Services. These services shall be covered under the diversion project to the extent that they are not covered by Medicare or Medicaid pursuant to Medicaid’s cost-sharing policies with Medicare.

1. Community Mental Health Services.

2. Dental Services.

3. Hearing Services.

4. Home Health Care Services.

5. Independent Laboratory and Portable X-ray Services.

6. Inpatient Hospital Services.

7. Outpatient Hospital/Emergency Medical Services.

8. Physicians Services.

9. Prescribed Drug Services.

10. Vision Services.

(b) Descriptions of these services and provider requirements shall be in accordance with the diversion provider’s contract with the department.

(3) Optional Services: The diversion provider may provide optional services, such as transportation for participants for necessary medical services, in accordance with its contract with the department.

(4) Expanded Services: The diversion provider may provide expanded services for participants in accordance with its contract with the department,

(5) Emergency Care Requirements: The diversion provider shall provide emergency care post-stabilization services in accordance with its contract with the department.

(6) Out of Network Use of Non-Emergency Services: The diversion provider shall adhere to the requirements outlined in its contract with the department when participants utilize non-emergency services outside of the diversion provider’s network.

(7) Case Management:

(a) The diversion provider shall directly provide case management services and shall be in compliance with Section 430.705(2)(b)2., F.S.

(b) In addition the diversion provider shall ensure that case managers attend and complete the following training:

1. Four (4) hours of in-service training annually on issues affecting the frail elderly;

2. Abuse, neglect, and exploitation training specifically involving the elderly; and

3. Alzheimer’s disease and related disorders annual continuing education training from an accredited entity, focusing on newly developed topics in the field.

4. The department shall approve the diversion provider’s internal training materials prior to their use for training purposes.

(c) The diversion provider may employ paraprofessionals, such as case aides, to assist case managers in the performance of their duties. However, the department shall approve this arrangement prior to using paraprofessionals for this purpose.

(d) In regards to participants, case managers shall complete at least:

1. One phone call and one face-to-face visit monthly for participants residing in the community; and

2. One phone call monthly and one face-to-face visit quarterly for participants residing in a facility.

(e) The ratio of case managers to participants shall be a maximum of:

1. One (1) to thirty-five (35) in the community; and

2. One (1) to forty-five (45) in facilities.

(8) Accreditation: All diversion providers shall receive accreditation from an organization that has been approved by the Agency for Health Care Administration. This requirement shall be completed within one year after contracting with the department. The department may extend the period of time for accreditation for those providers who are currently not accredited pursuant to this subsection.

(9) Care Planning:

(a) Each participant shall have a care plan. The care plan (also known as the plan of care or service plan) is the tool used by the case manager to document a participant’s assessed needs, desired outcomes, and services to be provided. The care plan is a plan of action, developed in conjunction with the participant, caregiver and/or family or representative. It is designed to assist the case manager in the overall management of the participant’s care.

1. The participant’s file shall include the care plan, which shall be signed by the participant, caregiver (or family or representative), and the case manager.

2. The participant or caregiver (or family or representative) shall receive a signed copy of the care plan.

(b) All changes in services in the care plan shall be documented in the participant’s file.

1. The file shall contain changes to the care plan and be signed by the participant, caregiver (or family or representative), and the case manager.

2. The participant or caregiver (or family or representative) shall receive a signed copy of the care plan. The original shall be included in the participant’s case file.

3. The participant’s case file shall have clear documentation for the reason for changes in services.

(b) The diversion provider shall make every effort to contract with service providers that the participant and the        caregiver (or family or representative) prefer. The participant’s case file shall include attempts to obtain the participant’s service provider preferences.

(10) Emergency/Disaster Plan:

(a) The diversion provider shall submit its emergency/disaster plan to the department no later than April 30 of each year.

(b) The diversion provider shall perform the following as it relates to computer system backup and recovery:

1. Prepare for the loss of information processing capabilities in the event of an emergency or disaster. Data and software essential to the continued operations of the diversion provider shall be routinely backed up. These backups shall be of sufficient extent and frequency to restore operations with a minimal interruption after a system failure from any cause.

2. Ensure security controls for back up resources meet the protection requirements of the primary resources.

3. Ensure a copy of the backed up data is stored in a secure, offsite location.

4. Submit to the department, annually or upon revision, written policies for backing up data and software in order to be online within twenty-four (24) hours after a emergency or disaster. These policies may be included in the emergency/disaster plan referenced in paragraph (a) of this subsection.

(c) Diversion providers shall conduct emergency/disaster training at least annually.

(d) The case manager shall make the necessary emergency arrangements with the participant’s family or other shelter arrangements during the enrollment process.

1. Emergency arrangements shall include emergency supplies, transportation to the emergency location, and coordination of emergency services with the participant’s family or other shelter arrangements.

2. The participant shall be provided with the case manager’s cell phone number and the diversion provider’s        emergency number.

3. The case manager shall review and update the participant’s emergency/disaster plan with the participant and family at least annually.

(e) The diversion provider shall submit its specific emergency/disaster plan to the department for the effected areas when watches are issued for the following: flood, tropical storm, hurricane, or other natural or manmade emergencies/disasters.

(11) Disenrollments:

(a) Upon notification of a participant’s death, the diversion provider shall disenroll the participant and void any claims for the months the participant remained enrolled after death. The diversion provider shall notify the local CARES and Department of Children and Families offices.

(b) The diversion provider shall submit other disenrollments or requests to change diversion providers to the local CARES office.

(c) The CARES office shall not accept disenrollment forms from anyone other than the participant’s current diversion provider. All disenrollment request forms shall be approved by the department.

(d) The current diversion provider shall continue to provide services to the participant until the documented effective date of disenrollment.

Specific Authority 430.08, 430.706 FS. Law Implemented 430.705(2)(b)2., 430.706 FS. History–New_______.

 

58N-1.011 Outcome Measures.

(1) Participant Satisfaction: Ninety percent (90%) of participants shall report positive satisfaction with services received based on the service satisfaction survey reference in Rule 58N-1.019, F.A.C.

(2) Caregiver, or Family or Representative Satisfaction: Ninety percent (90%) of participants’ caregivers (or families or representatives) shall report positive satisfaction with services received based on the service satisfaction survey referenced in Rule 58N-1.019, F.A.C.

(3) Nursing Home Placement: Out of the total number of diversion participants disenrolled from the program, not more than 10% shall have entered into a nursing home under the Medicaid state plan within 6 months after disenrollment.

(4) Provider Reimbursement: All service provider reimbursements shall be made and shall meet the timeliness requirements according to Section 641.3155, F.S.

(5) Provider Reporting: Ninety-five (95) percent of all diversion provider required reports shall be submitted to the department on or before the due date.

(6) Voluntary Disenrollment: Out of the total number of participants who voluntarily disenroll from a diversion provider, not more than ten (10) percent shall have:

(a) Disenrolled due to dissatisfaction with the delivery of services; and

(b) Enrolled with another diversion provider within three (3) months.

Specific Authority 430.08, 430.706 FS. Law Implemented: 430.705(2)(b)3., 430.706, 641.3155 FS. History–New_________.

 

58N-1.013 Quality Assurance Standards.

The diversion provider shall develop a quality assurance program with written policies and procedures that addresses the needs of participants, promotes improved clinical outcomes and quality of life, identifies and addresses service delivery issues, and monitors the quality and appropriateness of care provided to participants with special health care needs. The quality assurance program shall comply with applicable provisions of Section 409.912(27), F.S., and Section 641.51, F.S.

Specific Authority 430.08, 430.706 FS. Law Implemented 409.912(27), 430.706, 641.51 FS. History–New_______.

 

58N-1.015 Utilization Review.

Each diversion provider shall develop a utilization review methodology that shall include, at a minimum, the elements listed below. These elements shall include:

(1) Participants who received services with adverse or unexpected outcomes;

(2) Ethical issues and questions such as end-of-life decisions and advance directives;

(3) Targeted specific conditions and health service delivery issues;

(4) Generally accepted practice guidelines to objectively evaluate health service delivery issues and the care that the case manager delivered or failed to deliver;

(5) Management of participants’ diagnoses;

(6) Appropriateness and timeliness of services provided;

(7) Comprehensiveness of the care plan and the participant’s compliance or non-compliance with the care plan, and the effects on the desired outcomes;

(8) Evidence of special screening for, and monitoring of, high-risk participants or conditions; and

(9) Grievance and appeals identified through its policies and procedures in accordance with Rule 58N-1.017, F.A.C.

Specific Authority 430.08, 430.706 FS. Law Implemented 430.706 FS. History–New_______.

 

58N-1.017 Grievance and Conflict Resolution.

Diversion providers shall have detailed written procedures in place for participants that include a grievance process, an appeal process, and access to the Medicaid fair hearing system. The diversion provider shall develop, implement, and maintain a grievance system that complies with the requirements of Section 641.511, F.S., and federal laws and regulations.

Specific Authority 430.08, 430.706 FS. Law Implemented 430.706, 641.511 FS. History–New_________.

 

58N-1.019 Service Satisfaction.

Diversion providers shall conduct recipient and caregiver (or family or representative) service satisfaction surveys in accordance with its contract with the department. The main focus of the surveys shall be to determine satisfaction with the provision of services.

Specific Authority 430.08, 430.706 FS. Law Implemented 430.706 FS. History–New_________.