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Office of Mental Health

Home and Community Based Services Waiver
Guidance Document
Division of Children and Families

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Annual Administrative Review

Instructions: Complete all sections and submit to HCBS Waiver Program, Central Office, and a copy to the respective OMH Field Office Coordinator, 30 days prior to the agency’s annual site visit.  Information that is new or has changed from the previous year should be made bold.

Agency Name: Date:
Phone: Fax:
HCBS Waiver Manual Coordinator:
Number of individualized care coordinators currently at agency:
Number of ICC supervisors currently at agency:
Diversity of HCBS Waiver Staff (Linguistic/Cultural):
Number of children currently in enrollment process:
Number of children currently enrolled and receiving services:
Number of children currently on waiting list:
  1. Staff Information
    1. What is the average number of families per full-time ICC?
    2. Are the ICC staff qualified to provide ICC services?
      • ______ Yes ______ No   If no, explain:
    3. How many staff are approved to provide:
      • ______ Individualized Care Coordination
      • ______ Intensive In-Home Services
      • ______ Crisis Response Services Family Support Services
      • ______ Respite Care Skill Building
  2. Provider Network
    1. Are all six HCBS Waiver services available to families (Individualized Care Coordination, Intensive In-Home Services, Crisis Response Services, Family Support Services, Respite Care and Skill Building Services)?
      • ______ Yes ______ No   If no, explain:
    2. Is each HCBS Waiver service delivered comprehensively?  (For example, respite care is available on an emergency/planned, in-home, out-of-home, overnight/day capacity as outlined in the HCBS Waiver definition.) 
      • ______ Yes ______ No   If no, explain:
    3. Please list all current subcontractors and service(s) provided.  Are all subcontract agreements completed?
      • ______ Yes ______ No   If no, explain:
    4. What were some major areas that required negotiations?  Please cite some examples.
    5. How does the ICC Agency monitor the subcontractors?
    6. What reporting does the ICC Agency require of the subcontractors?
    7. Are the subcontractors providing the ICC Agency with flexible and timely means to access services for families?
    8. Are all workers’ credentials checked prior to delivery of services?  Who has the responsibility for this task?
    9. How is the work of the subcontract agencies’ staff supervised?
  3. Referral/Screening Process
    1. What is the ICC Agency’s procedure for contacting newly referred families?
    2. Please note referral problems and innovative methods of obtaining referrals.
  4. Enrollment Process
    1. Are any of the enrollment steps or requirements problematic or inhibiting services being provided in a timely manner?
    2. How long does the enrollment process take, from HCBS Waiver Application signing to HCBS Waiver Enrollment?
    3. Does your agency have any criteria that excludes a child and family from the HCBS Waiver other than the eligibility criteria?
    4. If a family is not accepted for the HCBS Waiver, what steps are there for a reevaluation or for referral to proper services?
    5. Provide an example of the process for doing a Strengths-Based Assessment?
    6. Provide an example of the process for developing a Service Plan and Budget?
    7. How is the family involved in the Strengths-Based Assessment and Service Plan development?
    8. Are family advocates used systematically in the enrollment process?
    9. How often is the Service Plan reviewed by the supervisor?
    10. Are there instances when the face-to-face contacts during the enrollment process (i.e., “Start-Up”) are less than the minimum requirement?
      • ______ Yes ______ No   If yes, explain:
    11. What is the average number of contacts between the ICC and family during the enrollment process?
    12. How does the agency monitor client contacts and ensure standards are met (face-to-face contacts: 6 for month, 3 for half month)?
  5. Flexible Service Dollars
    1. What is the mechanism for accessing Flexible Service Dollars?  Please note any problems with the mechanisms that have been implemented.
    2. How are Flexible Service Dollars monitored and documented?
    3. What are some strategies employed to use these funds in a cost efficient manner?
    4. What types of items are purchased with flexible service dollars?
    5. Does it appear that all of the available flexible service dollars will be used?
  6. Discharge/Disenrollment
    1. How is it determined that a child’s HCBS Waiver services should be terminated?
    2. How is the family a part of the discharge/disenrollment process and how is that documented?
    3. How is a discharge/disenrollment process reviewed by the supervisor?  The LGU?
    4. What is the procedure for discharging children from the HCBS Waiver to other services?
    5. What services have been helpful to a successful discharge?
    6. How is the potential new provider (if transferred to lower level of care or long term care) involved in the discharge/disenrollment process?
    7. What kinds of processes have been established to transition children to lower levels of care, to build upon their strengths and natural supports?
    8. What is the plan for follow-up with a child who has been discharged from the HCBS Waiver?
    9. Have you disenrolled anyone?  How did you transition that person to services needed?
    10. On an average, how long are children staying in the HCBS Waiver prior to disenrollment?
  7. Quality Assurance
    1. Incident Reporting
      1. What is the procedure for reporting incidents?
      2. Describe the review process for incidents.
      3. Are subcontractors trained and knowledgeable of their responsibilities regarding child abuse reports?
    2. Policies and Procedures
      1. Does the ICC Agency have written quality assurance policies and procedures for the HCBS Waiver?
      2. Are quarterly transmittals/updates maintained and shared with staff?
    3. Family Feedback
      1. What mechanism is in place for families to provide input into the services being provided by the ICC Agency? By subcontractors?
      2. How are family complaints and/or input documented?
      3. Is there a reasonable grievance procedure, including reporting, investigation and feedback to family members, in place? Are family members given OMH Family/Parent Advisor’s name, address and phone number to contact to provide feedback?
      4. Based on findings from the last Waiver Survey of parents and caregivers, what issue(s) has been identified for quality improvement activities?  How are these issues being addressed?  Are Waiver families involved in any of these activities?  How will the impact of these efforts be measured?
      5. What quality improvement activities have been undertaken based on any written recommendations from OMH stemming from the last Waiver survey? How are these issues being addressed? Are Waiver families involved in any of these activities?  How will the impact of these efforts be measured?
    4. Supervision
      1. Who has primary responsibility for supervision the ICC’s? Explain.
      2. What training and support is given to the supervisors?
      3. Is there a back-up supervision protocol?
      4. How accessible is supervision?
      5. Describe what is reviewed during the supervision sessions.
      6. How is the issue of cultural sensitivity/competence handled in supervision? Describe specific instances when this has been covered.
      7. How is practice of Individualized Care principles monitored in supervision?
      8. How is family input sought in evaluating the ICC?
  8. Program Safety
    1. Are ICC’s provided with training in dealing with potentially assaultive patients?
    2. How often are ICC’s and other Waiver service workers provided with appropriate follow-up regarding potentially assaultive patients?
    3. Is employee participation in training sessions documented?
    4. Describe the system that is in place to account for the whereabouts of all ICC’s and Waiver service providers when they are in the field.
    5. Does the program have formal safety protocols to be followed by ICC’s and other Waiver service providers when conducting home visits? How are these protocols communicated to ICC’s/other Waiver service providers?
      1. How are these protocols communicated to ICC’s/other Waiver service providers?
    6. Do protocols provide for accompanied visits when the patient’s history indicates assualtive behavior?
    7. Do programs provide ICC’s and other Waiver service providers with a means to summon assistance when necessary?
  9. Case Record Review
    1. How frequently are case records reviewed?  By whom?  What standards are used?
    2. How is the review documented in the case record?
    3. How are the service plan budget expectations monitored?
    4. Some subcontractor agencies have their own case recording requirements.  How are those coordinated with the requirements of the HCBS Waiver?
  10. Fiscal Review
    1. Please review a comparison between to-date budgeted amounts for subcontract services and actual expenditures. Please explain any wide discrepancies
    2. Are all HCBS Waiver services being utilized? 
      • ______ Yes ______ No   If no, why?
    3. Are enrollees’ usages of mental health outpatient services consistent with service plans and budgets? 
      • ______ Yes ______ No   If no, why?
    4. Are enrollees’ usages of psychiatric emergency and inpatient services consistent with service plans and budgets?
      • ______ Yes ______ No   If no, why?
    5. How many children have mental health benefits under non-Medicaid health insurance?  What are their levels of mental health benefits?

Comments or questions about the information on this page can be directed to the Home and Community Based Waiver Program.