Pervasive Level Training

1. Pervasive Level Training

2. Background and Scope • Approved 11/4/2004 • State of Arkansas lost $ because pervasive level wasn’t prior approved • Major oversight in place by DMS and CMS so strict compliance is necessary at all levels • Based on service needs • Any plan over $160.00/day • Max Rate of $130,056.80 per year (356.32/day)

3. Needs that require constant supports provided across environments that are potentially life-sustaining in nature. Supports are intrusive, long term and include a combination of any available waiver supports provided 24 hours a day, 7 days a week for 365 days a year. Waiver Definition 24/7/365

4. Justification • Identification of how the individual meets the definition • Clear statements identifying the exact condition that exists that is potentially life sustaining • Another way to state this “life sustaining” set of circumstances is explaining how the condition is “life threatening”

5. Existing Supports • Identify all supports that currently exist (Personal Care, DDTCS, Unpaid Staff, Nursing Services) • Include who is providing the supports

6. Needed Waiver Supports • Identify all of the waiver supports that are needed to assure health and safety in accordance with the Pervasive Level of Care definition

7. Change • Identify what has CHANGED that has increased the support needs • The individual’s - and not the staff’s needs (such as salary increase) – are the only needs that will be considered • A claim that the provider has been supplementing costs by foregoing administration reimbursement or supplementing from other provider funds must be proved

8. Supporting Evidence • Documentation of the medical, behavioral or other conditions (like a physical disability) that identifies and justifies the need

9. Requests Due to Behavior Provider Manual Regulation 230.211.F.d If the reason for pervasive service level is in whole or in part due to behavior issues, a copy of the most recent psychological information on behavioral intervention efforts to include: (1) A functional/behavior analysis of inappropriate behavior including possible antecedents (2) Description of inappropriate behaviors and consequences (3) Information related to increases or decreases in inappropriate behavior including time involved and frequency (4) Positive programming changes to include a description of the behaviors attempting to be established to replace the inappropriate behavioral expression.

10. Incident Reports • Attach copies of all incident reports including “IRIS Level” and provider’s internal reports (if any) • Direct staff daily reports are also acceptable – please compose a cover sheet for these that summarize dates and types of behavior(s) • All summaries are subject to audit by not only DDS Waiver but DDS Licensure, DMS or CMS • DDS staff will search IRIS for noted incident reports

11. Medical Requests • Identify physician orders/findings, assessments, hospitalizations, number of injuries/medical episodes • Include direct care case notes for the past year (or time in service if less than 12 months) • Identify how Nursing/Personal Care is being accessed through the State Plan • Detail how medication administration and/or medical procedures are being accomplished • Include incident reports

12. Requests due to a PhysicalDisability • Same as for Medical but specific to the physical disability that is requiring Pervasive Level of Care • When injury is part of the reason for the request, copies of all incident reports are to be attached • If medical treatment was not sought for the injuries, it must be clearly stated as to why medical treatment was not necessary

13. Incident Reporting Discrepancies • Remember that if “IRIS level” incidents are identified to have occurred, DDS specialists will access IRIS to verify • If discrepancies are found, the Pervasive request will be pended or delayed until the matter is resolved

14. ICAP Assessment • The ICAP assessment is the tool recognized and accepted by DDS to help establish the need for pervasive level supports

15. Why the ICAP? The ICAP includes a total service score which reflects the level of supports which may be needed by an individual. This service score includes both the physical abilities of the person as well as consideration of any problem behaviors that may be occurring.

16. Individual Needs Diagnostic terms such as “CP” or “Autism” or descriptive terms such as “mild,” “moderate” or “severe” do not adequately relate the different service needs of different individuals. For example, two people with CP may have vastly different service needs.

17. Terms of Support • Intermittent – Supports on an “as needed” basis. • Limited – Supports consistent over time, time-limited but not intermittent. • Extensive – Supports with regular involvement (e.g. daily), in at least some environments and not time-limited. • Pervasive – Supports that are consistent, high intensity, provided across environments and are intrusive. PLEASE NOTE: DDS combines the Intermittent and Limited service needs noted here into the Limited designation in the Waiver Manual and Regulation 230.213 Intermittent Limited Extensive PERVASIVE

19. ICAP Contents • The ICAP report submitted may be a copy of computer generated and/or narrative report which must include: • Domain Scores (Age and Standard scores) • Information on problem behaviors • Maladaptive Behavior Index Scores • Service Score/Level • Clear notation of the name of the respondent and their relationship to the consumer • Clear notation of the credentials of the person administering and writing the report

20. ICAP Discrepancies • When there are discrepancies noted by the DDS Psychology staff, these discrepancies must be resolved. This may include the submission of additional information on the ICAP submitted or the administration of a new ICAP • This can lead to a delay in DDS review

21. Remember… • Talk to the DDS Specialist and/or the Program Manager • Review pages 22 and 23 in the Waiver Manual - including the monthly visit and contact requirements. • Refer to 230.211 in the Medicaid Provider Manual - Particularly 230.211.F.3 (Incomplete Requests) - And 230.211.F.7 (Pervasive requests are reviewed at weekly Plan of Care meetings) • Use peer review before submitting requests

22. And finally ….. To improve the delivery of services to those who need them, understand these needs and reduce the time necessary to decide Pervasive Level of Care requests, DDS requires that the Area Manager and/or Specialist conduct a home visit and attend the MAPS for Pervasive Level requests.We ask that: • MAPS meetings for pervasive requests be held in the recipient’s home to allow for the home visit and attendance to the MAPS as required • Adequate advance notice of MAPS meetings to DDS staff to avoid other commitments being made that would prevent DDS attendance at the MAPS