Application Process, Care and Service Standards, Outcome Measures, Quality Assurance Standards, Utilization Review, Grievance and Conflict Resolution Procedures, Service Satisfaction

DEPARTMENT OF ELDER AFFAIRS
Division of Statewide Community Based Services

RULE NO: RULE TITLE
58N-1.001: Application Process
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

NOTICE 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. 34, August 24, 2007 issue of the Florida Administrative Weekly.

58N-1.001 Application Process.

(1) Entities Applicants who wish to apply as a provider services under for the Long-Term Care Community Diversion Pilot Project must enter into a contract with the Department of Elder Affairs, hereafter referred to as department complete DOEA Form LTCD-001, Department of Elder Affairs Long-Term Care Community Diversion Pilot Project Provider Application, July 2007, which is hereby incorporated by reference.

(1)(a) Interested entities should contact the department at the following address: Department of Elder Affairs, Division of Statewide Community-Based Services, Long-Term Care and Support Unit, 4040 Esplanade Way, Tallahassee, Florida 32399-7000, Attn: Long-Term Care and Support Unit Supervisor. The form is available from the Department of Elder Affairs (DOEA) Web site at http://elderaffairs.state.fl.us/english/forms/DOEAformLTCD001.pdf. The form is also available for the following address: 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].

(2)(b) Interested entities may alternately contact the Long-Term Care and Support Unit supervisor by telephone at [phone]. Applicants must follow the instructions in completing the application and submit it to the address as instructed on the application cover sheet.

(2) In addition, applicants must also enroll as Medicaid providers by completing the following Agency for Health Care Administration (AHCA) forms:

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

(b) Non-Institutional Medicaid Provider Agreement (February 2007).

(c) These forms are hereby incorporated by reference and may be obtained from the AHCA Web site at http://floridamedicaid.acs-inc.com/XJContent/Non-Institutional%20Provider%20Agreement?id=000003568505 and http://floridamedicaid.acs-inc.com/XJContent/Florida%20Medicaid%20Provider%20Enrollment%20Application?id=0000007453 63, respectively.

(d) These forms must be submitted to the department along with DOEA Form LTCD-001.

Specific Authority 430.7056 FS. Law Implemented 430.7056, 430.707 FS. History–New__________.

 

58N-1.009 Care and Service Standards.

(1) Medicaid Waiver Services: The provider must provide all Medicaid waiver services in accordance with its contract with the department. With the exception of nursing facility services, the long-term care services included under the diversion pilot projects are authorized under the Florida Nursing Home Diversion Waiver. The waiver services must meet all licensure and certification requirements as specified in Rule 58N-1.005, F.A.C.

(2) Case Management. Case management services must be provided by case managers directly employed by the diversion provider and cannot be a subcontracted service.

(a) Case managers must meet at least one of the following qualifications:

1. No change.

2. Have a Bachelor’s Degree from a college or university and have at least two (2) years of related case management experience; or

3. through 4. No change.

(b) No change.

(c) The diversion provider may employ paraprofessionals, such as case aides, to assist case managers.

1. Case aide services are adjunctive to case management services and may be provided by paraprofessionals under the direction of case managers.

2. Case aide services include assistance with:

a. Implementing plans of care by arranging and verifying the services provided by the subcontractors;

b. Obtaining access to appointments and other services as prescribed in the plans of care; and

c. Arranging linkages between providers and participants.

3. Case aide services do not include:

a. Developing plans of care;

b. Conducting assessments or reassessments; or

c. Participating directly with assessing participant health status, medical follow-up or discharge planning.

(c)(d) At a minimum, Ccase managers must have one face-to-face visit with each participant at least every ninety (90) calendar days from the date of enrollment.

(d)(e) The case manager must make the necessary emergency plans or other shelter arrangements with the participant or representative during the enrollment orientation process.

1. through 3. No change.

(e) The diversion provider may employ case aides to assist case managers.

1. Case aide services include assistance with:

a. Implementing plans of care by arranging and verifying the services provided by the subcontractors;

b. Obtaining access to appointments and other services as prescribed in the plans of care; and

c. Arranging linkages between providers and participants.

3. Case aide services do not include:

a. Developing plans of care;

b. Conducting assessments or reassessments; or

c. Participating directly with assessing participant health status, medical follow-up or discharge planning.

(3) Care Planning:

(a) Each participant must have a care plan. The care 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 with the participation of the case manager, the program in conjunction with the participant, the participant’s caregiver and/or family member or representative, and to the extent possible, the participant’s health care provider physician. It is designed to assist the case manager in the overall management of the participant’s care.

1. No change.

2. At any time a significant change is indicated, the participant or representative and case manager must acknowledge the change in writing. A significant change is defined as any deterioration or improvement in the participant’s mental, physical or social condition that would require an adjustment in his or her care plan. A significant change could result in an increase or decrease in services, depending upon the outcome.

3. No change.

(b) No change.

(4) No change.

(5) Disenrollments:

(a) In order to disenroll a participant from the diversion program, the diversion provider must follow the requirements outlined in its contract with the department complete DOEA Form LTCD-002, Department of Elder Affairs Long-Term Care Community Diversion Pilot Project Request for Disenrollment, July 2007, which is hereby incorporated by reference and available at the department’s Web site at http://elderaffairs.state.fl.us/english/forms/DOEAformLTCD0 02.pdf or from the following address: Department of Elder Affairs, Division of Statewide Community-Based Services, Long-Term Care and Support Unit, 4040 Esplanade Way, Tallahassee, Florida 32399-7000, Telephone number [phone].

(b) through (e) No change.

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

 

58N-1.011 Outcome Measures.

(1) Service Provider Reimbursement: Diversion providers must demonstrate that service provider reimbursements meet the timeliness requirements according to Section 641.3155, F.S. Providers will demonstrate compliance with this outcome measure by providing payment data during the department’s monitoring process.

(2) Diversion Provider Reporting: Diversion providers must submit all demonstrate that required reports as outlined in their contracts with the department are submitted to the department on or before the due date. Providers will demonstrate compliance with this outcome measure by submitting all reports by the specified due dates.

Specific Authority 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 must develop a quality assurance program with written policies and procedures as specified in the contract between the department and the diversion provider. The quality assurance program must comply with applicable provisions of Sections 409.912(27) and 641.51, F.S., and the diversion provider’s contract with the department.

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

 

58N-1.015 Utilization Review.

As part of its quality assurance program referenced in Rule 58N-1.013, F.A.C., each diversion provider must develop a utilization review methodology that must include, at a minimum, the following elements:

(1) through (3) No change.

(4) Comprehensiveness of the care plan and the participant’s compliance or non-compliance with the care plan, and the effects on the desired outcomes,; A comprehensive care plan includes services necessary for the participant to attain or maintain his or her highest mental, physical and social well being in order to live safely in a community setting.

(5) Evidence of special screening for, and monitoring of, high-risk participants whose diagnoses may result in adverse outcomes,; and High-risk participants are those whose mental, physical or social conditions, if not monitored on a regular basis, could deteriorate to the extent that they could no longer live safely in a community setting, necessitating an institutional placement.

(6) No change.

Specific Authority 430.706 FS. Law Implemented 430.706 FS. History–New__________.

 

58N-1.017 Grievance and Conflict Resolution.

Diversion providers must have detailed written procedures in place for participant grievance and appeal processes in accordance with their contracts with the department applicable state and federal laws for the particular type of diversion provider.

Specific Authority 430.706 FS. Law Implemented 430.706, 641.511 FS. History–New__________.

 

58N-1.019 Service Satisfaction.

(1) Diversion providers must conduct participant and caregiver (family/representative) service satisfaction surveys and report the survey results in accordance with the requirements outlined in its contract with the department.

(2) Diversion providers must submit statements of validity, reliability and unbiasedness along with the results of the participant and caregiver satisfaction surveys.

(a) The validity and reliability statements must address how participants and caregivers completing for these surveys have been statistically or otherwise established.

(b) through (c) No change.

(3) No change.

Specific Authority 430.706 FS. Law Implemented 430.706 FS. History–New__________.