Section 1

Administrative Overview

Applicants are encouraged to read each section of the RFP thoroughly. While sections such as the administrative overview may appear similar among RFPs, state purchasing agencies may add additional information as applicable. It is the responsibility of the applicant to understand the requirements of each RFP.

I. Procurement Timetable

Note that the procurement timetable represents the State’s best estimated schedule. Contract start dates may be subject to the issuance of a notice to proceed.

Activity	Scheduled Date
Public notice announcing Request for Proposals (RFP)	03/22/11
Distribution of RFP	03/22/11-04/01/11
RFP orientation session	04/04/11
Closing date for submission of written questions for written responses	04/08/11
State purchasing agency's response to applicants’ written questions	04/13/11
Discussions with applicant prior to proposal submittal deadline (optional)	None
Proposal submittal deadline	05/02/11
Discussions with applicant after proposal submittal deadline (optional)	None
Final revised proposals (optional)	None
Proposal evaluation period	05/03/11-05/09/11
Provider selection	05/10/11
Notice of statement of findings and decision	05/16/11
Contract start date	07/01/11

II. Website Reference

The State Procurement Office (SPO) website is http://hawaii.gov/spo/
	For	Click
1	Procurement of Health and Human Services	“Health and Human Services, Chapter 103F, HRS…”
2	RFP website	“Health and Human Services, Ch. 103F…” and ”The RFP Website” (located under Quicklinks)
3	Hawaii Administrative Rules (HAR) for Procurement of Health and Human Services	“Statutes and Rules” and “Procurement of Health and Human Services”
4	Forms	“Health and Human Services, Ch. 103F…” and “For Private Providers” and “Forms”
5	Cost Principles	“Health and Human Services, Ch. 103F…” and ”For Private Providers” and “Cost Principles”
6	Standard Contract -General Conditions	“Health and Human Services, Ch. 103F…” “For Private Providers” and “Contract Template – General Conditions”
7	Protest Forms/Procedures	“Health and Human Services, Ch. 103F…” and “For Private Providers” and “Protests”
Non-SPO websites (Please note: website addresses may change from time to time. If a link is not active, try the State of Hawaii website at http://hawaii.gov)
	For	Go to
8	Tax Clearance Forms (Department of Taxation Website)	http://hawaii.gov/tax/ click “Forms”
9	Wages and Labor Law Compliance, Section 103-055, HRS, (Hawaii State Legislature website)	http://capitol.hawaii.gov/ click “Bill Status and Documents” and “Browse the HRS Sections.”
10	Department of Commerce and Consumer Affairs, Business Registration	http://hawaii.gov/dcca click “Business Registration”
11	Campaign Spending Commission	http://hawaii.gov/campaign

III. Authority

This RFP is issued under the provisions of the Hawaii Revised Statutes (HRS) Chapter 103F and its administrative rules. All prospective applicants are charged with presumptive knowledge of all requirements of the cited authorities. Submission of a valid executed proposal by any prospective applicant shall constitute admission of such knowledge on the part of such prospective applicant.

IV. RFP Organization

This RFP is organized into five sections:

Section 1, Administrative Overview: Provides applicants with an overview of the procurement process.

Section 2, Service Specifications: Provides applicants with a general description of the tasks to be performed, delineates provider responsibilities, and defines deliverables (as applicable).

Section 3, Proposal Application Instructions: Describes the required format and content for the proposal application.

Section 4, Proposal Evaluation: Describes how proposals will be evaluated by the state purchasing agency.

Section 5, Attachments: Provides applicants with information and forms necessary to complete the application.

V. Contracting Office

The Contracting Office is responsible for overseeing the contract(s) resulting from this RFP, including system operations, fiscal agent operations, and monitoring and assessing provider performance. The Contracting Office is:

Department of Health,

Developmental Disabilities Division,

Case Management and Information Services Branch

3627 Kilauea Avenue, Room 109

Honolulu, Hawaii 96816

Phone: (808)733-9178 Fax: (808) 733-9182

VI. Orientation

An orientation for applicants in reference to the request for proposals will be held as follows:

Date:

April 4, 2011

Time:

9:00-11:00 a.m. HST

Location:

Diamond Head Health Center

3627 Kilauea Avenue, Room 104

Honolulu, Hawaii 96816

Please park in the metered public parking.

To participate via teleconference:

Call Toll free1-888-482-3560 enter the access code: 5876043 when requested. If you have trouble connecting, call Hawaiian TelCom’s Customer Care at 1-888-482-3558

Applicants are encouraged to submit written questions prior to the orientation. Impromptu questions will be permitted at the orientation and spontaneous answers provided at the state purchasing agency's discretion. However, answers provided at the orientation are only intended as general direction and may not represent the state purchasing agency's position. Formal official responses will be provided in writing. To ensure a written response, any oral questions should be submitted in writing following the close of the orientation, but no later than the submittal deadline for written questions indicated in the paragraph VII. Submission of Questions.

VII. Submission of Questions

Applicants may submit questions to the RFP Contact Person identified in Section 2 of this RFP. All written questions will receive a written response from the state purchasing agency.

Deadline for submission of written questions:

Date: April 8, 2011

Time:

4:30 p.m.

HST

State agency responses to applicant written questions will be provided by:

Date:

April 13, 2011

VIII. Submission of Proposals

A. Forms/Formats - Forms, with the exception of program specific requirements, may be found on the State Procurement Office website referred to in II. Website Reference. Refer to the Proposal Application Checklist for the location of program specific forms.

1. Proposal Application Identification (Form SPO‑H‑200). Provides applicant proposal identification.

2. Proposal Application Checklist. Provides applicants with information on where to obtain the required forms; information on program specific requirements; which forms are required and the order in which all components should be assembled and submitted to the state purchasing agency.

3. Table of Contents. A sample table of contents for proposals is located in Section 5, Attachments. This is a sample and meant as a guide. The table of contents may vary depending on the RFP.

4. Proposal Application (Form SPO-H-200A). Applicant shall submit comprehensive narratives that address all of the proposal requirements contained in Section 3 of this RFP, including a cost proposal/budget if required.

B. Program Specific Requirements. Program specific requirements are included in Sections 2, Service Specifications and Section 3, Proposal Application Instructions, as applicable. If required, Federal and/or State certifications are listed on the Proposal Application Checklist located in Section 5.

C. Multiple or Alternate Proposals. Multiple or alternate proposals shall not be accepted unless specifically provided for in Section 2 of this RFP. In the event alternate proposals are not accepted and an applicant submits alternate proposals, but clearly indicates a primary proposal, it shall be considered for award as though it were the only proposal submitted by the applicant.

D. Tax Clearance. Pursuant to HRS Section 103-53, as a prerequisite to entering into contracts of $25,000 or more, providers shall be required to submit a tax clearance certificate issued by the Hawaii State Department of Taxation (DOTAX) and the Internal Revenue Service (IRS). The certificate shall have an original green certified copy stamp and shall be valid for six (6) months from the most recent approval stamp date on the certificate. Tax clearance applications may be obtained from the Department of Taxation.website. (Refer to this section’s part II. Website Reference.)

E. Wages and Labor Law Compliance. If applicable, by submitting a proposal, the applicant certifies that the applicant is in compliance with HRS Section 103-55, Wages, hours, and working conditions of employees of contractors performing services. Refer to HRS Section 103-55, at the Hawaii State Legislature website. (See part II, Website Reference.)

· Compliance with all Applicable State Business and Employment Laws. All providers shall comply with all laws governing entities doing business in the State. Prior to contracting, owners of all forms of business doing business in the state except sole proprietorships, charitable organizations unincorporated associations and foreign insurance companies be registered and in good standing with the Department of Commerce and Consumer Affairs (DCCA), Business Registration Division. Foreign insurance companies must register with DCCA, Insurance Division. More information is on the DCCA website. (See part II, Website Reference.)

F. Hawaii Compliance Express (HCE). Providers may register with HCE for online proof of DOTAX and IRS tax clearance Department of Labor and Industrial Relations (DLIR) labor law compliance, and DCCA good standing compliance. There is a nominal annual fee for the service. The “Certificate of Vendor Compliance” issued online through HCE provides the registered provider’s current compliance status as of the issuance date, and is accepted for both contracting and final payment purposes. Refer to this section’s part II. Website Reference for HCE’s website address.

G. Campaign Contributions by State and County Contractors. Providers are hereby notified of the applicability of HRS Section 11-205.5, which states that campaign contributions are prohibited from specified State or county government contractors during the term of the contract if the contractors are paid with funds appropriated by a legislative body. For more information, FAQs are available at the Campaign Spending Commission webpage. (See part II, Website Reference.)

H. Confidential Information. If an applicant believes any portion of a proposal contains information that should be withheld as confidential, the applicant shall request in writing nondisclosure of designated proprietary data to be confidential and provide justification to support confidentiality. Such data shall accompany the proposal, be clearly marked, and shall be readily separable from the proposal to facilitate eventual public inspection of the non-confidential sections of the proposal.

Note that price is not considered confidential and will not be withheld.

I. Confidentiality of Personal Information. Act 10 relating to personal information was enacted in the 2008 special legislative session. As a result, the Attorney General’s General Conditions of Form AG Form 103F, Confidentiality of Personal Information, has been amended to include Section 8 regarding protection of the use and disclosure of personal information administered by the agencies and given to third parties.

J. Proposal Submittal. All mail-ins shall be postmarked by the United States Postal System (USPS) and received by the State purchasing agency no later than the submittal deadline indicated on the attached Proposal Mail-in and Delivery Information Sheet. All hand deliveries shall be received by the State purchasing agency by the date and time designated on the Proposal Mail-In and Delivery Information Sheet. Proposals shall be rejected when:

· Postmarked after the designated date; or

· Postmarked by the designated date but not received within 10 days from the submittal deadline; or

· If hand delivered, received after the designated date and time.

The number of copies required is located on the Proposal Mail-In and Delivery Information Sheet. Deliveries by private mail services such as FEDEX shall be considered hand deliveries and shall be rejected if received after the submittal deadline. Dated USPS shipping labels are not considered postmarks. No faxed proposals and/or submission of proposals on diskette/CD or transmission by e-mail, website or other electronic means will be permitted.

IX. Discussions with Applicants

A. Prior to Submittal Deadline. Discussions may be conducted with potential applicants to promote understanding of the purchasing agency’s requirements.

B. After Proposal Submittal Deadline - Discussions may be conducted with applicants whose proposals are determined to be reasonably susceptible of being selected for award, but proposals may be accepted without discussions, in accordance HAR Section 3-143-403.

X. Opening of Proposals

Upon receipt of a proposal by a state purchasing agency at a designated location, proposals, modifications to proposals, and withdrawals of proposals shall be date-stamped, and when possible, time-stamped. All documents so received shall be held in a secure place by the state purchasing agency and not examined for evaluation purposes until the submittal deadline.

Procurement files shall be open to public inspection after a contract has been awarded and executed by all parties.

XI. Additional Materials and Documentation

Upon request from the state purchasing agency, each applicant shall submit any additional materials and documentation reasonably required by the state purchasing agency in its evaluation of the proposals.

XII. RFP Amendments

The State reserves the right to amend this RFP at any time prior to the closing date for the final revised proposals.

XIII. Final Revised Proposals

If requested, final revised proposals shall be submitted in the manner, and by the date and time specified by the state purchasing agency. If a final revised proposal is not submitted, the previous submittal shall be construed as the applicant’s best and final offer/proposal. The applicant shall submit only the section(s) of the proposal that are amended, along with the Proposal Application Identification Form (SPO-H-200). After final revised proposals are received, final evaluations will be conducted for an award.

XIV. Cancellation of Request for Proposal

The RFP may be canceled and any or all proposals may be rejected in whole or in part, when it is determined to be in the best interests of the State.

XV. Costs for Proposal Preparation

Any costs incurred by applicants in preparing or submitting a proposal are the applicants’ sole responsibility.

XVI. Provider Participation in Planning

Provider participation in a state purchasing agency’s efforts to plan for or to purchase health and human services prior to the state purchasing agency’s release of a RFP, including the sharing of information on community needs, best practices, and providers’ resources, shall not disqualify providers from submitting proposals if conducted in accordance with HAR Sections 3-142-202 and 3-142-203.

XVII. Rejection of Proposals

The State reserves the right to consider as acceptable only those proposals submitted in accordance with all requirements set forth in this RFP and which demonstrate an understanding of the problems involved and comply with the service specifications. Any proposal offering any other set of terms and conditions contradictory to those included in this RFP may be rejected without further notice.

A proposal may be automatically rejected for any one or more of the following reasons:

(1) Rejection for failure to cooperate or deal in good faith.
(HAR Section 3-141-201)

(2) Rejection for inadequate accounting system. (HAR Section 3-141-202)

(3) Late proposals (HAR Section 3-143-603)

(4) Inadequate response to request for proposals (HAR Section 3-143-609)

(5) Proposal not responsive (HAR Section 3-143-610(a)(1))

(6) Applicant not responsible (HAR Section 3-143-610(a)(2))

XVIII. Notice of Award

A statement of findings and decision shall be provided to all applicants by mail upon completion of the evaluation of competitive purchase of service proposals.

Any agreement arising out of this solicitation is subject to the approval of the Department of the Attorney General as to form, and to all further approvals, including the approval of the Governor, required by statute, regulation, rule, order or other directive.

No work is to be undertaken by the awardee prior to the contract commencement date. The State of Hawaii is not liable for any costs incurred prior to the official starting date.

XIX. Protests

Any applicant may file a protest against the awarding of the contract. The Notice of Protest form, SPO-H-801, is available on the SPO website. (See paragraph II, Website Reference.) Only the following matters may be protested:

(1) A state purchasing agency’s failure to follow procedures established by Chapter 103F of the Hawaii Revised Statutes;

(2) A state purchasing agency’s failure to follow any rule established by Chapter 103F of the Hawaii Revised Statutes; and

(3) A state purchasing agency’s failure to follow any procedure, requirement, or evaluation criterion in a request for proposals issued by the state purchasing agency.

The Notice of Protest shall be postmarked by USPS or hand delivered to 1) the head of the state purchasing agency conducting the protested procurement and 2) the procurement officer who is conducting the procurement (as indicated below) within five working days of the postmark of the Notice of Findings and Decision sent to the protestor. Delivery services other than USPS shall be considered hand deliveries and considered submitted on the date of actual receipt by the state purchasing agency.

Head of State Purchasing Agency	Procurement Officer
Name: Kimberly Arakaki	Name: Jean Luka
Title: Chief, Case Management and Information Services Branch	Title: Supervisor, Contracts and Resource Development Section
Mailing Address: 3627 Kilauea Avenue, Room 109, Honolulu, Hawaii 96816	Mailing Address: 3627 Kilauea Avenue, Room 109, Honolulu, Hawaii 96816
Business Address: 3627 Kilauea Avenue, Room 109, Honolulu, Hawaii 96816	Business Address: 3627 Kilauea Avenue, Room 109, Honolulu, Hawaii 96816

XX. Availability of Funds

The award of a contract and any allowed renewal or extension thereof, is subject to allotments made by the Director of Finance, State of Hawaii, pursuant to HRS Chapter 37, and subject to the availability of State and/or Federal funds.

XXI. General and Special Conditions of Contract

The general conditions that will be imposed contractually are on the SPO website. (See paragraph II, Website Reference). Special conditions may also be imposed contractually by the state purchasing agency, as deemed necessary.

XXII. Cost Principles

In order to promote uniform purchasing practices among state purchasing agencies procuring health and human services under HRS Chapter 103F, state purchasing agencies will utilize standard cost principles outlined in Form SPO-H-201, which is available on the SPO website (see paragraph II, Website Reference). Nothing in this section shall be construed to create an exemption from any cost principle arising under federal law.

Section 2

Service Specifications

I. Introduction

A. Overview, purpose or need

In accordance with Chapter 333F, Hawaii Revised Statutes (HRS), the Department of Health (DOH), Developmental Disabilities Division (DDD), is responsible for developing, administering, coordinating, and setting direction for a comprehensive system of supports and services for persons with developmental disabilities or mental retardation. The purpose of this RFP is to procure services for individuals with developmental disabilities/mental retardation (DD/MR) who are eligible for services under Chapter 333F.

Services being procured will be known as Crisis Network Services (CNS).

The target population for CNS shall be individuals with DD/MR with challenging behaviors. Examples of challenging behaviors include physical aggression towards others, property destruction, sexual inappropriateness, self-injury, refusal of medical treatment, verbal outbursts, psychiatric symptoms, and sleep disorders.

CNS shall provide a prevention-based system of behavioral supports and services for individuals with challenging behaviors, their families, caregivers, and providers. CNS shall develop skills and expertise of stakeholders through training and consultation as well as provide effective prevention-oriented supports. Crisis services and out-of-home residential services, temporary for children, shall be provided if determined necessary.

A key PROVIDER activity to increase the capacity of the behavioral supports system is to develop a Crisis Network. The Crisis Network will consist of representatives from service providers, families and relevant State agencies. The Crisis Network shall be convened by the PROVIDER and the DDD on a monthly basis to develop mutual support and build on collaborative efforts for a comprehensive, prevention-based and effective system of behavioral supports. The PROVIDER will enhance the capacity of the Crisis Network by providing group training and separate consultation on individuals. Monthly meetings of the Crisis Network will also provide input to the PROVIDER on behavioral issues that impact on the delivery of CNS.

To maximize State funding and provide a seamless statewide system of supports, CNS shall be provided for individuals in need using a combination of DD/MR Medicaid Waiver and Purchase of Service (POS) 100% State funding. If an individual is Medicaid eligible and admitted into the DD/MR Medicaid Waiver, the PROVIDER shall bill the waiver for any authorized DD/MR Medicaid Waiver service that is billable. If an individual is not eligible for Medicaid or not admitted to the waiver, funds under this POS contract shall be used for Crisis Outreach, Crisis Shelter and Residential Habilitation services.

B. Planning activities conducted in preparation for this RFP

Planning activities for the CNS RFP included a Request for Information (RFI) session held on March 10, 2011. It is anticipated that eligible respondents to this Request for Proposal (RFP) may include: (1) developmental disabilities service providers with expertise in supporting persons with developmental disabilities and challenging behaviors or (2) organizations that support persons with co-occurring developmental disabilities and mental illness.

C. Description of the goals of the service

The goals of the CNS are to: (1) develop and coordinate education/ training/prevention efforts to increase skills and expertise of stakeholders who support individuals with developmental disabilities/mental retardation with challenging behaviors; (2) provide means for families, caregivers, and providers to request and access immediate assistance for Crisis Outreach and Crisis Shelter services, twenty-four (24) hours a day, seven (7) days a week; (24/7) and (3) develop and provide temporary residential settings for children and residential settings for adults with challenging behaviors.

Such services shall not supplant or duplicate entitlements and services required by state or federal statutes.

D. Description of the target population to be served

The target population to be served shall be adults and children with DD/MR who have been determined eligible for services, pursuant to Section 333F-2, HRS, by the Department of Health (DOH), Developmental Disabilities Division (DDD), Case Management and Information Services Branch (CMISB), on the island of Oahu, and its Community Services for the Developmentally Disabled Sections in the counties of Kauai, Maui, and Hawaii. For purposes of this Agreement, the CMISB shall refer eligible individuals to the CNS based on a CNS referral process developed by the STATE. CNS shall be available to all individuals regardless whether they are enrolled or not enrolled in the DD/MR Medicaid Waiver program.

E. Geographic coverage of service

Services shall be provided statewide to serve eligible individuals in the counties of Oahu, Hawaii, Kauai, and Maui County.

F. Probable funding amounts, source, and period of availability

Approximate State funding: $900,000.00 for the period July 2011, the planned contract start date, or Notice to Proceed, whichever is later, through June 2012, subject to availability of State funds.

DDD plans to amend DD/MR Medicaid Waiver services in July 2011. For such services, billing will be through the DD/MR Medicaid Waiver, effective July 2011. Rates for specific services under the DD/MR Medicaid Waiver services may increase in July 2011.

II. General Requirements

A. Specific qualifications or requirements, including but not limited to licensure or accreditation

The PROVIDER shall be authorized as a DD/MR Medicaid Waiver program provider by the DOH/DDD and have a contract with the Department of Human Services (DHS) to provide DD/MR Medicaid Waiver services. The PROVIDER shall comply with the requirements of the “DOH Standards for Home and Community Based Services for Persons with Developmental Disabilities/Mental Retardation” dated July 1, 2006, and any subsequent amendments to said Standards for all DD/MR Medicaid Waiver Program services.

The PROVIDER shall have training and at least two (2) years of experience in working with children and adults with developmental disabilities, mental retardation, or mental illness, with emphasis in behavioral intervention. These qualifications and experiences shall include, but is not limited to, a service delivery approach in assessing individuals’ needs and strengths, and developing person-centered plans.

The PROVIDER shall have training and experience in completing Functional Behavior Assessments (FBAs), developing and implementing Positive Behavior Support (PBS) Plans including the training of plans, and crisis intervention.

The PROVIDER shall have organizational knowledge, training and/or experience in operating 24/7 crisis response team(s) and a 24/7 licensed residential setting.

The PROVIDER shall have experience in working collaboratively with public and private service organizations on a local level.

B. Secondary purchaser participation

(Refer to HAR Section 3-143-608)

After-the-fact secondary purchases will be allowed.

Planned secondary purchases

None

C. Multiple or alternate proposals check one

(Refer to HAR Section 3-143-605)

Allowed Unallowed

D. Single or multiple contracts to be awarded check one

(Refer to HAR Section 3-143-206)

Single Multiple Single & Multiple

Criteria for multiple awards: contract will be awarded as needed to meet goal of coordinated statewide services.

E. Single or multi-term contracts to be awarded check one

(Refer to HAR Section 3-149-302)

Single term (2 years or less) Multi-term (more than 2 years)

Contract terms:

Contract terms: A one year contract is planned, covering the period July 1, 2011, through June 30, 2012. The contract may be extended for not more than five (5) additional twelve (12) month periods, without re-solicitation, upon mutual agreement in writing at least sixty (60) days prior to the expiration of the contract and the execution of a supplemental contract. The contract may be extended provided that the contract price shall remain the same or is adjusted per any contract price adjustment provision. The initial period shall commence on the contract start date or Notice to Proceed, whichever is later.

F. RFP contact person

The individual listed below is the sole point of contact from the date of release of this RFP until the selection of the successful provider(s). Written questions should be submitted to the RFP contact person and received by the day and time specified in Section 1, paragraph I (Procurement Timetable) of this RFP.

Jean Luka, Supervisor, Contracts and Resource Development Section,

Case Management and Information Services Branch

3627 Kilauea Avenue, Room 109

Honolulu, Hawaii 96816

Phone: (808) 733-9178 Fax: (808) 733-9182

Email: jean.luka@doh.hawaii.gov

III. Scope of Work

The scope of work encompasses the following tasks and responsibilities:

A. Service Activities

(Minimum and/or mandatory tasks and responsibilities)

1. Crisis Network, Training and Consultation Services

a. The PROVIDER shall convene monthly meetings to develop the Crisis Network to meet the following outcomes:

1) Increased knowledge base and capacity of agency providers, families, and others to support the behavioral needs of individuals in their home and community environments.

2) Development of mutual support among providers, state agencies, and families in the Crisis Network.

3) Development of collaborative “best practices” to address the behavioral needs of individuals.

4) Identification of issues impacting the behavioral needs of individuals that may include, but is not limited to, the following:

a) Resources for behavioral supports

b) System efficiencies

c) Strategies for increasing capacity

d) Training needs

e) Gaps in services

f) Prioritization of curriculum topics

b. The PROVIDER shall provide Crisis Network, Training and Consultation using a “train the trainer” approach. The number of hours for training and consultation shall be approved by the STATE.

1) The rate shall be inclusive of all preparation, coordination, materials, supplies, set-up and debriefing time and rental of meeting space, if applicable. Costs for travel to the neighbor island areas such as airfare and car rental may be covered by the STATE if determined as necessary by the STATE. The PROVIDER shall not charge or accept any fees from individuals or the individual’s family for services provided under this contract.

2) The PROVIDER shall be responsible for all coordination of training including decision-making on target groups, curriculum, announcements, invitations, attendance and arrangement of sites for training. The PROVIDER shall work with the STATE in planning monthly network meetings and shall keep written documentation of Crisis Network activities, training and consultation.

c. The PROVIDER shall develop a curriculum and provide training at least monthly as requested by the Crisis Network. Training and consultation shall be identified and prioritized by the Crisis Network and may include, but is not limited to, the following topics:

1) Psychotropic medications

2) Medication side-effects and interactions

3) PBS

4) Behavioral intervention consistent with PBS

5) Dual diagnoses – mental retardation/mental illness

6) Crisis prevention and intervention

7) Person-centered planning

8) FBAs

9) Specific conditions and disorders such as Prader-Willi Syndrome, autism, etc.

10) Community resources (behavioral)

11) Skills training in relation to challenging behaviors

12) Communication strategies for individuals with challenging behaviors

13) Development of natural supports

d. The PROVIDER shall develop a plan and meet the Crisis Network, Training and Consultation outcomes which shall include, but is not limited to, the following:

1) Approach to meet outcomes.

2) Strategy to meet outcomes such as a best practice newsletter, sharing of success stories, featuring direct support worker’s learning, provider buy-in ideas.

3) The PROVIDER shall provide data to measure training outcomes including baseline data. Such measures may include pre and post testing, number of Adverse Events Reports (AER’s), number of PBS Plans implemented, utilization of Emergency Outreach and Emergency Shelter services, collaborative efforts with other agencies, number of community education efforts regarding target population needs.

4) The PROVIDER shall submit an annual report on Crisis Network, Training and Consultation outcomes which shall include the following:

i. Goals, accomplishments, future outcomes, recommendations.

b) Summarized findings including outcome data.

e. The PROVIDER shall provide consultation services to the STATE in developing an effective spectrum of residential alternatives and supports. The number of hours for consultation services shall be determined by the STATE.

2. Training and Consultation for Individuals

a. Training and consultation services shall be defined as the provision of supports to individuals and their circle of support to implement proactive strategies/activities that will reduce challenging behaviors, minimize the need for crisis services and preserve the individual’s current living situation or program.

b. Training and consultation services shall be time-limited, intermittent, and shall not duplicate services offered by entitlements, available health insurance, or the State Medicaid Plan. Documentation of services may include evaluation, assessment, consultation, reports or plans and shall be provided within fourteen (14) days of service provision.

1) The PROVIDER shall have qualified, experienced and, if applicable, licensed personnel for the provision of training and consultation.

2) The following array of assessments and consultation services shall be provided as needed:

a) Psychiatric

b) Psychological

c) Speech/language/communicative

d) Nutritional

e) Behavioral specialist

3) The PROVIDER shall provide training for families, caregivers, and providers based on the Individualized Service Plan (ISP) or Plan of Care (POC). Training areas shall include, but is not limited to, the following:

a) FBA

b) PBS Plan and its implementation

c) Medication management and monitoring of side effects

4) The PROVIDER shall collaborate with other agencies or facilities pre- and post-discharge, when appropriate, to provide any necessary training and supports.

5) The PROVIDER shall monitor and follow-up to ensure challenging behaviors are reduced by the implementation of the PBS Plan.

3. Emergency Outreach Services

a. Emergency Outreach services shall be defined as immediate on-site crisis support for situations in which the individual’s presence in their home or program is at risk due to the display of challenging behaviors that occur with intensity, duration, and frequency that endangers his or her safety or the safety of others, or results in the destruction of property.

1) The PROVIDER shall:

a) Maintain 24/7 availability for families and caregivers to call for Emergency Outreach assistance.

b) Provide Emergency Outreach services 24/7.

c) Accept all referrals from DOH/DDD; there shall be a “no reject” policy.

d) Provide Emergency Outreach services based on the POC from the DOH case manager, if available.

e) Provide face-to-face Emergency Outreach in the location where the crisis is occurring by one (1) or more trained Emergency Outreach workers. Ninety-five percent (95%) of crisis calls shall be responded to face-to-face by a Emergency Outreach worker within forty-five (45) minutes or less. Exceptions to the 45-minute response time for the counties of Hawaii, Maui and Kauai may be made if justified due to geographical remoteness.

f) Evaluate all referred individuals to determine if a crisis indeed exists. For situations where a crisis does not exist, facilitate a temporary solution in the individual’s living situation and coordinate follow-up with the DOH case manager. Examples of temporary solutions may be giving the caregiver ideas and suggestions of what to do or how to best work with individual in a particular situation.

g) Assess for potential harm.

h) Have access to or provide needed psychiatric and/or psychological services.

i) Coordinate outreach services, when appropriate, with each individual’s DOH case manager and circle of supports.

j) Work with the police department to assess and divert those individuals who may be DD/MR and at risk for arrest to needed services or settings, if appropriate.

k) Discuss the need for Emergency Shelter services with the DOH case manager and a Emergency Shelter provider, if necessary.

l) Complete arrangements including transportation for more intensive services such as a Emergency Shelter or hospitalization in the event the outreach services are not sufficient to stabilize the crisis.

m) Provide post-crisis documentation to include report of events and actions taken and recommendations for follow-up to the DOH case manager and others, as appropriate.

2) The PROVIDER shall provide Emergency Outreach interventions to de-escalate crisis situations that include, but are not limited to, the following:

a) Telephone consultation with the family, caregiver, or program staff for advice on how best to manage the situation.

b) On-site consultation, training, and technical assistance to family, caregivers, or providers to reduce challenging behaviors.

c) Direct, hands-on staffing support to ensure the individual’s safety and the safety of others.

d) Short-term, time-limited follow-up monitoring of the individual and situation for stability after the crisis. Short-term, time-limited monitoring shall not exceed two (2) hours of billable time.

e) Review existing PBS Plan to determine effectiveness and, if appropriate, recommend necessary follow-up action as the result of the Emergency Outreach.

4. Emergency Shelter Services

a. Emergency Shelter services shall be defined as emergency out-of-home placement of individuals in need of intensive intervention in order to avoid institutionalization or more restrictive placement and for return to the current or a new living situation once stable. Emergency Shelter services shall include discharge planning at the point of admission.

1) The PROVIDER shall provide the following, as appropriate:

a) Provide Emergency Shelter services 24/7.

b) Accept all DOH/DDD referrals based on bed availability.

c) Ensure that all staff on-site are trained and meet all state and federal requirements.

d) Provide transportation services, as needed.

e) Access and make available the following specific services, which shall include, but are not limited to:

i. Psychiatric assessment, treatment, and/or consultation including psychotropic medication management and monitoring.

ii. Psychological assessment, treatment, and/or consultation including completion of a FBA and development of a PBS Plan.

iii. Medical assessment, treatment, and/or consultation and medication administration, as necessary.

iv. Crisis stabilization and intervention services with the provision of a safe environment to calm and manage the individual.

2) Upon admission the PROVIDER shall develop an interim plan to address the individual’s need(s) for crisis stabilization and intervention.

3) The PROVIDER shall develop an Individual Plan (IP) in coordination with the DOH case manager or designee and Emergency Shelter staff within seven (7) days of admission.

The IP shall be based on the POC from the DOH case manager and a service delivery approach that includes:

a) Person-centered aspects of the Individualized Service Plan (ISP) and the individual’s input, as appropriate.

b) Discharge criteria that include an estimated length of stay.

c) PBS Plan to reduce challenging behaviors that include specific methods or approaches to be implemented to achieve goals and objectives.

d) Training for families, caregivers, and providers upon discharge for post-discharge community-based living and services, if indicated.

4) The PROVIDER shall seek voluntary or involuntary emergency hospitalization for an individual when deemed clinically necessary and appropriate to ensure the individual’s safety and the safety of others. The PROVIDER shall report an individual’s hospital admission as an Adverse Event and follow Adverse Event procedures for reporting.

5) The PROVIDER shall have access to psychiatric/psychological/medical services 24/7 for assessment, treatment, and consultation for any medical/health needs that arise.

6) The PROVIDER shall provide Emergency Shelter services in a setting that is licensed and certified as a Special Treatment Facility for adults and children, as applicable.

7) The PROVIDER shall provide Emergency Shelter services upon a pre-authorized approval from the DOH case manager as documented on the POC for up to seven (7) days. Additional Emergency Shelter services shall be authorized by the DDD.

8) The PROVIDER shall provide Emergency Shelter services for an individual for no more than ninety (90) consecutive days per stay. Exceptions to the ninety (90) consecutive days shall be authorized by the DDD.

9) The PROVIDER shall provide discharge planning services for all individuals to include, but not limited to the following:

a) Discussion and identification of the residential setting for the individual upon discharge by relevant staff, current or prospective caregivers, circle members and the individual, if possible.

b) Transition planning that may include onsite visits, prospective residential visits, or overnight visits in prospective residential settings.

c) Necessary supports resources or services needed upon discharge especially to a new or unfamiliar setting.

d) Training to families, caregivers, and providers on the implementation of the PBS Plan.

10) The PROVIDER shall provide assistance and time-limited monitoring for a period up to one (1) month post discharge to ensure stability in the post-discharge setting utilizing training and consultation services.

11) The PROVIDER shall maintain and comply with Hawaii Administrative Rules (HAR), Title 11, Chapter 98, Special Treatment Facilities in the provision of Emergency Shelter services.

a) Physical or chemical restraints shall meet all applicable federal and state regulations for individuals with DD/MR.

i. All physical and chemical restraints shall be by physician’s orders that specify the duration and circumstances under which the restraints are to be used.

ii: Restraints may only be imposed by a facility to ensure the physical safety of the individual or others and less restrictive interventions have been determined to be ineffective. Clear criteria for use shall be documented in the individual’s IP.

iii. Mandt or other behavioral/crisis management certification is required for all staff with direct resident contact to ensure safe and proper use of restraints and alternatives. Consent, data collection and monitoring procedures shall also be documented.

iv. All incidents of physical or chemical restraints shall be reported as an Adverse Event.

5. Residential Habilitation Services for Children effective July 1, 2011

a. Residential Habilitation shall be defined as individually tailored supports that assist with the acquisition, retention, or improvement in skills related to living in the community. These supports include adaptive skill development, assistance with activities of daily living, community inclusion, transportation, social and leisure skill development, that assist the individual to reside in the most integrated setting appropriate to his/her needs. Services also include personal care and protective oversight and supervision.

1) The PROVIDER shall work with the DDD to procure, develop or provide an out-of-home residential setting for children that meets all applicable government requirements for licensure and certification.

a) The out-of-home residential setting shall provide care only for children under the age of eighteen (18) years or as determined by the DDD.

b) The out-of-home residential setting shall provide 24/7 care, support and training while the child is in the home.

c) Caregivers/direct support workers shall meet DDD certification standards.

d) The PROVIDER shall have staff with a master’s degree in behavioral sciences, education, or a therapeutic field from an accredited university or college with one year experience working with persons with disabilities to oversee, train, and revise if necessary, FBAs, PBS Plans, data collection, and recommendations for family reunification based on data.

e) Caregivers/direct support workers shall demonstrate ability to address behavioral issues and meet all training requirements as determined by the DDD, including, but not limited to, the following:

i. Person-Centered Planning

ii. PBS

iii. MANDT or other behavioral/crisis management system compatible with PBS

iv. Specialized topics as related to the individuals’ behavioral needs, diagnoses, history as determined by the DDD and the provider

v. Medication administration according to Chapter 16-89, HAR Subchapter 15, Delegation of Special Tasks of Nursing Care to Unlicensed Assistive Personnel

vi. Stress management

vii. General administration processes

2) Residential Habilitation services shall not exceed twelve (12) months and shall include, but is not limited to, the following:

a) Working with the child, family, circle of supports, and DOH case manager to meet the goal of re-unification. Re-unification activities shall include the family’s involvement in assessment, planning, development and implementation of the child’s PBS Plan and identified supports needed to return home.

b) Provide transition services and supports to the child’s family home, if necessary.

c) Exceptions to the time limit shall be reviewed on a case-by-case basis by the DDD.

d) In situations where family re-reunification is not possible, the PROVIDER shall provide supports necessary for transitioning to a new setting.

3) The PROVIDER shall ensure that Residential Habilitation supports and services include, but are not limited to, the following:

a) A person-centered approach to plan for the child’s needs as identified on the ISP and/or POC.

b) Development of an IP within thirty (30) days that shall identify the supports and services to be provided.

c) The IP shall include a PBS Plan to reduce challenging behaviors in order for the child to return to the family or a community home.

d) The IP shall determine the length of stay in the residential setting and discharge criteria necessary for return to the family or a community home.

e) On-going training for the caregivers that enable caregivers to successfully address the reduction of challenging behaviors in accordance with the child’s PBS Plan.

f) Provision of oversight of the home including support to the Residential Habilitation staff, as necessary.

g) Work collaboratively with the DOE in the provision of services:

i. 24/7 on-call supports in and out of the home to the child, family or caregivers to include Crisis Outreach.

ii. Provision of community-based supports and services to include access to activities outside the residential setting.

iii. Such services shall not supplant or duplicate entitlements and services required by state or federal statutes.

h) Provision of transportation to community activities such as medical appointments, community events, and recreational activities.

7. Residential Habilitation Services for Adults

Residential Habilitation shall be defined as individually tailored supports that assist with the acquisition, retention, or improvement in skills related to living in the community. These supports include adaptive skill development, assistance with activities of daily living, community inclusion, transportation, adult educational supports, social and leisure skill development, that assist the participant to reside in the most integrated setting appropriate to his/her needs. Residential Habilitation also includes personal care and protective oversight and supervision.

B. Management Requirements (Minimum and/or mandatory requirements)

1. Personnel

a. Training and Consultation Services

1) A licensed psychiatrist who has completed a psychiatric residency and preferably is Board certified shall be responsible for training and consultation on all matters pertaining to psychotropic medications, medication side effects and interaction, and management of psychiatric disorders and symptoms. Conjoint training responsibility with a clinical pharmacist is desired in the area of medication.

2) A licensed psychologist shall be responsible for oversight and quality of training, consultation, assessment, and plan development and for all matters or activities pertaining to management of individuals with challenging behaviors in need of Emergency Outreach, Emergency Shelter, or Residential Habilitation services. Individual supervision shall be provided to staff responsible for FBAs and PBS Plans at a minimum of one hour per week.

3) Staff with a master’s degree in behavioral sciences, education, or therapeutic field from an accredited university or college with one (1) year experience working with persons with disabilities shall be responsible for administering FBAs, developing a PBS Plan, training direct service workers in the implementation of a PBS Plan for individuals with challenging behaviors in need of Emergency Outreach, Emergency Shelter, or Residential Habilitation services at the direction or supervision of a licensed psychologist.

4) A licensed registered nurse (RN) shall be responsible for training and consultation in medication administration.

b. Emergency Outreach

1) A licensed psychiatrist who completed a psychiatric residency and preferably is Board certified shall be immediately accessible and available for consultation.

2) A Service Supervisor, defined as a bachelor’s level in behavioral sciences, education or therapeutic field from an accredited college with one (1) year of experience in working with individuals with DD/MR, shall provide clinical supervision of direct support workers.

3) The PROVIDER shall have a multidisciplinary team to consult with, as needed, to include master’s degree level behavioral specialist or psychologist, MSW, and RN.

4) Direct support staff shall have at least one (1) year experience with working with individuals with DD/MR and training in crisis intervention, PBS, and Mandt or other behavioral Emergency management compatible with PBS.

5) Direct support staff shall have access to clinical consultation and supervision twenty (24) hours per day, seven (7) days per week.

c. Emergency Shelter

1) A licensed psychiatrist who completed a psychiatric residency and preferably is Board certified shall be immediately accessible and available for consultation.

2) A Service Supervisor, defined as a bachelor’s level in behavioral sciences, education or therapeutic field from an accredited college, shall provide clinical supervision of direct support workers.

3) The Service Supervisor shall oversee the facility operation.

4) A RN, psychiatrist, licensed social worker or psychologist shall be accessible and available for consultation and supervision, as appropriate.

5) Direct support staff shall have at least one (1) year experience with working with individuals with DD/MR, training in crisis intervention and PBS.

6) Direct support staff shall have 24/7 access to clinical supervision and consultation.

7) Mandt or other behavior/crisis management certification compatible with PBS is required for all staff with direct contact with individuals with DD/MR.

d. Residential Habilitation Services for Children

1) Caregivers (direct support workers) shall have one (1) year experience in working with individuals with DD/MR.

2) The Residential Habilitation setting for children shall meet DDD certification requirements.

3) A master’s degree supervisor in behavioral sciences education, or therapeutic field from an accredited university or college with one (1) year experience working with persons with disabilities shall oversee, train, and revise if necessary, FBAs, PBS Plans, data collection, and recommendations for family reunification based on data.

4) A licensed psychologist shall provide one hour of individual supervision to the master’s level supervisor on a weekly basis.

e. Residential Habilitation Services for Adults

1) Caregivers (direct support workers) shall meet DDD certification requirements.

2) A Service Supervisor shall provide oversight, consultation and monthly supervision of caregivers/direct support workers.

The PROVIDER shall ensure that all program staff receives training in the areas of:

a. Contract requirements.

b. Program orientation with emphasis on individuals with DD/MR with challenging behaviors.

c. PBS

d. Mandt or other behavioral crisis management compatible with PBS.

e. Training required under the DD/MR Medicaid Waiver.

2. Administrative

The PROVIDER shall have administrative support staff to provide reporting, record keeping, disbursement, and other program requirement functions. Direct services provided for individuals in the DD/MR Medicaid Waiver shall be billed to the waiver.

Records shall be available for inspection by staff of the DDD and the DHS.

3. Quality assurance and evaluation specifications

The PROVIDER shall have a quality assurance and evaluation program that shall include, but not be limited to, the following:

a. An agency-directed plan that reflects what the organization independently uses to monitor, evaluate, and improve the services and supports delivered. The PROVIDER’S plan shall incorporate periodic measurement, reporting of outcome measures and performance indicators to meet the goal of CNS and improve the CNS delivery system.

b. A risk management plan that provides for ongoing monitoring, documented assessment and trending of Adverse Events on a quarterly basis, and situations/issues that affect individual health and safety.

1) The risk management process shall review appropriateness of action taken, follow-up and document preventative action taken.

2) Adverse Events requirements shall be in accordance with the requirements of the “DOH Standards for Home and Community Based Services for Persons with Developmental Disabilities/Mental Retardation” dated July 1, 2006 and any subsequent amendments to said Standards for all DD/MR Medicaid Waiver Program services.

3) A documented training plan including timelines shall be required for all Adverse Events for staff members responsible for delivery of CNS.

c. A training plan for staff members who are responsible for the delivery of CNS.

d. An ongoing consumer satisfaction survey of services provided to include individuals, if appropriate, families and/or guardian and other members of the individual’s circle of support, other service providers, and state agencies.

4. Output and performance/outcome measurements

The PROVIDER shall report output, performance, and outcome measurements to the STATE in a format to be determined by the DDD. Information shall include, but not be limited to, individuals’ demographics, crisis referral information, POC information, staffing and capacity patterns, Adverse Events and risk management, outcomes, regulatory compliance, resource utilization, coordination activities, training activities, billing for the DD/MR Medicaid Waiver and POS contract.

The required content and formats of all reports shall be subject to ongoing review and modification by the DDD.

5. Experience

The PROVIDER shall have organizational knowledge, training and/or experience in operating 24/7 crisis response team(s) and a 24/7 licensed residential setting.

The PROVIDER shall have experience in working collaboratively with public and private service organizations on a local level.

6. Coordination of services

The PROVIDER shall demonstrate the statewide capability to coordinate services with other agencies and resources in the community. The applicant shall summarize experiences working with the community and a description of the experiences in coordinating services for individuals with DD/MR.

7. Reporting requirements for program and fiscal data

a. The PROVIDER shall comply with the following reporting and documentation requirements to be determined by the STATE.

b. The PROVIDER shall submit reports in the format prescribed by the STATE to the Developmental Disabilities Division, Case Management and Information Services Branch, Contracts and Resource Development Section, 3627 Kilauea Avenue, Room 109, Honolulu, Hawaii 96816.

c. All program and fiscal reports shall be subject to resolution of the STATE’S findings and recommendations resulting from program monitoring and fiscal monitoring of the PROVIDER’S services under this Agreement.

C. Facilities

The PROVIDER shall assure that facilities meet all state requirements for licensure, Emergency Shelter services shall be provided in a setting that is licensed by the Office of Health Care Assurance (OHCA) and certified as a specialized treatment facility as applicable. Residential Habilitation shall be certified and licensed by the DDD and/or OHCA, as applicable.

Pursuant to Act 69, Session Laws of Hawaii, 2010, no contract proposals shall be accepted from any applicant who lacks any license necessary to conduct the business being sought by the request for proposals.

Acknowledgement

The PROVIDER shall provide information to individuals and their families or circle members who are referred for Crisis Network Services or want information about the program. The PROVIDER shall acknowledge on all printed materials, including program brochures and other publicly distributed matters and at public presentations, and PROVIDER websites, if available, that the program is funded under a contract with the Department of Health, Developmental Disabilities Division.

IV. COMPENSATION AND METHOD OF PAYMENT

The pricing structure for service activity areas “a” through “d” shall generally be based on fixed unit rate. The allotments for each of the service activity areas are estimates only.

a.	Crisis Network, Training and Consultation Services: Training and Consultation for Individuals: Estimated $58,334 allotted
b.	Emergency Outreach Services: Estimated $11,382 allotted
c.	Emergency Shelter Services: Estimated $232,400 allotted
d.	Residential Habilitation Services: Estimated $136,266 allotted for adults Estimated $93,937 allotted for children
e.	System Coordination Services: Estimated $347,681

UUnits of service and unit rate

a.	Crisis Network, Training and Consultation Services: Training and Consultation for Individuals: $150.00/hour Psychiatrist $104.28/hour Psychologist $87.92/hour Dietician $87.92/hour Behaviorist $87.92/hour Speech
b.	Emergency Outreach Services: Fixed unit rate of $79.20/hour
c.	Emergency Shelter Services: Fixed unit rate of $504.80 /day
e.	Residential Habilitation Services: Fixed unit rate of $187.50/day Residential Habilitation Services for Children: Fixed unit rate of $294.00/day

All payments are on based on a cost reimbursement structure. The PROVIDER will need to submit monthly invoices of services rendered along with monthly reports to be determined the Department of Health, Developmental Disabilities Division. Upon satisfactory review, payment will be made promptly within the state fiscal limitations and structure. Payments may be issued based on the availability of funds.

Section 4

Proposal Evaluation

I. Introduction

The evaluation of proposals received in response to the RFP will be conducted comprehensively, fairly and impartially. Structural, quantitative scoring techniques will be utilized to maximize the objectivity of the evaluation.

II. Evaluation Process

The procurement officer or an evaluation committee of designated reviewers selected by the head of the state purchasing agency or procurement officer shall review and evaluate proposals. When an evaluation committee is utilized, the committee will be comprised of individuals with experience in, knowledge of, and program responsibility for program service and financing.

The evaluation will be conducted in three phases as follows:

· Phase 1 - Evaluation of Proposal Requirements

· Phase 2 - Evaluation of Proposal Application

· Phase 3 - Recommendation for Award

Evaluation Categories and Thresholds

Evaluation Categories		Possible Points
*Administrative Requirements*

*Proposal Application*		100 Points
Program Overview	0 points
Experience and Capability	20 points
Project Organization and Staffing	10points
Service Delivery	60 points
Financial	10 Points

TOTAL POSSIBLE POINTS		100 Points

VII. Evaluation Criteria

A. Phase 1 - Evaluation of Proposal Requirements

1. Administrative Requirements

The PROVIDER shall be authorized as a DD/MR Home and Community Based Services (HCBS) Medicaid Waiver program provider by the Department of Health, Developmental Disabilities Division and have a contract with the Department of Human Services (DHS) to provide DD/MR HCBS Medicaid Waiver services.

2. Proposal Application Requirements

· Proposal Application Identification Form (Form SPO-H-200)

· Table of Contents

· Program Overview

· Experience and Capability

· Project Organization and Staffing

· Service Delivery

· Financial (All required forms and documents)

· Program Specific Requirements (as applicable)

B. Phase 2 - Evaluation of Proposal Application

(100 Points)

Program Overview: No points are assigned to Program Overview. The intent is to give the applicant an opportunity orient evaluators as to the service(s) being offered.

1. Experience and Capability (20 Points)

The State will evaluate the applicant’s experience and capability relevant to the proposal contract, which shall include:

A. Necessary Skills
· Demonstrated skills, abilities, and knowledge relating to the delivery of the proposed services.	2
B. Experience
· Description of projects/contracts pertinent to the proposed services and individuals with challenging behaviors. References provided.
o The PROVIDER shall have at least two (2) years of experience in working with children and adults with DD/MR or mental illness, with emphasis in behavioral intervention.	1

o The PROVIDER shall have qualifications and experiences that include a service delivery approach in assessing individualized needs and strengths and developing person-centered plans.	1
o The PROVIDER shall have training and experience in completing FBAs, developing and implementing PBS Plans including the training of plans and crisis intervention.	1
o The PROVIDER shall have organizational knowledge, training and experience in operating 24/7 crisis services and a 24/7 licensed residential setting.	1
o The PROVIDER shall have experience in working collaboratively with public and private service organizations on a local level.	1
C. Quality Assurance and Evaluation
· The PROVIDER shall have a quality assurance and evaluation program that shall include, but not be limited to, the following:
o An agency-directed plan that reflects what the organization independently uses to monitor, evaluate, and improve the services and supports delivered incorporating periodic measurement and reporting of outcome measures and performance indicators to meet goal of CNS and the PROVIDER’s plan to use outcome measurements and performance indicators to improve the CNS delivery system.	2
o A risk management plan that provides for ongoing monitoring, documented assessment and trending of Adverse Events on a quarterly basis, and situations/issues that affect individual health and safety.	3
o A training plan for staff members who are responsible for the delivery of CNS.	2
o An ongoing satisfaction survey to include individuals, if appropriate, families and/or guardian and other members of the individual’s circle of support, other service providers, and state agencies.	1
D. Coordination of Services
· Demonstrated capability to coordinate statewide services with other agencies and resources in the community. The applicant provided summary of working with the community and a description of the experiences in coordinating services for individuals with DD/MR.	4
· Letters of agreement are required to describe coordination of services if multiple providers intend to provide the array of CNS services.
E. Facilities
· Adequacy of facilities relative to the proposed services. If facilities are not presently available, are there plans to secure facilities and are timelines reasonable.	1
· Does facilities meet ADA requirements and state requirements for licensure.

2. Project Organization and Staffing (10 Points)

The State will evaluate the applicant’s overall staffing approach to the service that shall include:

A. Staffing
· Proposed Staffing: Description of proposed staffing pattern, client/staff ratio, and proposed caseload capacity is reasonable to ensure viability of the services.	2
· Staff Qualifications: Description of minimum qualifications (including experience) for staff assigned to the program.	3
· If staffing not currently available, plan including timelines is reasonable to ensure array of services.	1
B. Project Organization
· Supervision and Training: Demonstrated ability to supervise, train and provide administrative direction to staff relative to the delivery of the proposed array of services.	3
· Organization Chart: Organization’s approach and rationale for the structure, functions, and staffing for the proposed service activities and tasks are demonstrated.	1

3. Service Delivery (60 Points)

A. The applicant shall describe the following for crisis network services:

· Approach and strategy to meeting the goal of the service through its service activities. (Section 2. III. A)

· Capacity to provide the required service. (Section 2. III. B)

· Ability to provide or coordinate full array of CNS services.

· Ability to provide or coordinate statewide service activities.

o If multiple providers intend to provide array of services, work plan should include coordination among providers. If providers intend to provide specific service activity(ies), work plan should include willingness and experience to coordinate with other providers.

· Ability to meet the minimum and/or mandatory management requirements for Personnel, Administration, Quality Assurance and Evaluation, Output and Performance/Outcome Measurements, Reporting Requirements for Program and Fiscal Data. (Section 2. III. B)

· Development of a work plan, including implementation strategy that is logical and realistic in its timelines and schedules to accomplish the following major service activities and tasks (Section 2. III. A):

o Crisis Network, Training and Consultation, and Training and Consultation for Individuals to include, at a minimum, the following components:

Ø Monthly training and consultation for the network.

Ø Availability or development of curriculum on suggested topics.

Ø Workplan for training and consultation services.

Ø Training for stakeholders on identified training areas: FBA, PBS and implementation, medication management and monitoring.

Ø Plan to meet outcomes including developing Crisis Network.

Ø Management requirements for training and consultation.

Ø Lead staff

Ø Psychiatrist responsible for training and consultation on all matters pertaining to psychotropic medications.

Ø Psychologist

Ø Master’s degree staff for FBA, PBS Plan and training of PBS Plan.

Ø RN

o Emergency Outreach and Emergency Shelter services

Ø 24/7 availability

Ø Face-to-face response capability

Ø Workplan for Emergency Outreach, and Emergency Shelter

Ø Management requirements

Ø Direct support staff availability

Ø Supervisory staff availability

Ø Team availability

Ø Psychiatric oversight/availability

o Residential Habilitation for Children

Ø Ability to procure, develop or provide an out-of-home residential setting for children.

Ø Training and oversight capability of Residential Habilitation services for children with emphasis on PBS.

Ø Work plan to include plan and approach with the family to meet goal of re-unification including the family’s involvement in assessment, planning, development and implementation of a PBS Plan.

Ø Lead staff

o Residential Habilitation for Adults

Ø Recruitment, training and oversight of Residential Habilitation services for adults

Ø Management requirements for Residential Habilitation settings

Ø Direct support staff

Ø Lead staff for CNS contract

Ø Lead staff

· Clear description of work assignments and responsibilities. (Section 2. III. A)

· Identify lead staff for CNS contract, if appropriate, and/or lead staff for each of the service activities, including role and responsibilities of lead staff.

4. Financial (10 Points)

The budgets for fixed unit rate fully supports the scope of service and requirements of the Request for Proposal, are reasonable, given program resources and operational capacity. The cost reimbursement budget fully supports the scope of service and requirements of the Request for Proposal, is reasonable for personnel costs and comparable to positions in the community, and non-personnel costs are reasonable and adequately justified.
Crisis Network, Training and Consultation Services	1 point
Emergency Outreach Services	1 point
Emergency Shelter Services	1 point
Residential Habilitation Services for Adults	1 point
Residential Habilitation Services for Children	1 point
System Coordination	1 point

Adequacy of accounting system
Most recent audited or compiled financial statements	4 points

C. Phase 3 - Recommendation for Award

Each notice of award shall contain a statement of findings and decision for the award or non-award of the contract to each applicant.

Attachment C

STATE DEPARTMENT OF HEALTH

DEVELOPMENTAL DISABILITIES DIVISION

DD/MR MEDICAID WAIVER SERVICES PROGRAM PROVIDER STANDARDS

(07/01/06)

I. GENERAL REQUIREMENTS

A. Purpose

B. Definitions as Used in These STANDARDS

C. Exemptions

II. PROVIDER REQUIREMENTS

A. Agency Requirements

B. Personnel Requirements

C. Qualifications

D. Training

E. Supervision

F. Reporting Requirements

G. Quality Assurance

H. Records and Service Delivery Documentation

I. Individual Plan

J. Medications

K. Service Limitations/Exclusions/Restrictions

L. Non-compliance with These STANDARDS

M. Appeal of the Department of Human Services’ Decision

III. DOH CASE MANAGEMENT RESPONSIBILITIES

A. Participant Access

B. Participant-Centered Service Planning

C. Service Delivery

D. General

E. Specialized Medical Equipment and Supplies

F. Environmental Accessibility Adaptations

G. Vehicular Modifications

H. Assistive Technology

I. Personal Emergency Response System (PERS)

IV. SERVICES

A. Chore

B. Personal Assistance/Habilitation

C. Residential Habilitation

D. Adult Day Health

E. Supported Employment

F. Respite

G. Skilled Nursing

H. DD/MR Emergency Outreach, Respite and Shelter

I. Training and Consultation

J. Transportation

I. GENERAL REQUIREMENTS

A. Purpose

The purpose of these STANDARDS is to establish minimum requirements for the provision of DD/MR Medicaid Waiver Services Program.

B. Definitions as Used in These STANDARDS

As used in these STANDARDS, the following terms are defined as follows:

“Activities of Daily Living” (ADLs) means activities related to personal care including, but not limited to, bathing, dressing, toileting, transferring, and eating.

“Associated Costs” means costs associated with personal assistance/habilitation services to meet outcomes/goals of increasing independence, developing natural supports, learning, developing relationships, contributing through employment/volunteering/ participation. Associated costs may include, but are not limited to, membership fees, admission costs for activities and events, supplies and informational materials such as art supplies, books, videos and CDs specific and necessary to meet the PARTICIPANT’S goal/outcome. Associated costs shall be provided for the PARTICIPANT’S benefit only and shall be negotiated and mutually agreeable to the PARTICIPANT, Department of Health (DOH) Case Manager (CM), circle of supports and PROVIDER. See STANDARDS, IV. SERVICES, for full definition.

“Behavioral Specialist” means a person who possesses a Master’s Degree in the behavioral sciences, education, nursing, or therapeutic field from an accredited university or college with one (1) year experience working with persons with disabilities in assessment, individual planning, and training regarding behaviors. The experience shall include Functional Behavioral Assessments (FBAs) and/or the development of Positive Behavioral Support (PBS) plans.

“Case Manager” means the DOH-DDD (DOH-DDD CM) case manager who provides targeted case management services as defined in Title 17, Chapter 1738, Hawaii Administrative Rules (HAR).

“Circle of Supports” refers to the PARTICIPANT’S family, friends, DOH-DDD CM, and other persons identified by the PARTICIPANT as being important to the planning process, such as PROVIDER representatives.

“Chore” means services that are needed to maintain the home in a clean, sanitary and safe environment, including the performance of general household tasks (e.g., meal preparation and routine household care). These services are provided only when the PARTICIPANT or anyone else in the household, or other relatives, caregiver, landlord, community/volunteer agency, or third party payor is not capable or responsible for performing or financially providing for them. In the case of rental property, the responsibility of the landlord, pursuant to the lease agreement, is examined prior to any authorization of service. See STANDARDS, IV. SERVICES, for full definition.

“Crisis Contingency Plan” means the plan developed by circle of supports to identify a plan of action in case of an emergency situation(s).

“Designated Representative” means an individual identified by the circle of supports to make decisions for a PARTICIPANT receiving services under the DD/MR Medicaid Waiver Services Program when the PARTICIPANT is unable to make his or her own decisions and there is no legal guardian or durable power of attorney.

“Direct Support Worker” means staff hired by the PROVIDER in accordance with the STANDARDS to provide services under the DD/MR Medicaid Waiver Services Program for a PARTICIPANT as specified in the Waiver Action Plan (WAP) or Individual Plan (IP).

“Family Member” means the Natural, adoptive, step, in-law, or hanai father, mother, brother or sister, son or daughter, and grandfather or grandmother.

“Functional Behavioral Assessment” (FBA) means a process/analysis that is completed by a Behavioral Specialist, which identifies a problem behavior of a PARTICIPANT in order to determine the function or purpose of the behavior to develop interventions to teach acceptable alternatives to the behavior. The process is as follows:

(1) Identify the behavior that needs to change

(2) Collect data on behavior

(3) Develop a hypothesis about the reason for behavior

(4) Develop a behavioral support plan to help change the behavior

(5) Evaluate the effectiveness of the intervention

“Hanai” means a child, who is taken permanently to be reared, educated and loved by individual(s) other than the child’s natural parents at the time of the child’s birth or early childhood. The child is given outright, and the natural parents renounce all claims to the child.

“ICF-MRC” means an intermediate care facility for persons with developmental disabilities or mental retardation (DD/MR) as defined in 42 C.F.R. § 440.150.

“Instrumental Activities of Daily Living” (IADLs) are more complex life activities such as light housework, laundry, meal preparation, transportation, grocery shopping, using the telephone, managing one’s medication, and money management.

“Individual Plan” (IP) is a written plan that is developed and implemented by a PROVIDER within thirty (30) calendar days of the service start date, which delineates the goals, objectives, interventions, and outcomes of the services DD/MR Medicaid Waiver Services Program based upon the DOH-DDD Waiver Action Plan. See STANDARDS, II. PROVIDER REQUIREMENTS, for full definition.

“Individualized Service Plan” (ISP) means the written plan that is required by Hawaii Revised Statutes (HRS) § 333F-6, which is developed by the individual, with the input of family, friends, and other persons identified by the individual as being important to the planning process. The ISP shall be a written description of what is important to the person, how any issue of health or safety needs shall be addressed, and what needs to happen to support the person in the person’s desired life. See HRS § 333F for full definition.

“Licensed Practical Nurse” (LPN) is a person licensed as a practical nurse by the State of Hawaii, pursuant to Chapter 457, HRS.

“Measurable” means to describe an objective or task in terms that delineate when the PARTICIPANT has accomplished the objective or task.

“Medical Treatment” means treatment that is rendered by a physician, nurse practitioner, ambulance or emergency medical personnel, or emergency room medical staff.

“Medicaid Waiver Program” means a Medicaid Home and Community-Based Services program under 42 C.F.R. § 440.180 and § 441.300.

“Natural Supports” means supports that are available to the PARTICIPANT within the family, circle of supports, and community and that are unpaid.

“Nursing Care Plan” means a care plan that is developed and written by a registered nurse (RN), which addresses the PARTICIPANT’S specific nursing needs. The nursing care plan includes an assessment of the PARTICIPANT’S problems, interventions, and evaluations.

“On-Site Supervision” means supervision that is provided by Service Supervisor:

(1) At the site or location where services are rendered;

(2) In the presence of the direct support worker and the PARTICIPANT receiving services; and

(3) While the PARTICIPANT is receiving services as specified in the IP.

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“Participant” means an individual who meets the DD/MR Medicaid Waiver Services Program eligibility criteria and who has been admitted into the program.

“Personal Assistance/Habilitation” (PAB) means a range of assistance and/or training to enable program PARTICIPANTS to accomplish tasks that they would normally do for themselves if they did not have a disability. Such assistance shall include active supervision (readiness to intervene as necessary) and interaction with PARTICIPANTS. Services may include personal assistance or training to meet outcomes/goals of increasing independence, developing natural supports, learning, developing relationships, contributing through employment/volunteering/participation and their associated costs. See STANDARDS, IV. SERVICES, for full definition.

“Physician” means a person who is licensed to practice medicine or osteopathy in Hawaii under Chapter 453 or 460, HRS.

“Positive Behavioral Support Plan” (aka “Behavioral Support Plan”) means a plan that is developed by a Behavioral Specialist. The plan shall be comprised on the following:

(1) Interventions that consider the context within which the behavior occurs;

(2) Interventions that address the functionality of the problem behavior

(3) Interventions that can be justified by the outcomes; and

(4) Outcomes that are acceptable to the PARTICIPANT, the PARTICIPANT’S family, and the PARTICIPANT’S circle of supports.

“Primary Caregiver” means the caregiver living in the home with the PARTICIPANT who has primary responsibility for the PARTICIPANT’S care and well-being.

“Provider” (PROVIDER) means an agency, company, or individual that has entered into a written PROVIDER Agreement with DHS to provide services under the DD/MR Medicaid Waiver Services Program to PARTICIPANTS as described in these STANDARDS.

“Registered Nurse” (RN) means a person who is licensed as a registered nurse in the State of Hawaii pursuant to Chapter 457, HRS.

“Satisfactory Skills Verification” means verification of skills determined by an appropriate Service Supervisor as defined in these STANDARDS and special tasks of nursing care, if applicable, to ensure competency in implementing the IP.

“Sharps Container” means a rigid, puncture resistant, disposable container with a lid and a prominent biohazard label indicating needle container. The container shall be closable, leak-proof on sides and bottom, easily accessible, and maintained upright throughout use. The container shall be replaced routinely and not allowed to overfill.

“Sharps” or “Sharps Material” means needles, scalpel blades, skin lancets, bleeding time devices, and any other material that can easily puncture the skin and should be handled with extreme caution.

“Service Supervisor” means an individual identified by PROVIDER with responsibility for programmatic, administrative, personnel, and contract compliance. A Service Supervisor is required for all services under the DD/MR Medicaid Waiver Services Program, except Training and Consultation, Transportation, Specialized Medical Equipment and Supplies, Environmental Accessibility Adaptations, Vehicular Modifications, Assistive Technology and Personal Emergency Response System. Refer to STANDARDS, II. PROVIDER REQUIREMENTS, for specific qualifications.

“Special Task Of Nursing Care” or “Special Tasks” means procedures that require nursing education or that require nursing education and training in order to be performed safely. Refer to HAR Title 16, Chapter 89, Subchapter 15 (Delegation of Special Tasks of Nursing Care to Unlicensed Assistive Personnel).

“Stand-By Assistance” means Personal Assistance/Habilitation service (PAB Level 1 only) for PARTICIPANTS requiring up to twenty-four (24) hour supervision, monitoring, and/or intermittent indirect or direct assistance. Stand-by assistance is typically rendered during periods in which the PARTICIPANT is asleep and may wake needing assistance.

“Waiver Action Plan” (WAP) means the plan that is developed by the DOH-DDD CM within one (1) week of a PARTICIPANT’S admission to the DD/MR Medicaid Waiver Services Program which identifies: 1) goals; 2) desired outcomes; 3) timelines for achieving outcomes; 4) services identified to achieve outcomes; 5) frequency, duration and service PROVIDER(S). The WAP is approved by the PARTICIPANT and the PARTICIPANT’S legal guardian and is authorized by the DOH-DDD CM.

The WAP shall serve as the interim IP until an Individual Plan, developed by the PROVIDER, is finalized, but not to exceed thirty (30) days. See STANDARDS, III. DOH CASE MANAGEMENT RESPONSIBILITIES, for full definition.

C. Exemptions from STANDARDS FOR DD/MR Medicaid Waiver Services Program

1. Requests for exemptions from the DD/MR Medicaid Waiver Services Program standards by a PROVIDER agency shall be submitted in writing to the DOH.

2. Requests for exemptions shall be denied if the exemption will create a hazard to health or safety as determined by DOH and DHS.

3. An exemption may be renewed at the discretion of the and the DHS.

4. Exemptions granted by the DOH and the DHS, whether expressed or implied, shall be documented and shall not be transferred from one PROVIDER agency to another.

II. PROVIDER REQUIREMENTS

A. PROVIDER Agency Requirements

The PROVIDER shall have:

1. Been authorized as a DD/MR Medicaid Waiver Services Program PROVIDER by the DOH and the DDD; and

2. A PROVIDER Agreement with the DHS.

B. PROVIDER Personnel Requirements

The PROVIDER shall be responsible for:

1. Ensuring that staff requirements are met prior to service provision;

2. Ensuring that staff-to-PARTICIPANT ratios are in accordance with service requirements;

3. Maintaining sufficient number of qualified personnel or subcontractors to ensure optimal health and safety of PARTICIPANTS and to ensure continuity of services for PARTICIPANTS.

C. PROVIDER Qualifications

1. The PROVIDER shall maintain a personnel file for all staff (supervisors and direct support workers) and subcontractors providing services under the DD/MR Medicaid Waiver Services Program that documents qualifications and employment/contractual requirements, as applicable. Qualifications and employment/contractual requirements shall include, but are not limited to, the following:

a. Current Hawaii professional licenses, certificates, and liability insurance;

b. Appropriate education and/or work experience;

c. Minimum age requirements as defined by Hawaii State labor laws;

d. Current valid Hawaii State driver’s license and access to a vehicle;

e. Current job descriptions or legally valid subcontractor agreements;

f. The provision of an orientation to the DD/MR Medicaid Waiver Services Program and job responsibilities, agency policies and procedures including emergency protocols, alcohol and drug-free workplace policy, and policies to protect PARTICIPANT rights and confidentiality of PARTICIPANT records;

g. A signed statement from each direct support worker and subcontractor to declare understanding of the PROVIDER’S abuse/criminal history policies;

h. A signed statement, updated annually, indicating no history of any criminal conviction such as convictions of theft, abuse, neglect, or assault.

2. The PROVIDER shall also assure that staff qualifications meet additional requirements for specific services as stated in the STANDARDS.

a. DIRECT SUPPORT WORKERS

1) Qualifications for Direct Support Workers for Chore, PAB Level 1, PAB Level 2, Res/Hab Level 1, Res/Hab Level 2, ADH Level 1, ADH Level 2, ADH Level 3, Supported Employment, and Respite:

a) Current tuberculosis (TB) clearance according to DOH Standards;

b) First aid and cardiopulmonary resuscitation (CPR) training;

c) Criminal History check according to the Standards set forth by the DHS;

d) APS and/or CPS checks according to the Standards set forth by the DHS;

e) Satisfactory skills (skill level as defined and identified in the IP) as verified and documented by a Service Supervisor, as stated in the STANDARDS, prior to service delivery and in the event of any changes to the IP.

2) Qualifications for Direct Support Workers for PAB Level 3:

a) Current tuberculosis (TB) clearance according to DOH Standards;

b) First aid and cardiopulmonary resuscitation (CPR) training;

c) Criminal History check according to the Standards set forth by the DHS;

d) APS and/or CPS checks according to the Standards set forth by the DHS;

e) Associate in Arts (AA) degree or at least fifty (50) college credits from an accredited college or university;

f) Satisfactory skills (skill level as defined and identified in the IP) as verified and documented by a Service Supervisor (Behavioral Specialist) , as stated in the STANDARDS, prior to service delivery and in the event of any changes to the IP.

3) Qualifications for Direct Support Workers for Res/Hab Level 3/Behavioral, Res/Hab Level 4 and Res/Hab Level 5:

a) Current tuberculosis (TB) clearance according to DOH Standards;

b) First aid and cardiopulmonary resuscitation (CPR) training;

c) Criminal History check according to the Standards set forth by the DHS;

d) APS and/or CPS checks according to the Standards set forth by the DHS;

e) Satisfactory skills (skill level as defined and identified in the IP) as verified and documented by a Service Supervisor (Behavioral Specialist), as stated in the STANDARDS, prior to service delivery and in the event of any changes to the IP;

f) Successful completion of training provided or certified by the DDD to include the following:

i. Person-Centered Planning;

ii. PBS;

iii. Mandt system or other behavioral/crisis management system compatible with PBS.

4) Qualifications for Direct Support Workers for Res/Hab Level 3/Medical:

a) RN licensed in the State of Hawaii;

b) Current TB clearance according to DOH Standards;

c) Current CPR certification;

d) Criminal History Check according to the Standards set forth by the DHS;

e) APS and/or CPS check according to the Standards set forth by the DHS.

5) Qualifications for Direct Support Workers for DD/MR Emergency Services see IV. SERVICES, DD/MR Emergency Outreach, Respite and Shelter.

6) Qualifications for Family Members as Direct Support Workers for Chore, PAB Level 1, PAB Level 2, Supported Employment, and Respite:

a) Criminal History check according to the Standards set forth by the DHS;

b) APS and/or CPS checks according to the Standards set forth by the DHS;

c) Satisfactory skills (skill level as defined and identified in the IP) as verified and documented by a Service Supervisor, as stated in the STANDARDS, prior to the service delivery and in the event of any changes to the IP;

d) Recommended for Family Members as Direct Support Workers: TB, First Aid, CPR.

b. SERVICE SUPERVISORS

1) Qualifications for Service Supervisor for Chore, PAB Level 1, Res/Hab Level 1, Res/Hab Level 2, ADH Level 1, Supported Employment and Respite:

a) Bachelor's degree from an accredited college or university in social sciences or education; or

b) Bachelor’s degree from an accredited college or university in another field with one (1) year verifiable experience working directly with individuals with disabilities or the elderly; or

c) RN licensed in the State of Hawaii;

d) Staff qualifications from foreign colleges and universities, which are accredited, will be acceptable. The PROVIDER must document verification of accreditation from foreign colleges and universities. Acceptance of admission to a graduate program at the University of Hawaii, Hawaii Pacific University, or Chaminade College will be acceptable criteria to meet staff qualification.

2) Qualifications for Service Supervisor for PAB Level 2, Res/Hab Level 3, and ADH Level 2, for PARTICIPANTS with behavioral needs:

a) A RN, licensed in the State of Hawaii, with training in PBS provided or certified by the DDD, and continuing education and/or training in the area of PBS at least once every two (2) years; or

b) Bachelor’s degree from an accredited college or university in social sciences or education or Bachelor’s degree from an accredited college or university in another field with two (2) years verifiable experience working directly with individuals with disabilities or the elderly, PBS training provided or certified by the DDD, and continuing education and/or training in the area of PBS at least once every two (2) years; or

c) Behavioral Specialist;

d) RN, licensed in the State of Hawaii, for special tasks of nursing (tasks that have been delegated by a RN as specified in HAR Title 16, Chapter 89, Subchapter 15, (“Delegation of Nursing Tasks to Unlicensed Assistive Personnel”) (HAR § 16-89-100; HAR § 16-89-111; HAR 16-89-112; HAR § 16-89-113; and HAR § 16-89-114);

e) Staff qualifications from foreign colleges and universities, which are accredited, will be acceptable. The PROVIDER must document verification of accreditation from foreign colleges and universities. Acceptance of admission to a graduate program at the University of Hawaii, Hawaii Pacific University, or Chaminade College will be acceptable criteria to meet staff qualification.

3) Qualifications for Service Supervisor for PAB Level 2, Res/Hab Level 3, and ADH Level 3, for PARTICIPANTS with medical needs:

a) RN licensed in State of Hawaii.

4) Qualifications for Service Supervisor for PAB Level 3, Res/Hab Level 4 and Res/Hab Level 5:

a) Behavioral Specialist;

b) RN, licensed in the State of Hawaii, for special tasks of nursing (tasks that have been delegated by a RN as specified in HAR Title 16, Chapter 89, Subchapter 15, (“Delegation of Nursing Tasks to Unlicensed Assistive Personnel”) (HAR § 16-89-100; HAR § 16-89-111; HAR 16-89-112; HAR § 16-89-113; and HAR § 16-89-114).

5) Qualifications for Service Supervisors for DD/MR Emergency Services see IV. SERVICES, DD/MR Emergency Outreach, Respite and Shelter.

6) Qualifications for RN or LPN:

a) RN or LPN who is licensed in the State of Hawaii;

b) Current TB clearance according to DOH Standards;

c) Current CPR certification;

d) Criminal History check according to the Standards set forth by the DHS;

e) APS and/or CPS check according to the Standards set forth by the DHS.

D. PROVIDER Training Requirements

1. The PROVIDER shall have an orientation for new direct support workers to include, but not be limited to, the following topics:

a. Overview of Individuals with DD/MR

b. Basic Health and Safety

c. Adverse Events Reporting

d. Ethical Conduct

2. The PROVIDER shall provide ongoing continuing education for direct support workers and/or Service Supervisors, at a minimum, on an annual basis. Training areas may include:

a. Positive Behavioral Supports

b. Documentation

c. Communication

3. The PROVIDER shall document the provision of training.

E. PROVIDER Supervision

The PROVIDER shall be responsible for service and direct support worker supervision as specified in the STANDARDS. Supervision shall include, but not be limited to, the following:

1. On-site monitoring of services being delivered to PARTICIPANT. This supervision shall take place either on a scheduled or non-scheduled basis;

2. Assessing the quality of service implementation and activities as specified in the IP including PARTICIPANT’S responsiveness and progress toward achieving outcomes; such assessments shall be documented in the PARTICIPANT’S record;

3. Ensuring that each direct support worker is trained in the manner and method of providing service to the PARTICIPANT before the direct support worker works independently with the PARTICIPANT;

4. Ensuring that each direct support worker is made aware of any and all information from the PARTICIPANT’S record that is essential for the direct support worker to work effectively and safely with the PARTICIPANT;

5. Ensuring that the needs of each PARTICIPANT are matched with a direct support worker who has received training in the services to be provided to the PARTICIPANT and is knowledgeable about the needs and preferences of the PARTICIPANT;

6. Ensuring that the place in which the service is delivered is suitable to the activity, is able to physically accommodate the PARTICIPANT in a safe, comfortable manner, and that the PARTICIPANT’S privacy and preferences are known to direct support workers and are respected; and

7. Identifying barriers to services and achieving outcomes including recommendations.

F. PROVIDER Reporting Requirements

1. The PROVIDER shall review and report PARTICIPANT outcomes for each DD/MR Medicaid Waiver Program service, except Respite and Transportation, quarterly and annually, or more frequently as identified in the STANDARDS, IV. SERVICES, or ISP and/or WAP.

2. The report shall include review of PARTICIPANT outcomes.

a. The report shall also include review of each IP and recommendations for revision, if necessary.

b. The annual report shall include twelve (12) months of review of PARTICIPANT outcomes and can include the last period’s review of PARTICIPANT outcomes and IPs. The twelve (12) month period shall begin when services are initiated.

3. Reporting requirements for Respite and Transportation are specified in the STANDARDS, IV. SERVICES, in applicable sections.

4. Reports shall summarize PROVIDER progress towards outcomes identified in the IP, any significant events that may impact on the PARTICIPANT’S progress and recommendations, if any.

5. Reports shall be based on:

a. Service delivery documentation;

b. Supervisory observation of actual service delivery provided at intervals specified in the STANDARDS, IV. SERVICES and/or ISP and/or WAP;

c. Assessment of service delivery method(s);

d. Evaluation of the progress to meet outcomes; and

e. PARTICIPANT satisfaction of services.

6. The PROVIDER shall:

a. Provide copies of the reports to the DOH-DDD CM;

b. Provide copies of the reports to the PARTICIPANT and the PARTICIPANT’S legal or designated representative as requested;

c. Assure reports are completed and distributed thirty (30) days after the end of the quarter or frequency identified in the service or ISP and/or WAP and thirty (30) days after the end of the year; and

d. Document the distribution of reports.

G. PROVIDER Quality Assurance

1. Internal Quality Assurance

a. In keeping with the Quality Management Strategy set forth in the Centers for Medicare and Medicaid Services (CMS), each PROVIDER shall have an internal quality management program to ensure the following processes: discovery, remediation, and improvement.

1) Discovery processes: involves collecting data and direct PARTICIPANT experiences, e.g., satisfaction survey/interview, in order to assess the ongoing implementation of the services and supports, identifying strengths and opportunities for improvement.

a) Data sources must be identified, e.g., Adverse Event Reports, IP for service outcomes;

b) Timelines for reviews must be identified, e.g., frequency of reviews;

c) Person(s) responsible for reviews must be identified, e.g., staff, committee membership.

2) Remediation: taking action to remedy specific problems or concerns that arise.

a) Process of reviews and recommendations;

b) Process for follow up of recommendations;

c) Process for documentation of review, recommendations and follow up completed;

d) Types of remediation;

e) Trending analysis process.

3) Continuous Improvement: utilizing data and quality information to engage in actions that lead to continuous improvement of services and supports.

a) Quarterly reports to the DOH and DHS:

i. PARTICIPANT’S status/improvements;

ii. Discovery information;

iii. Remediation efforts;

iv. Continuous improvement status;

v. Problems and concerns.

b) System improvement:

i. Issues resolved;

ii. Recommendations.

2. The internal quality management program shall describe the processes and policies and procedures for the focus areas:

a. PARTICIPANT-centered service planning and delivery

1) IP(s) for service(s) address(es) goals and outcomes for which PROVIDER service(s) have been identified to meet;

2) Service(s) is/are delivered in accordance with the IP for the service(s), including type, scope, amount, duration, and frequency specified in the IP;

3) The IP(s) for service(s) are in keeping with PARTICIPANT’S preferences, personal goals, needs and abilities, and health status;

4) PARTICIPANTS have the authority and are supported to direct and manage their own service(s) to the extent they wish;

5) Significant changes in the PARTICIPANT’S needs or circumstances promptly trigger consideration of modifications in the IP(s) for service(s), e.g., health status deteriorates, increased frequency of behaviors, outcomes met.

b. PROVIDER Capacity and Capabilities

1) PROVIDER demonstrates that required licensure and/or certification standards are met and adheres to other standards prior to their furnishing waiver services;

2) PROVIDER shall have policies and procedures to

administer and implement the DD/MR Medicaid Waiver Services Program;

3) PROVIDER demonstrates that training is provided in accordance with State requirements and these STANDARDS;

4) PROVIDER demonstrates that direct support workers possess the requisite skills, competencies and qualifications to support PARTICIPANTS effectively;

5) PROVIDER demonstrates the ability to provide services and supports in an efficient and effective manner consistent with the IP(s) for service(s).

c. PARTICIPANT Safeguards

1) PARTICIPANT health risk and safety considerations are assessed and potential interventions identified that promote health, independence, and safety with the informed involvement of the PARTICIPANT;

2) There are systematic safeguards in place to protect PARTICIPANTS from critical incidents and other life-endangering situations;

3) Behavioral interventions are implemented according to approved behavioral support plans;

4) Medications are managed efficiently and appropriately in accordance with applicable State laws;

5) There are safeguards in place to protect and support PARTICIPANTS in the event of natural disasters or other public emergencies.

d. PARTICIPANT Rights and Responsibilities

1) PARTICIPANTS are informed and supported to freely exercise their fundamental constitutional and federal and state statutory rights that shall include, but not be limited to:

a) Being treated with understanding, dignity, and respect;

b) Being free from exploitation, neglect, and abuse;

c) Receiving individually defined and appropriate services and supports;

d) Privacy and confidentiality including privacy in treatment and in personal care;

e) Freedom of choice of services and supports and PROVIDERS;

f) Being fully informed, prior to or at the time of service start date, of services to be provided by the PROVIDER;

g) Being informed of the PROVIDER’S policies and procedures governing PARTICIPANT conduct;

h) Being given advance notice of at least two (2) weeks of PROVIDER change in services (transfer) or discharges, except in an emergency.

2) PARTICIPANTS are informed of and supported to freely exercise their Medicaid due process rights.

3) PARTICIPANTS are informed of how to register grievances and complaints and are supported in seeking their timely resolution.

e. PARTICIPANT Outcomes and Satisfaction

1) PARTICIPANTS achieve desired (positive) outcomes.

2) PARTICIPANTS and their families/guardians, as appropriate, express satisfaction with their services and supports.

f. System Performance as related to quality improvement and financial integrity

1) System supports PARTICIPANTS efficiently and effectively and constantly strives to improve quality.

2) Financial accountability shall assure that claims are made for services that have been rendered to eligible waiver PARTICIPANTS, authorized in the ISP and/or WAP, provided by qualified PROVIDERS:

a) Monthly verification of Medicaid eligibility of PARTICIPANTS through DHS MedQuest phone or website;

b) All invoices are verified as correct;

c) Payment for services shall only be made when the identical service is not authorized through the Medicaid State Plan, from start date of service provision by a PROVIDER and shall not include reimbursement for any DD/MR Medicaid Waiver services while a PARTICIPANT is suspended from the DD/MR Medicaid Waiver Services Program;

d) Claims are consistent with DOH-DDD prior authorizations and ISP and/or WAP for services under the DD/MR Medicaid Waiver Services Program; and

e) Reimbursement for services shall not be provided prior to admission to the DD/MR Medicaid Waiver Services Program.

3. Requirements

a. Adverse Event Reporting

1) The PROVIDER shall notify the DOH-DDD CM and DHS of the following adverse events:

a) Changes in the PARTICIPANT’S condition requiring medical treatment;

b) Hospitalization of the PARTICIPANT;

c) Death of the PARTICIPANT;

d) All bodily injuries sustained by the PARTICIPANT for which medical treatment (i.e., treatment rendered by a physician, nurse practitioner, ambulance or emergency medical personnel, or emergency room medical staff) and/or follow up is necessary, regardless of cause or severity;

2) The PROVIDER shall document training and periodic reviews and/or random drills conducted for appropriate staff to ensure timely and appropriate actions taken in such emergencies.

c. The PROVIDER shall:

1) Cooperate with the State DOH and DHS, and the United States Department of Health and Human Services or their authorized representatives when evaluations are conducted, both announced and unannounced, on the quality, adequacy, and timeliness of services provided. Evaluations may include:

a) Review of administrative, fiscal, and personnel records;

b) Review of PARTICIPANT’S service delivery notes and records;

c) Review of documentation of service delivery time and efforts for PARTICIPANTS;

d) Observations of service delivery; and

e) Interviews with PARTICIPANTS and direct support workers and supervisors.

2) Develop and implement adequate measures for corrective actions required, according to agreed upon timelines.

H. PROVIDER Records and Service Delivery Documentation

1. The PROVIDER shall maintain a confidential case file for each PARTICIPANT.

2. The individual case file shall include current:

a. Emergency and personal identification information including, but not limited to, the following:

1) PARTICIPANT’S address, telephone number;

2) Names and telephone numbers of the family, licensed or certified care PROVIDER, relative, designated representative and/or guardian;

3) Physician's name(s) and telephone number(s);

4) Pharmacy name, address and telephone number if necessary to assure PARTICIPANT health and safety;

5) Health plan information.

b. The PARTICIPANT’S ISP and/or WAP and IP;

c. Medical information, which shall include, but is not limited to:

1) Medical orders as applicable for waiver services;

2) Precautions for participation in an activity;

3) Diagnoses or conditions;

4) Infections, contagious or communicable conditions;

5) Current medications;

6) Known allergies;

7) Special health care needs; and

8) Special nutritional needs.

d. Crisis contingency plan, if one is necessary, for the PARTICIPANT;

e. PBS plan, if one is necessary, for the PARTICIPANT;

f. Documentation that the PARTICIPANT and/or family/guardian acknowledge that he/she has been informed of the PARTICIPANT’S rights and grievance procedures.

3. The PROVIDER shall maintain service delivery documentation, records and reports for all PARTICIPANTS that include, at a minimum, the following:

a. Date, time, duration, and location of service delivery;

b. Documentation of activities or type of service rendered during service delivery:

1) Progress notes, contact logs, attendance and other service delivery documentation;

2) Data collected that measures PARTICIPANT progress in relation to the PARTICIPANT’S IP objectives, if applicable.

c. Name of direct support worker providing services; and

d. Date, location, name and title of supervisor conducting the required on-site supervision and/or telephone contacts.

4. The PARTICIPANT record is a legal document that shall be kept in detail to permit effective professional review and provide information for necessary follow-up and care.

a. Individual PARTICIPANT records shall be kept in a manner that ensures legibility, order, timely signing and dating of each entry in black or blue ink.

b. Documentation of verbal or written reports and follow-up, as necessary, received from other agencies, the PARTICIPANT’S family, the PARTICIPANT’S legal, designated representative, or caregiver to determine whether action needs to be taken by the PROVIDER.

I. Individual Plan (IP)

The PROVIDER shall assure IPs for all PARTICIPANTS are developed and written based on the ISP and/or WAP, incorporating verbal and written information received from the PARTICIPANT, the DOH-DDD CM, other agencies, the PARTICIPANT’S family, or the PARTICIPANT’S legal or designated representative for the following services:

1. Chore

2. Personal Assistance/Habilitation

3. Residential Habilitation

4. Adult Day Health

5. Supported Employment

6. Respite

7. Skilled Nursing

8. DD/MR Emergency Outreach, Respite and Shelter

1. The IP:

a. Shall be developed and shall be approved by a Service Supervisor as defined in the STANDARDS and shall be based on the ISP and/or WAP;

b. Shall include the PARTICIPANT, the DOH-DDD CM, and members of the PARTICIPANT’S circle of supports in its development, and shall be approved by the PARTICIPANT and/or legal guardian;

c. Shall be developed, written and implemented within thirty (30) calendar days of the service start date; the ISP and/or WAP shall serve as the interim IP until the Individual Plan is finalized;

d. Shall detail the specific activities, methods, or approaches with timeframes for achievement to be implemented, including behavioral supports, to achieve the desired goals and outcomes identified in the ISP and/or WAP;

e. Shall meet the requirements as specified in the STANDARDS of each service under the DD/MR Medicaid Waiver Services Program;

f. Shall be written in terms easily understood by the PARTICIPANT, the primary caregiver, and direct support worker;

g. The ISP and/or WAP shall serve as an interim IP until the Individual Plan is finalized, not to exceed thirty (30) days, following the service start date.

2. The PROVIDER shall assure that:

a. Direct support workers required to implement the IP are adequately and appropriately trained;

b. The training be conducted prior to the implementation of the IP;

c. The training be documented;

d. The PARTICIPANT or the PARTICIPANT’S legal or designated representative, and the DOH-DDD CM receive copies of the IP within seven (7) calendar days of its initiation and subsequent revisions;

e. The distribution of copies of the IP shall be documented.

J. Medications

0 1. The following shall apply to medications ingested or administered during the hours the PARTICIPANT is in a DD/MR Medicaid Waiver Services Program or receiving services under the DD/MR Medicaid Waiver Services Program from a PROVIDER:

1 a. Physician prescribed medications may be self-administered by a PARTICIPANT when the PARTICIPANT is physically and cognitively able to do so;

b. The PARTICIPANT may self-inject prescribed medications when the physician has written orders to permit this;

c. The PARTICIPANT may be assisted with medications when:

1) The medication has been pre-measured;

2) The medication is in individual doses;

3) The container is clearly labeled by the PARTICIPANT’S caregiver, pharmacist, physician, RN or LPN with the PARTICIPANT’S name and the time and route for the medication; and

4) The PARTICIPANT is able to take the single dose of medication independently. The PROVIDER staff assisting with the medication shall not place the medication in the PARTICIPANT’S mouth.

2. Assistance with medication includes, but is not limited to, the following:

a. Placing the labeled container with the pre-measured medication in the PARTICIPANT’S hand;

b. Assisting the PARTICIPANT with opening the container and dropping the medication into the PARTICIPANT’S hand when needed;

c. Instructing the PARTICIPANT to take the medication;

d. Helping the PARTICIPANT to drink a liquid in order to swallow the medication;

e. Watching and observing the PARTICIPANT to ensure that the medication has been swallowed; and

f. Documenting the assistance with medication in the PARTICIPANT’S chart.

3. Medication administration shall be performed by a RN or a LPN under the supervision of a RN:

a. When the PARTICIPANT is unable physically or cognitively to self-administer his or her own medications, even with assistance; and

b. For injectable medications except when the physician has written orders to permit this as specified in paragraph J. 1. b.

4. The PARTICIPANT’S record shall include the following information for each prescribed medication that the PARTICIPANT will take during the PROVIDER’S service hours:

a. General information on recommended dosages and the medication’s effect;

b. Instructions for PARTICIPANT monitoring;

c. Potential drug or food interactions;

d. Use of physical and chemical restraints shall be by physician’s orders that specify the duration and circumstances under which the restraints are to be used;

e. The PROVIDER shall follow the procedures for reporting Adverse Events (see PROVIDER Quality Assurance) observed by the PROVIDER, including medication errors and unexpected reactions to drugs or treatment, as specified in the STANDARDS.

K. Service Limitations/Exclusions/Restrictions

1. Services under the DD/MR Medicaid Waiver Services Program are used only when mandated resources (for example, the Hawaii Medicaid State Plan, the Division of Vocational Rehabilitation (DVR), the Department of Education) and family and community resources are not available. Whenever there are multiple options, waiver funding will be used to purchase the most cost-effective alternative.

2. Services under the DD/MR Medicaid Waiver Services Program shall not be provided to a minor by the child's parent, stepparent, or legal guardian of the minor or by the PARTICIPANT’S spouse.

3. Non-billable activities include:

a. Attendance at general staff in-service training;

b. Preparation and submission of progress reports;

c. Preparation of billing statements.

L. Non-Compliance with These STANDARDS

1. If the DOH or the DHS or their designees determine that the PROVIDER has failed to comply with any of the applicable DD/MR Medicaid Waiver Services Program requirements, the DOH or the DHS or their designees shall notify the PROVIDER of such non-compliance.

2. If the areas of non-compliance are not corrected within the time specified in the notice or in the accepted plan of correction, the DHS designee may:

a. Assess the safety and well-being of the PARTICIPANTS and the PROVIDER’S ability to provide services as outlined in the ISP and/or WAP and the IP;

b. Initiate action to ensure the health, safety, and well-being of the PARTICIPANTS; and/or

c. Terminate this Agreement.

M. Appeal of DHS’s Decision

In the event the contract with the PROVIDER is terminated and the PROVIDER wishes to appeal this decision, the PROVIDER shall follow the procedures of Title 17, Chapter 1736, HAR, to appeal the DHS decision.

III. DOH CASE MANAGEMENT RESPONSIBILITIES

A. PARTICIPANT Access

1. Services under the DD/MR Medicaid Waiver Services Program shall be made available as described in the Hawaii Disability Rights Center (HDRC) Settlement Agreement (August 2005) to those individuals who meet the eligibility requirements specified in the approved waiver application.

2. PARTICIPANT eligibility requirements for admission into the DD/MR Medicaid Waiver Services Program include the following:

a. Be determined to have a developmental disability and/or mental retardation by DOH-DDD;

b. Be determined by DHS as needing ICF/MR level of care prior to admission and annually thereafter;

c. Be determined by DHS to be medically or categorically needy and eligible for Medicaid federal reimbursement; and

d. Voluntarily choose to receive services under the DD/MR Medicaid Waiver Services Program in the community.

3. Admission to the DD/MR Medicaid Waiver Services Program shall be initiated by the DOH-DDD CM and authorized by DHS.

4. DOH-DDD CM shall inform PARTICIPANTS of all options regarding services under the DD/MR Medicaid Waiver Services Program and PROVIDERS.

5. At a minimum, one (1) service under the DD/MR Medicaid Waiver Services Program shall be provided on the day of admission.

a. In the rare situation where unforeseen circumstances preclude the provision of waiver service delivery on the date of admission, the DOH-DDD CM may suspend the PARTICIPANT until service can be provided.

B. PARTICIPANT-Centered Service Planning

1. All PARTICIPANTS admitted into the DD/MR Medicaid Waiver Services Program shall have an ISP and/or a WAP authorizing services by the DOH-DDD CM.

a. The ISP is the written plan required by HRS § 333F-6 that is developed by the PARTICIPANT, with the input of family, friends, and other persons identified by the PARTICIPANT as being important to the planning process. The plan shall be a written description of what is important to the person, how any issue of health or safety shall be addressed, and what needs to happen to support the PARTICIPANT in the PARTICIPANT’S desired life.

b. The ISP is operationalized as the form used by the DOH-DDD CM to document the information in B. 1. a. above and includes an “action plan” which describes what services and supports have been identified to meet the goals and outcomes identified by the PARTICIPANT.

c. The WAP is the “action plan” for waiver services, describing the PARTICIPANT’S goals and outcomes, the waiver services identified to meet the PARTICIPANT’S goals and outcomes, the frequency, duration, and service PROVIDER(S). The WAP:

1) Shall serve as the interim IP until an Individual Plan, developed by the PROVIDER, is finalized not to exceed thirty (30) days;

2) In lieu of an immediate change to the ISP, serves as the document authorizing waiver services; and

3) May be incorporated into the ISP action plan.

2. The ISP service planning shall identify the PARTICIPANT’S:

a. Preferences and personal goals;

b. Needs and abilities;

c. Health status;

d. Preferences regarding directing and managing their own services and supports;

e. Use of natural supports;

f. Use of other non-waiver services and supports including, but not limited to, educational, vocational, and other community resources.

3. The following documents shall be attached to the ISP, if applicable:

a. Physician’s orders for the use of physical or chemical restraints or for waiver services such as Skilled Nursing or Training or Consultation, if applicable;

b. Crisis contingency plan;

c. Emergency plan that addresses what happens in the event of natural disasters;

d. PBS plan/behavioral intervention plan;

e. IEP;

f. Assessments and recommendations of health professionals such as physical therapists, speech therapists, psychologists.

4. The ISP and/or WAP shall also identify the PARTICIPANT’S:

a. Frequency of supervision of service(s) if supervision is above the minimum requirements for the service(s) as stated in the STANDARDS;

b. Documentation that waiver services may be provided by the PARTICIPANT’S family members if:

1) The PARTICIPANT is an adult child in the household;

2) The PARTICIPANT chooses the family member as the direct support worker;

3) The CM documents that:

a) The family member is unable to provide services without compensation; and

b) The family member is the most qualified PROVIDER; or

c) The family member is the only available PROVIDER of care (e.g., geographical remoteness).

c. Documentation of exceptions to the 1:1 staff to PARTICIPANT ratio for waiver services, made on a case-by-case basis, as follows:

1) More than 1:1 direct support worker coverage can include two (2) direct support workers providing services to one (1) PARTICIPANT if the following conditions are met:

a) The DOH-DDD CM, PARTICIPANT, guardian, family discusses staffing needs;

b) The DOH-DDD CM documents that the PARTICIPANT’S health and safety needs justifies more than the 1:1 direct support worker coverage.

2) Less than 1:1 direct support worker coverage can include one (1) direct support worker providing services to more than one (1) PARTICIPANT if the following conditions are met:

a) The DOH-DDD CM, PARTICIPANT, guardian, family discusses staffing needs;

b) The PARTICIPANT’S needs as identified in the ISP and/or WAP can be met by the less than 1:1 direct support worker coverage;

c) The DOH-DDD CM documents the PARTICIPANT’S health and safety needs requires less than the 1:1 direct support worker coverage.

5. With the consent of the PARTICIPANT and/or the PARTICIPANT’S legal guardian or designated representative, the most current ISP and attachments, as applicable, and WAP shall be made available to the PROVIDER prior to the start of a new waiver service.

6. The ISP which includes the WAP shall be updated at least annually and in response to the changing needs of the PARTICIPANT.

a. A current WAP shall be revised, developed, approved, and authorized for any change in waiver service or status prior to the start of the change; or

b. Re-authorized annually and made available to the PROVIDER within seven (7) days, if there are no changes.

7. The ISP and/or WAP shall be approved by the PARTICIPANT and/or legal guardian and authorized by the DOH-DDD CM.

a. With the consent of the PARTICIPANT and/or the PARTICIPANT’S legal guardian or designated representative, shall be made available to the PROVIDER within thirty (30) working days.

C. Service Delivery

1. The DOH-DDD CM shall provide assistance, as needed, to obtain and coordinate services and supports to promptly address identified issues.

a. For Res/Hab Services Level 4, authorization for services shall be time-limited (not to exceed twelve (12) months) and shall be authorized only if the following conditions are met:

1) Agreement of parents (and/or family) to actively participate in the FBA and development of the PBS plan;

2) Agreement of parents to implement the PBS plan to successfully manage target behaviors of the child that are temporarily interfering with family functioning;

3) Agreement that the child will return to the family home within twelve (12) months of services;

4) If the child does not return to the family home within twelve (12) months of service, services will be discontinued and a referral will be made to DHS to address placement issues.

2. The DOH-DDD CM shall monitor to ensure that services are provided in accordance with the PARTICIPANT’S ISP and/or WAP.

3. When the DOH-DDD CM is informed of significant changes in the PARTICIPANT’S condition, needs or circumstances, the ISP and/or WAP may be modified accordingly.

4. Regular and periodic monitoring shall include obtaining PARTICIPANT’S and/or legal guardian’s/designated representative’s feedback to assess the PARTICIPANT’S well being, health status, and effectiveness of services in achieving goals and outcomes.

5. The DOH-DDD CM shall authorize waiver services to be provided according to the STANDARDS to meet the goals and outcomes identified in the ISP and/or WAP.

6. The PARTICIPANT, the PARTICIPANT’S parent/legal guardian, and/or DOH-DDD CM shall notify waiver service PROVIDERS identified by the PARTICIPANT for cost share.

7. Notification of hospitalizations or suspensions from services are to be communicated from the PARTICIPANT, parent/guardian, care PROVIDERS, and service PROVIDERS to the DOH-DDD CM. If the case manager is notified of hospitalizations or other suspensions from service, the case manager will notify all other parties.

a. The DOH-DDD CM shall notify DHS of the dates of hospitalization using the DHS Prior Authorization form.

8. The DOH-DDD CM shall inform the PROVIDER of termination of services from the PROVIDER at least two (2) weeks in advance of service end date, unless conditions jeopardizing the PARTICIPANT’S health and welfare exist.

a. Notification to End Services form (NES 7/06) shall be signed by the PARTICIPANT and/or guardian;

b. The NES form shall be sent to the PROVIDER at least two (2) weeks prior to service end date;

c. In cases where PARTICIPANT health and welfare may be in jeopardy, the DOH-DDD CM shall fax NES form to the PROVIDER. The signed NES form shall follow.

D. General

1. The DOH-DDD CM shall create service authorizations in the Management Information System (MIS) prior to service month.

2. DOH-DDD CMs may refer the following types of review requests to the DOH-DDD’s Utilization Review Committee for review:

a. Services where more than a 1:1 staffing ratio is identified in the ISP and/or WAP;

b. For PARTICIPANTS living independently in their own home, exceptions to service limitations in the STANDARDS;

c. PARTICIPANTS with budgets over the institutional threshold;

d. Service requests representing more than a twenty-five (25) percent increase in a PARTICIPANT’S budget;

e. Consultation.

E. Specialized Medical Equipment and Supplies

1. Service Definition

Specialized Medical Equipment and Supplies to include devices, controls, or appliances, specified in the service plan, which enable PARTICIPANTS to increase their abilities to perform Activities of Daily Living, or to perceive, control, or communicate with the environment in which they live.

This service also includes items necessary for life support, ancillary supplies and equipment necessary to the proper functioning of such items, and durable and non-durable medical equipment not available under the Medicaid State Plan. Items reimbursed with waiver funds are in addition to any medical equipment and supplies furnished under the State plan and exclude those items that are not of direct medical or remedial benefit to the PARTICIPANT. All items shall meet applicable standards of manufacture, design, and installation.

2. PROVIDER Requirements for the Distribution of Supplies

a. Meet applicable state licensure, registration, and certification requirements (be authorized by manufacturer to sell supplies).

F. Environmental Accessibility Adaptations

1. Service Definition

Those physical adaptations to the PARTICIPANT’S home, required by the PARTICIPANT'S service plan and based on a home safety assessment or evaluation, that are necessary to ensure the health, welfare and safety of the PARTICIPANT or that enable the PARTICIPANT to function with greater independence in the home. Such adaptations include the installation of ramps and grab-bars, widening of doorways, modification of bathroom facilities, or the installation of specialized electric and plumbing systems that are necessary to accommodate the medical equipment and supplies that are necessary for the welfare of the PARTICIPANT.

2. Limitations

a. Limit of $25,000 per request, one (1) request every five (5) years, with exceptions made by the DOH-DDD for health and safety of 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. These exclusions include, but are not limited to:

1) Carpeting;

2) Roof repair;

3) Other general household repairs;

4) Central air conditioning;

5) Adaptations, modifications, or improvements to the existing home that add to the total square footage of the home except when necessary to complete an adaptation;

6) Adaptations, modifications, improvements or repairs to the existing home that are required to meet the basic standards for compliance with the Americans with Disabilities Act;

7) Adaptations, modifications, improvement or repairs to the existing home that are required to meet the basic standards for compliance with State regulations for home licensure or certification;

8) Adaptations, modifications, improvements or repairs to the existing home where long-term residency of the PARTICIPANT cannot be assured. Long-term residency shall be defined as five (5) consecutive years;

9) Duplicate adaptations, modifications or improvements regardless of the payment source. For example, if the client has a safe and usable ramp, a second ramp shall not be approved;

10) New residential construction (e.g., homes or apartment buildings), even if the new dwelling is designed to be accessible by and/or accommodate the needs of PARTICIPANTS with disabilities.

c. Modifications, adaptations, improvements, or repairs of the existing home shall be limited to the family home or PARTICIPANT’S owned home. The DOH and DHS shall not be responsible for paying any cost of restoring a site to its original configuration or condition after completion of the modification/adaptation.

3. PROVIDER Requirements for the Installation of Environmental Adaptations

a. Be a licensed contractor; and

b. Provide services in accordance with applicable State and county building codes.

G. Vehicular Modifications

1. Service Definition

Adaptations to an automobile or van to accommodate the special needs of the PARTICIPANT. Vehicle adaptations are specified by the service plan as necessary to enable the PARTICIPANT to integrate more fully into the community and to ensure the health, welfare and safety of the PARTICIPANT.

2. Limitations

a. The following are specifically excluded:

1) Adaptations or improvements to the vehicle that are of general utility and are not of direct medical or remedial benefit to the PARTICIPANT;

2) Purchase or lease of a vehicle; and

3) Regularly scheduled upkeep and maintenance of the modification.

b. Limitation of $15,000 per modification; one (1) request every seven (7) years.

3. PROVIDER Requirements for Vehicular Modifications

a. Meet applicable state licensure, registration, and certification requirements (be authorized by the manufacturer to sell, install, and/or repair equipment);

b. Ensure that all items meet applicable standards for manufacture, design, and installation.

H. Assistive Technology

1. Service Definition

Assistive Technology device means an item, piece of equipment, or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, or improve functional capabilities of PARTICIPANTS. Assistive Technology service means a service that directly assists a PARTICIPANT in the selection, acquisition, or use of an Assistive Technology device. Assistive Technology includes:

a. The evaluation of the Assistive Technology needs of a PARTICIPANT, including a functional evaluation of the impact of the provision of appropriate Assistive Technology and appropriate services to the PARTICIPANT in the customary environment of the PARTICIPANT;

b. Services consisting of purchasing, leasing, or otherwise providing for the acquisition of Assistive Technology devices for PARTICIPANTS;

c. Services consisting of selecting, designing, fitting, customizing, adapting, applying, maintaining, repairing, or replacing Assistive Technology devices;

d. Coordination and use of necessary therapies, interventions, or services with assistive technology devices, such as therapies, interventions, or services associated with other services in the service plan;

e. Training or technical assistance for the PARTICIPANT, or where appropriate, the family members, guardians, advocates, or authorized representatives of the PARTICIPANT; and

f. Training or technical assistance for professionals or other individuals who provide services to, employ, or are otherwise substantially involved in the major life functions of the PARTICIPANT.

2. PROVIDER Requirements for the Distribution of Equipment

a. Meet applicable state licensure, registration, and certification requirements (be authorized by the manufacturer to sell, install, and/or repair equipment);

b. Ensure that all items meet applicable standards for manufacture, design, and installation.

I. Personal Emergency Response System (PERS)

1. Service Definition

PERS is an electronic device that enables waiver PARTICIPANTS to secure help in an emergency. The PARTICIPANT may also wear a portable “help” button to allow for mobility. The system is connected to the PARTICIPANT’S phone and programmed to signal a response center once a “help” button is activated. The response center is staffed by trained professionals, as specified herein.

2. PROVIDER Requirements for the PERS

a. Demonstrate and instruct the PARTICIPANT in the use of PERS;

b. Monitor the PERS by conducting monthly testing of the system;

c. Act immediately to repair or replace equipment in the event of a malfunction;

d. Provide trained professionals to operate the PERS response center; and

e. Have in place procedures for handling electrical power outages and telephone system problems.

IV. SERVICES

A. CHORE

1. Intent of Service

Chore services shall be provided for the PARTICIPANT or shall be essential to the PARTICIPANT’S health and welfare and not part of regular chore routine carried out by members of the household.

2. Service Definition

Services needed to maintain the 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, moving heavy items of furniture in order to provide safe access and egress. Services also consist of the performance of general household tasks (e.g., meal preparation and routine household care). These services are provided only when the PARTICIPANT or anyone else in the household, or other relatives, caregiver, landlord, community/volunteer agency, or third party payor is not capable or responsible for performing or financially providing for them. In the case of rental property, the responsibility of the landlord, pursuant to the lease agreement, is examined prior to any authorization of service.

3. Service Provision

a. Chore services may be provided without the PARTICIPANT present at the time of service delivery.

4. Location of Services

a. Chore services shall be provided in the PARTICIPANT’S home or community setting and shall not be provided in licensed or certified care settings.

b. Residential settings include:

1) PARTICIPANT’S family home;

2) PARTICIPANT’S own place of residence.

5. Staffing Requirements

a. The staff to PARTICIPANT ratio for Chore is 1:1 or may be less than 1:1. Exceptions to the 1:1 staff to PARTICIPANT ratio are made on a case-by-case basis and shall be based on needs identified in the ISP and/or WAP.

1) More than 1:1 direct support worker coverage can include two (2) direct support workers providing services to one (1) PARTICIPANT.

2) Less than 1:1 direct support worker coverage can include one (1) direct support worker providing services to more than one (1) PARTICIPANT.

6. Direct Support Worker and Supervision Qualifications: see II. PROVIDER REQUIREMENTS, C. PROVIDER QUALIFICATIONS.

7. Supervision

a. On-site supervision of services being delivered to PARTICIPANTS shall be conducted quarterly or more frequently if indicated in the ISP and/or WAP;

b. On-site supervision of Chore services shall consist of verification of service completion and PARTICIPANT satisfaction.

8. Service Limitations/Exclusions/Restrictions

a. Chore services shall not be provided in licensed or certified care settings;

b. Chore services shall be provided for the PARTICIPANT or shall be essential to the PARTICIPANT’S health and welfare and not part of regular chore routine carried out by members of the household;

c. Chore services shall not include house maintenance such as yard work, house painting, and minor repairs. For PARTICIPANTS living independently in their own home, such basic maintenance chore services may be considered on a case-by-case basis;

d. Chore services shall not be provided to minor children;

e. Chore services shall not be provided by PARTICIPANT’S spouse;

f. Chore services shall be prorated when the staff to PARTICIPANT ratio is less than 1:1;

g. Chore services shall be prorated for common areas of the house.

B. PERSONAL ASSISTANCE/HABILITATION aka PAB

1. Intent of Service

a. PAB may be used to accomplish the following:

1) Independence with eating, bathing, dressing, personal hygiene;

2) Building natural supports;

3) Being self-sufficient (taking care of one’s self and one’s needs to live in own home);

4) Exploring opportunities to identify and expand personal interests;

5) Building skills in self-advocacy;

6) Supporting income-producing endeavors (e.g., micro-enterprise).

2. Service Definition

A range of assistance or training to enable program PARTICIPANTS to accomplish tasks that they would normally do for themselves if they did not have a disability. Such assistance shall include active supervision (readiness to intervene as necessary) and interaction with PARTICIPANTS. This may take the form of hands-on assistance (actually performing a task for the person) or training or multi-step instructional cuing as a part of a plan to prompt the PARTICIPANT to perform a task. Personal care services may be provided on an episodic or on a continuing basis. Health-related services that are provided may include skilled or nursing care to the extent permitted by State law. Such assistance may include assistance or training in the performance of ADLs (bathing, dressing, toileting, transferring, maintaining continence) and IADLs (more complex life activities, e.g., personal hygiene, light housework, laundry, meal preparation, transportation, grocery shopping, using the telephone, medication and money management).

Services may include personal assistance or training to meet outcomes/goals of increasing independence, developing natural supports, learning, developing relationships, contributing through employment/volunteering/ participation and their associated costs.

Services may be provided in or outside the PARTICIPANT’S home.

Recommendations of specialized therapies could be incorporated within this service.

3. Service Provision

a. Associated costs

1) Can include, but are not limited to, membership fees, admission costs for activities and events, supplies and informational materials such as art supplies, books, videos and CDs specific and necessary to meet the PARTICIPANT’S goal/outcome;

2) Shall not be used for illegal activities;

3) Shall be included in the PARTICIPANT’S IP;

4) Shall be for the PARTICIPANT’S benefit only;

5) Shall be negotiated and mutually agreeable to the PARTICIPANT, DOH-DDD CM, circle of supports and PROVIDER;

6) May include reimbursement to the direct support worker for mileage exceeding twenty (20) miles per day to meet PARTICIPANT goals and outcomes during service provision.

b. Staff providing PAB services who assist PARTICIPANTS with medications shall be trained by a RN. The RN shall verify and document the staff’s skills competency.

c. PAB services shall consist of three levels, PAB Level 1 and PAB Level 2 and PAB Level 3. The PAB level shall be determined by the DOH-DDD CM based on an ICAP behavioral score and health assessment.

1) PAB Level 1

a) PARTICIPANTS receiving PAB Level 1 do not require any special tasks of nursing care, i.e., nurse delegated tasks.

2) PAB Level 2

a) ICAP scores for PARTICIPANTS receiving PAB Level 2 shall fall within -34 to -70 range;

b) PARTICIPANTS requiring special tasks of nursing (tasks that have been delegated by a RN as specified in HAR Title 16, Chapter 89, Subchapter 15, (“Delegation of Nursing Tasks to Unlicensed Assistive Personnel”) (HAR § 16-89-100; HAR § 16-89-111; HAR 16-89-112; HAR § 16-89-113; and HAR § 16-89-114).

3) PAB Level 3

a) ICAP scores for PARTICIPANTS receiving PAB Level 3 shall fall within the 40-69 range and include PARTICIPANTS with avoidant or aggressive behaviors that may cause harm to self or others;

b) PAB Level 3 services are time-limited, averaging three (3) months and up to six (6) months; exceptions may be authorized by the DOH-DDD;

c) PAB Level 3 services may be provided in conjunction with a FBA and/or in accordance with a PBS plan and shall include outcome-based measurable data;

d) PAB Level 3 shall be limited to fifteen (15) hours per week, three (3) hours per day and shall not exceed four (4) hours in one (1) session;

e) PAB Level 3 services may be provided in conjunction with PAB Level 2 and PAB Level 1 services as follows:

i. Situations where current staffing ratio is more than 1:1, i.e., two (2) direct support workers to one (1) PARTICIPANT;

ii. Staffing is maintained with PAB Level 3 direct support worker replacing a PAB Level 2 or PAB Level 1 direct support worker to maintain staffing ratio;

iii. PAB Level 3 services provided in conjunction with PAB Level 2 or PAB Level 1 services shall be allowed for one (1) month for transition purposes;

iv. Exceptions to the one (1) month limit may be considered on a case-by-case basis by the DOH-DDD.

f) PAB Level 3 services may be provided in conjunction with Res/Hab Level 1, Res/Hab Level 2 and Res/Hab Level 3.

4) The daily twenty-four (24) hour PAB Level 1 service shall typically include eighteen (18) hours of one-to-one (1:1) service and six (6) hours of stand-by assist. Stand-by assist is typically rendered at night when the PARTICIPANT requires intermittent intervention by the direct support worker.

5) PAB Level 2 is allowable on an hourly basis for twenty-four (24) hours for PARTICIPANTS with an ICAP score for maladaptive behavior of -46 to -70 and require intervention on a twenty-four (24) hour basis or for PARTICIPANTS with need for medical intervention on a twenty-four (24) hour basis.

6) The PROVIDER shall keep records to report associated costs.

7) Transportation is not reimbursable for staff travel to and from the PARTICIPANT’S home or site designated for start of service provision.

4. Location of Services

a. PAB Level 1 and PAB Level 2 services shall be provided in a residential or community setting that ensures the health and safety of the PARTICIPANTS.

b. Residential settings include:

1) PARTICIPANT’S family home;

2) PARTICIPANT’S own home or place of residence (that is not licensed or certified);

c. Community settings include, but are not limited to:

1) Community recreational sites;

2) Generic public settings.

5. Staffing Requirements

a. The staff to PARTICIPANT ratio for PAB Level 1 and PAB Level 2 is 1:1. Exceptions to the 1:1 staff to PARTICIPANT ratio are made on a case-by-case basis and will be based on needs identified in the ISP and/or WAP.

1) More than 1:1 direct support worker coverage can include two (2) direct support workers providing services to one (1) PARTICIPANT.

2) Less than 1:1 direct support worker coverage can include one (1) direct support worker providing services to more than one (1) PARTICIPANT.

6. Direct Support Worker and Supervision Qualifications: see II. PROVIDER REQUIREMENTS, C. PROVIDER QUALIFICATIONS.

7. Service Provision by Family Members as Direct Support Workers

a. Service provision by family members should not replace “usual and customary” efforts (e.g., teaching the PARTICIPANT personal skills such as teeth brushing);

b. The family member will provide services in accordance with the STANDARDS of services;

c. The family member will only provide services to the PARTICIPANT for approved services as stated in the ISP and/or WAP.

8. Supervision

a. On-site supervision for PAB Level 1 and PAB Level 2 shall be conducted monthly or more frequently as indicated in the WAP;

b. On-site supervision for PAB Level 3 shall be conducted for two (2) hours per week:

1) The Behavioral Specialist shall receive one (1) hour of individual and one (1) hour of group supervision on a monthly basis from a psychologist licensed in the State of Hawaii;

2) On-site supervision for PAB Level 3 services shall be provided in accordance with the DOH-DDD’s Guidelines for Addressing Difficult Behaviors dated December 19, 2005, and any subsequent revisions to these Guidelines.

9. Service Limitations/Exclusions/Restrictions

a. PAB services shall be provided in accordance with the DOH-DDD’s Guidelines for PAB services and any subsequent revisions to these Guidelines;

b. PAB Level 1, PAB Level 2, and PAB Level 3 services shall not be provided to children (aged 3 to 20) as part of, or related to, any educational entitlement services or to replace traditional educational service hours;

c. PAB services shall not be provided to minor children by parents, step-parents, or legal guardian of the minor, or by PARTICIPANTS’ spouses;

d. PAB services shall be prorated when the staff to PARTICIPANT ratio is less than 1:1;

e. PAB Level 1 and PAB Level 2 services cannot be provided in licensed or certified settings for in home services.

C. RESIDENTIAL HABILITATION aka RES/HAB

1. Intent of Service

a. Res/Hab shall be used to cover PARTICIPANTS’ physical care and training above and beyond the general care and supervision under the State Supplemental Payment/Level of Care (SSP/LOC) for certified and licensed residential settings, as Adult Foster Home (AFH), Developmental Disabilities Domiciliary Home (DDDH), and Adult Residential Care Home (ARCH) Extended Adult Residential Care Home (E-ARCH) and defined in HAR Title 11, Chapter 148, Chapter 89, Chapter 100, and Chapter 101, respectively.

b. Res/Hab is used to increase independence with ADLs, develop communication, social, recreational, and leisure skills, and/or enhance independent living, self-direction, and choice-making.

2. Service Definition

Res/Hab means individually tailored supports that assist with the acquisition, retention, or improvement in skills related to living in the community. These individually specific supports include adaptive skill development, assistance with Activities of Daily Living, community inclusion, transportation, adult educational supports, social and leisure skill development, that assist the PARTICIPANT to reside in the most integrated setting appropriate to his/her needs. Res/Hab does not include general care and protective oversight and supervision which are required under the facility’s license or certification requirements.

Personal care/assistance may be a component part of Res/Hab services but may not comprise the entirety of the service.

Recommendations of specialized therapies as indicated could be incorporated within this service.

3. Service Provision

a. There are five levels of Res/Hab services: Level 1, Level 2, Level 3 (Behavioral/Medical), Level 4 (Special Treatment Facility/TLP) and Level 5 (24/7).

b. The level of Res/Hab services shall be determined by the PARTICIPANT’S ICAP scores and/or target population characteristics as follows:

1) Level 1 - service score from 40-69;

2) Level 2 - service score from 1-39 or maladaptive score from
-23 to -33;

Level 2a (Behavioral) - service score from 1-39 or maladaptive score from -23 to -33 as well as exceptional needs such as frequent and significant challenging behaviors, e.g., continuous yelling and screaming at night;

Level 2a (Medical) - physical needs that include total care and total dependence on caregiver;

3) Level 3 (Behavioral) - maladaptive scores from -34 to -70 for behavioral needs to include intense and continuous interventions to address significant challenging behaviors that present danger to self, others, and property;

Level 3 (Medical) - Medical needs that include nursing observation and assessment of PARTICIPANT secondary to such skilled nursing activities such as aspiration precautions, catheterization, infection control, inhalation treatments, medication management and administration, ostomy care, oxygen therapy and aerosolized treatments, seizure management and precautions, suctioning, tube feeding and management, wound care requiring sterile procedures, IV (intravenous), shots - IM (intramuscular), and SQ (subcutaneous) TPN (total parenteral nutrition) feedings in vein;

4) Level 4 - maladaptive scores from -34 to -70

Special Treatment Facility/Therapeutic Living Program (STF/TLP), certification and licensure in accordance with HAR, Chapter 98;

5) Level 5 - maladaptive scores from -46 to -70

Higher frequency, intensity and duration of challenging behaviors requiring 24-7 intervention (awake staff).

c. Exceptions to the Res/Hab Levels and supports shall be reviewed on a case-by-case basis by the DOH-DDD.

d. Res/Hab may include activities such as learning skills to become more independent, preparing own meals, doing laundry, ADLs, social skills (fostering interpersonal relationships), learning to be part of a family unit and/or to share a household (roommate), using leisure time, e.g., light gardening, taking care of own pet, practicing and mastering skills in the home before transferring skills to community setting, behavioral intervention/redirection, making choices, using the telephone.

e. Res/Hab services may be provided in conjunction with the following waiver services:

1) Res/Hab Level 1 and Res/Hab Level 2

a) Skilled Nursing

b) ADH

c) DD/MR Emergency Outreach

d) Training and Consultation

e) PAB Level 3

f) PAB outside home allowed but not provided by PARTICIPANT’S primary and substitute caregiver

2) Res/Hab Level 3-Medical

a) ADH

b) DD/MR Emergency Outreach

c) Training and Consultation

3) Res/Hab Level 3 - Behavioral

a) ADH

b) DD/MR Emergency Outreach

c) Training and Consultation

d) Respite provided by same Res/Hab PROVIDER

e) PAB Level 3

f) PAB outside home allowed but not provided by PARTICIPANT’S primary and substitute caregiver

4) Res/Hab Level 4

a) DD/MR Emergency Outreach

5) Res/Hab Level 5

a) DD/MR Emergency Outreach

b) Training and Consultation

f. Res/Hab Level 4

1) Res/Hab Level 4 services shall not exceed twelve (12) months and shall include, but not be limited to, the following:

a) Working with the child, family, circle of supports, and DOH-DDD CM to meet the goal of family competency and reduction of child’s challenging behavior(s);

b) Service activities shall include the family’s involvement in assessment, planning, development, and implementation of the child’s PBS plan and identified supports needed to return home.

2) Provide transition services and supports to the child’s family home, if necessary;

3) Exceptions to the time limit shall be reviewed on a case-by-case basis by the DOH-DDD;

4) The PROVIDER shall ensure that Res/Hab Level 4 supports and services include, but are not limited to, the following:

a) A person-centered approach to plan for the child’s needs as identified on the ISP and/or WAP;

b) Development of an IP within thirty (30) days that shall identify the supports and services to be provided;

c) The IP shall include a PBS plan to reduce challenging behaviors in order for the child to return to the family or a community home;

d) The IP shall determine the length of stay in the residential setting and discharge criteria necessary for return to the family or a community home;

e) On-going training for the caregivers that enable caregivers to successfully address the reduction of challenging behaviors in accordance with the child’s PBS plan;

f) Provision of oversight of the home including support to the Res/Hab staff, as necessary;

g) Work collaboratively with the child’s school in the provision of services:

i. 24/7 on-call supports in and out of the home to the child, family, or caregivers to include DD/MR Emergency Outreach;

ii. Provision of community-based supports and services to include access to activities outside the residential setting;

iii. Such services shall not supplant or duplicate entitlements and services required by state or federal statutes.

h) Provision of transportation to community activities such as medical appointments, community events, and recreational activities.

g. Res/Hab Level 5

1) Shall be reviewed annually by DOH-DDD CM and the DOH-DDD Utilization Review Committee;

2) Shall include 24-7 awake staffing.

4. Location of Services

a. Res/Hab services shall be provided in licensed and/or certified community residential settings.

5. Staffing Requirements

a. The staff to PARTICIPANT ratio for Res/Hab Level 5 is 1:1.

6. Direct Support Worker and Supervision Qualifications: see II. PROVIDER REQUIREMENTS, C. PROVIDER QUALIFICATIONS.

7. Additional Requirements and Supervision for Res/Hab

a. All Res/Hab Levels: An agency RN shall be available for consultation for PARTICIPANT medical needs;

b. Res/Hab Level 5: A RN shall review PARTICIPANT medical needs status on a monthly basis;

c. Res/Hab Level 3: The Service Supervisor shall have access to a Behavioral Specialist and/or RN;

d. On-site supervision for Res/Hab Level 1 and Res/Hab Level 2 and Res/Hab Level 3 shall be conducted monthly;

e. On-site supervision for Res/Hab Level 4 shall be conducted two (2) times per month. In addition:

1) The Behavioral Specialist shall receive one (1) hour of individual and one (1) hour of group supervision per month from a psychologist licensed in the State of Hawaii.

f. On-site supervision for Res/Hab Level 5 shall be conducted three (3) times per month. In addition:

1) The Behavioral Specialist shall receive one (1) hour of individual and one (1) hour of group supervision per month from a psychologist licensed in the State of Hawaii.

8. Reporting requirements for Res/Hab

a. Res/Hab Level 3, Res/Hab Level 4, and Res/Hab Level 5 shall include monthly reporting;

b. Res/Hab Level 5 reporting shall include data to support continued need for 24-hour intervention and efficacy in addressing challenging behaviors.

9. Service Limitation/Exclusions/Restrictions

a. Payment is not made for the cost of room and board, the cost of building maintenance, upkeep and improvement, other than such costs for modifications or adaptations to a residence required to assure the health and welfare of residents or to meet the requirements of the applicable life safety code;

b. Payment is not made, directly or indirectly, to members of the PARTICIPANT'S immediate family (parents, guardians, siblings).

D. ADULT DAY HEALTH (ADH)

1. Intent of Service

a. Offering opportunities for meaningful participation in community activities;

b. Developing associations with community members;

c. Discovering ways for PARTICIPANTS to make contributions;

d. Establishing roles of leadership and partnership within one’s community.

2. Service Definition

Services generally furnished six (6) or more hours per day on a regularly scheduled basis for one (1) or more days per week, or as specified in the service plan, in a non-institutional, community-based setting, encompassing both health and social services needed to ensure the optimal functioning of the PARTICIPANT. Meals provided as part of these services shall not constitute a “full nutritional regimen” (three (3) meals per day).

Activities shall include training in ADLs, IADLs, communication, socialization, and prevocational skills. Such activities shall be provided in both the ADH and community settings.

Recommendations of specialized therapies as indicated in the service plan could be incorporated within this service.

3. Service Provision

a. There are three levels of ADH services: Level 1, Level 2, and Level 3. The level of ADH shall correlate to the PARTICIPANT’S staff to PARTICIPANT ratio needs and the following target population guidelines:

1) The target population for ADH Level 1 may include PARTICIPANTS who may benefit from group training and/or activities;

2) The target population for ADH Level 2 may include PARTICIPANTS with, but not limited to, the following:

a) Behavioral needs requiring a Behavioral Support Plan or PARTICIPANTS with ICAP scores of -34 to -70;

b) Health concerns that require monitoring, intervention and supervision such as specialized skin care positioning, uncontrolled seizures, diabetes, etc.;

c) Need for specialized therapies incorporated within the IP;

d) Inability to self-preserve.

3) The target population for ADH Level 3 may include PARTICIPANTS with, but not limited to, the following medical needs:

a) Unstable respiratory status requiring continuous nursing assessment and care skills. This includes oxygen, suctioning, updraft treatments, chest P.T., and proper positioning. The PARTICIPANT may have a tracheotomy and a history of respiratory failure;

b) Need for frequent monitoring and assessment of vital signs, i.e., administration of multiple medications and respective assessment of response status;

c) Insulin-dependent diabetes and/or with fragile diabetics with unstable blood sugars;

d) Congestive heart failure, arrhythmia or a history of cardiac failure;

e) Nasogastric (NG) and gastrostomy tube feedings with history of aspiration and complicating factors such as tube medication administration, stoma site assessment, or frequent dressing.

b. The IP for ADH shall have a minimum of three goals based on the ISP and/or WAP.

c. ADH services can include, but are not limited to, the following activities:

1) Practicing skills in personal care activities such as brushing teeth, dressing, grooming, toileting, and eating;

2) Building communication skills;

3) Making new friends and developing new relationships;

4) Establishing the opportunity to participate in:

a) Activities which increase independence and interdependence;

b) Pre-vocational skill building;

c) Activities that produce income;

d) Educational activities;

e) Volunteer work;

f) Senior activities.

5) Exploring work opportunities and work interests;

6) Exploring leisure and recreational activities;

7) Increasing opportunities to make a valued contribution to the community;

8) Making choices in order to pursue paths that match the PARTICIPANT’S interests and skills;

9) Increasing community exploration that aids in the familiarity with and the use of community resources and participation in community activities;

10) Increasing the skills necessary to perform typical daily activities such as shopping, banking, using the telephone, paying bills, budgeting, and cooking.

d. The PROVIDER shall:

1) Offer a full day of ADH services for six (6) or more hours per day on a regularly scheduled basis for one (1) or more days per week in settings outside of the residential setting and within the community;

2) Offer a half day of ADH as three (3) hours but less than six (6) hours of service per day on a regularly scheduled basis for one (1) or more days per week in settings outside the residential setting and within the community;

3) Provide a daily lunch meal for PARTICIPANTS attending full day services and, if necessary, in accordance with modified diets as prescribed by the physician:

a) The cost of meals is included in the rate paid to the contract PROVIDER;

b) If the three (3) hour block of time occurs during the hours of lunch, a lunch or snack meal may be provided.

4) Provide transportation between the PARTICIPANT’S place of residence and the ADH site as well as transportation to community settings during the ADH program day:

a) The cost of transportation is included in the rate paid to the PROVIDER.

4. Location of Service

a. The PROVIDER shall assure that ADH services shall be provided in the community in a setting that assures the health and safety of the PARTICIPANTS.

b. The PROVIDER shall assure that the ADH facility:

1) Is clean, ventilated, equipped with proper lighting, addresses physical safety and has adequate space for the PARTICIPANTS served;

2) Is equipped with fire extinguishers that are inspected and certified annually by a licensed sales or service representative;

3) Has smoke alarms that are inspected;

4) Has a fire safety inspection conducted annually by the fire marshal or designated county fire official for each site; or

5) The request for annual fire safety inspection shall be documented;

6) Conducts monthly fire drills at random times and document fire drill outcomes, problems, and corrective actions:

7) Provides safe and secure storage of materials such as:

a) Hazardous materials such as poison and cleaning supplies;

b) Medication;

c) Sharps containers and the disposal of sharps material.

c. The PROVIDER shall offer ADH activities outside of the facility and in community settings of the PARTICIPANT’S choice as identified in the PARTICIPANT’S ISP and/or WAP.

5. Staffing Requirements

a. The PROVIDER shall provide an adequate staff to PARTICIPANT ratio for PARTICIPANTS in community settings that assure implementation of the IP and the health and safety of the PARTICIPANTS.

b. The recommended staff to PARTICIPANT ratio for ADH Level l is one (1) direct support worker to four (4) PARTICIPANTS.

c. The recommended staff to PARTICIPANT ratio for ADH Level 2 and ADH Level 3 is one (1) direct support worker to three (3) PARTICIPANTS.

d. The PROVIDER of ADH Level 3 shall have a RN immediately accessible and available for PARTICIPANTS with medical/nursing needs when necessary:

1) Immediately accessible shall be defined as having phone communication and protocol in place;

2) Immediately available shall be defined as staff being designated as standby or on call for the ADH service;

3) A crisis contingency plan shall be in place for the PARTICIPANT, especially for any medical needs of PARTICIPANTS.

e. The PROVIDER of ADH Level 2 and ADH Level 1 shall have a Service Supervisor accessible and available for PARTICIPANTS with needs as necessary:

1) Immediately accessible shall be defined as having phone communication and protocol in place;

2) Immediately available shall be defined as staff being designated as standby or on call for the ADH service;

3) A crisis contingency plan shall be in place for the PARTICIPANT, especially for any behavioral or medical/health needs of PARTICIPANTS.

6. Direct Support Worker and Supervision Qualifications: see II. PROVIDER REQUIREMENTS, C. PROVIDER QUALIFICATIONS.

a. For ADH Level 3, RN and LPN, according to Chapter 457, HRS, related to nursing.

7. Supervision

a. On-site supervision of services being delivered to PARTICIPANTS with skilled nursing needs shall be provided by a RN or a LPN under the supervision of a RN;

b. Onsite supervision shall be conducted monthly or more frequently as identified in the ISP and/or WAP.

8. Service Limitations/Exclusions/Restrictions

a. Meals provided as part of these services shall not constitute a “full nutritional regimen” (three (3) meals per day).

E. SUPPORTED EMPLOYMENT

1. Intent of Service

a. The goals of Supported Employment services are to 1) provide long-term ongoing support to PARTICIPANTS in competitive employment and 2) increase PARTICIPANT independence.

2. Service Definition

Supported Employment services consists of intensive, ongoing supports that enable PARTICIPANTS, for whom competitive employment at or above the minimum wage is unlikely, and who, because of their disabilities, need supports to perform in a regular work setting. Supported Employment is conducted in a variety of settings, particularly work sites where persons without disabilities are employed. Supported Employment includes activities needed to sustain paid work by PARTICIPANTS, including job development, placement, supervision and training and retention. When Supported Employment services are provided at a work site where persons without disabilities are employed, payment is made only for the adaptations, supervision and training required by PARTICIPANTS receiving waiver services as a result of their disabilities but does not include payment for the supervisory activities rendered as a normal part of the business setting.

Documentation is maintained in the file of each PARTICIPANT receiving this service that the service is not available under a program funded under section 110 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act (20 U.S.C. § 1401 et seq).

Federal financial participation is not claimed for incentive payments, subsidies, or unrelated vocational training expenses such as the following:

a. Incentive payments made to an employer to encourage or subsidize the employer's participation in a Supported Employment program;

b. Payments that are passed through to users of Supported Employment programs; or

c. Payments for vocational training that is not directly related to an individual's Supported Employment program.

3. Service Provision

a. Job development is defined as activities generally completed at a potential job site or in the community that lead to the development of employment opportunities that assist a PARTICIPANT with a disability in locating a job:

1) Job development activities may take place prior to employment of the PARTICIPANT (face-to-face contact with the PARTICIPANT is not required during these activities);

2) Job development activities are temporary and are discontinued once the PARTICIPANT has located a job;

3) Job development activities shall not supplant DVR services;

4) Job development services shall not exceed units authorized by the DOH-DDD CM;

5) The DOH-DDD CM shall review the ISP and/or WAP, IP, and PARTICIPANT progress to determine number of units.

b. Job placement activities may include the following:

1) Job matching, application, and interview processes;

2) Working side by side with a newly placed client at a job site to do the following activities:

a) Analyze the job and break into manageable components;

b) Identify and solve problems before they become crises for the PARTICIPANT, employer, or co-worker;

c) Teach effective job keeping skills to the PARTICIPANT;

d) Gradually reduce the time spent at the job site as the PARTICIPANT becomes better adjusted and more independent;

e) Assessment of employment stability and provision of specific services or the coordination of services are needed to maintain stability shall be done within first month of employment;

f) The PROVIDER shall document at a minimum twice-monthly contact with the PARTICIPANT, face to face, and once a month contact with the employer. Documentation of contact with employers and PARTICIPANTS shall consist of dates, type of contacts, summary of discussion and actions taken;

g) If indicated in the WAP, off-site monitoring may occur.

c. Supported Employment services shall be reduced as PARTICIPANT independence is increased.

d. The employment site shall be competitive and integrated.

1) Competitive employment shall be defined as:

a) Full-time or part-time work;

b) Hourly goals for weekly employment are determined on an individual basis;

c) Wage compensation shall be consistent with or above the State’s minimum wage;

d) Wage compensation must be made in accordance with Fair Labor Standards Act;

e) Wage compensation must be paid on a basis consistent with those wages paid to non-disabled workers with similar job functions.

2) Integrated work setting shall be defined as:

a) The employment provides daily contact in the immediate work setting with other employees who are not disabled and/or contact with the general public;

b) An employment setting that is not exclusive to individuals with disabilities.

e. Job development activities shall include an assessment of the PARTICIPANT to assure individualized job development activities with prospective competitive employment setting.

f. Supported Employment services does not include transportation.

g. Transportation is not reimbursable for staff travel to an

Item	Reference in RFP	Format/Instructions Provided	Required by Purchasing Agency		Completed by Applicant
General:
Proposal Application Identification Form (SPO-H-200)	Section 1, RFP	SPO Website*	X
Proposal Application Checklist	Section 1, RFP	Attachment A	X
Table of Contents	Section 5, RFP	Section 5, RFP	X
Proposal Application (SPO-H-200A)	Section 3, RFP	SPO Website*	X
Tax Clearance Certificate (Form A-6)	Section 1, RFP	Dept. of Taxation Website (Link on SPO website)*
Cost Proposal (Budget)
SPO-H-205	Section 3, RFP	SPO Website*
SPO-H-205A	Section 3, RFP	SPO Website* Special Instructions are in Section 5
SPO-H-205B	Section 3, RFP,	SPO Website* Special Instructions are in Section 5
SPO-H-206A	Section 3, RFP	SPO Website*
SPO-H-206B	Section 3, RFP	SPO Website*
SPO-H-206C	Section 3, RFP	SPO Website*
SPO-H-206D	Section 3, RFP	SPO Website*
SPO-H-206E	Section 3, RFP	SPO Website*
SPO-H-206F	Section 3, RFP	SPO Website*
SPO-H-206G	Section 3, RFP	SPO Website*
SPO-H-206H	Section 3, RFP	SPO Website*
SPO-H-206I	Section 3, RFP	SPO Website*
SPO-H-206J	Section 3, RFP	SPO Website*
Certifications:
*Federal Certifications*		Section 5, RFP
Debarment & Suspension		Section 5, RFP
Drug Free Workplace		Section 5, RFP
Lobbying		Section 5, RFP
Program Fraud Civil Remedies Act		Section 5, RFP
Environmental Tobacco Smoke		Section 5, RFP
Program Specific Requirements:



	^{Authorized Signature}			^Date

Section 1 Administrative Overview

Section 2 - Service Specifications

Section 3 - Proposal Application Instructions

Section 4 – Proposal Evaluation

Section 5 – Attachments

Head of State Purchasing Agency

4

A. Staffing

· If staffing not currently available, plan including timelines is reasonable to ensure array of services.

B. Project Organization

· Supervision and Training: Demonstrated ability to supervise, train and provide administrative direction to staff relative to the delivery of the proposed array of services.

· Organization Chart: Organization’s approach and rationale for the structure, functions, and staffing for the proposed service activities and tasks are demonstrated.

0

1. The PROVIDER shall maintain a confidential case file for each PARTICIPANT.

2. The individual case file shall include current:

0 1. The following shall apply to medications ingested or administered during the hours the PARTICIPANT is in a DD/MR Medicaid Waiver Services Program or receiving services under the DD/MR Medicaid Waiver Services Program from a PROVIDER:

1 a. Physician prescribed medications may be self-administered by a PARTICIPANT when the PARTICIPANT is physically and cognitively able to do so;

All Mail-ins		DOH RFP COORDINATOR