Maryland – Family Supports (MD.1466.R01.02), Community Supports (MD.1506.R01.02), and Community Pathways (MD.0023.R07.03)

Waiver Title

Family Supports (MD.1466.R01.02), Community Supports (MD.1506.R01.02), and Community Pathways (MD.0023.R07.03)

Description of Emergency

COVID-19 pandemic. This amendment will apply waiver-wide for each waiver included in this Appendix, to all individuals impacted by the virus or the response to the virus (e.g. closure of day programs, etc.)

Waiver Description

Family Supports Waiver (MD.1466.R01.00): Provides personal supports, respite care services, support broker services, assistive technology and services, behavioral support services, environmental assessment, environmental modifications, family and peer mentoring supports, family caregiver training and empowerment services, housing support services, individual and family directed goods and services, nurse case management and delegation services, nurse consultation, participant education, training and advocacy supports, transportation, vehicle modifications for individuals w/DD ages 0 – 21 years of age. Community Supports Waiver (MD.1506.R01.00): Provides career exploration, day habilitation, medical day care, personal supports, respite care services, support broker services, assistive technology and services, behavioral support services, community development services, employment discovery and customization (ending June 30, 2021), employment services (beginning December 1, 2019), environmental assessment, environmental modifications, family and peer mentoring supports, family caregiver training and empowerment services, housing support services, individual and family directed goods and services, nurse case management and delegation services, nurse consultation, nurse health case management, participant education, training and advocacy supports, supported employment (ending June 30, 2021), transportation, vehicle modifications for individuals w/DD ages 0 – no max age. Community Pathways (0023.R07.00): Provides career exploration, community living-group home, day habilitation, live-in caregiver supports, medical day care, personal supports, respite care services, supported employment (ending June 30, 2021), support broker services, assistive technology and services, behavioral support services, community development services, community living-enhanced supports (beginning July 1, 2020), employment discovery and customization (ending June 30, 2021), employment services (beginning December 1, 2019), environmental assessment, environmental modifications, family and peer mentoring supports, family caregiver training and empowerment, housing support services, individual and family directed goods and services, nurse case management and delegation, nurse consultation, nurse health case management, participant education, training and advocacy supports, remote support services, shared living, supported living (beginning July 1, 2019), transition services, transportation, vehicle modifications for individuals w/DD ages 0 – no max age

Start Date

13-03-20

End Date

12-03-21

Description of Transition Plan

All activities will take place in response to the impact of COVID-19 as efficiently and effectively as possible based upon the complexity of the change.

Area(s) Affected

Area Affected

These actions will apply across the waivers to all individuals impacted by the COVID-19 virus

Access and Eligibility

Increase Cost Limits

The projected cost of Waiver program services set forth in the person-centered plans of individuals applying for enrollment in either the Family Supports Waiver or the Community Supports Waiver may exceed the currently established cost limit up to $50,000 to support expediting the waiver application processing as long as the services needed are included in the associated waiver program. Additional services in excess of the individual cost limit The actual cost of Waiver program services set forth in the person-centered plans of participants enrolled in either the Family Supports Waiver or Community Supports Waiver may exceed the currently established cost limit due to change in service needs and limits approved in this Appendix K authority without prior authorization from the DDA, as long as the services needed are included in the associated waiver program.

Modify Targeting Criteria

N/A

Services

Modify Scope or Coverage

Modifications to: Community living – Group Homes, Supported Living, Employment services, Supported Employment, Employment Discovery and Customization, Career Exploration, Community Development Services, Day Habilitation, Medical Day Care, Behavioral Support Services, Environmental Modifications, Family and Peer Mentoring Supports, Family Caregiver Training and Empowerment Services, Housing Support Services, Individual and Family Directed Goods and Services, Nurse Consultation, Nurse Health Case Management, Nurse Case Management and Delegation Services, Personal Supports, Remote Support Services, Respite Care Services, Support Broker Services, Vehicle Modifications.

Exceed Service Limitations

The following waiver services limits may be temporarily exceeded to provide needed services for emergency service provision based on current authorized funding unless specified below. When the emergency is declared to end, service requirement exceptions and utilization of services for individuals must return to the approved standards and frequency and duration as authorized in a participant’s person-centered plan prior to the emergency unless otherwise authorized by the DDA. Service Requirements and Limits in Appendix C-1/C-3 Residential Services (Set forth in the Community Pathways Waiver) Community Living – Group Home Additional authorizations may be added for shared supports in each group home, based on the participants’ needs, as follows unless otherwise authorized by the DDA: 1. Up to 8 additional hours in a home serving up to three participants; 2. Up to 16 additional hours, in a home serving up to five participants; and 3. Up to 24 additional hours, in a home serving up to nine participants. Supported Living and Personal Supports Additional authorizations may be added for shared supports in each home based on the participants’ needs, as follows unless otherwise authorized by the DDA: • Up to 8 additional hours in a home serving up to three participants; Meaningful Day Services including: Employment Services, Supported Employment, Employment Discovery and Customization, Career Exploration, Community Development Services (CDS), and Day Habilitation (Set forth in the Community Pathways Waiver and the Community Supports Waiver) 1. Services can be provided any day of the week and exceed eight hours a day and 40 hours per week within a person’s authorized budget. 2. The timeframe for completion of currently authorized Employment Discovery and Customization activities may exceed the required six (6) month authorization period but cannot exceed the end date of the Appendix K as specified in section F. 3. The requirement that a minimum of six hours of services be provided during a single day is temporarily suspended. Support Services (Set forth in all Three Waiver programs: Community Pathways Waiver, Community Supports Waiver, and Family Support Waiver) Environmental Modifications Cost may exceed a total of $15,000, if approved by the DDA. Family and Peer Mentoring Services Family and Peer Mentoring Services may exceed 8 hours per day. Family Caregiver Training and Empowerment Family Caregiver Training and Empowerment services can exceed 10 hours of training.

Housing Support Services

Housing Support Services may exceed 8 hours per day.

Individual and Family Directed Goods and Services (IFDGS)

Staff recruitment and advertising dedicated funding may be increased to up to $1000 per personcentered plan year.

Nursing Services including Nurse Consultation, Nurse Health Case Management, and Nurse

Case Management and Delegation

1. Initial Nursing Services can be provided without prior authorization by the DDA.

2. Increases to Nurse Case Management and Delegation Services needed as a result of the change in the participant’s health status or after the participant’s discharge from a hospital or skilled nursing facility can be provided without prior authorization by the DDA.

Personal Supports

1. Legal guardians and relatives may be paid for greater than 40-hours per week for services

without prior authorization by the DDA.

2. Personal Support services may exceed 82 hours per week without prior authorization by

the DDA within the authorized budget.

3. Participants may exceed their current authorization by the DDA within their overall

authorized budget without prior authorization by the DDA.

Respite Care Services

An additional up to 360 hours specifically related to the COVID – 19 emergency can be provided without prior authorization by the DDA.

Support Broker Services

Support Broker Services may be provided up to 20 hours per month, unless otherwise authorized by the DDA without prior authorization by the DDA.

Add Services

N/A

Expand Settings

Due to possible need to relocate participants due to the need for separating, self-isolating, or quarantining, services may be provided in alternative settings including, but not limited to, hotels, schools, churches, other community established sites, alternative facility based setting, or the home of a direct care worker. The Department proposes to temporarily allow adjustments to settings where services can be provided that may differ from those identified in the State’s approved waivers. Maryland will also submit this request for expanding settings in which HCBS services can be provided under an 1135 Waiver in order to waive the settings regulation requirements as necessary. Temporary adjustments to service setting requirements would cease to be valid per Section F of the General Information section of this document.

Provide Service Out of State

Waiver Program services under the self-directed and traditional service delivery model may be provided in surrounding states including: 1. Services provided in an out of State provider-owned and controlled settings based on a provider agreement with the out-of-state provider, and 2. Services may be provided by DDA-licensed or certified providers and staff in privatelyowned or leased sites. Each participant’s Coordinator of Community Services will monitor the provision of Waiver program services in out-of-state settings by contacting the participant via telephone on a monthly basis, at minimum.

Allow Payment for Services by Families

N/A

Modify Provider Qualifications

Modification of Provider Qualifications

Licensing and Certification Renewals Pursuant to the Governor’s authority under the Constitution and Laws of Maryland, on March 12, 2020, the Governor issued an Executive Order extending the expiration date of all licenses, permits, registrations, and other authorizations issued by any agency of the State of Maryland, including, but not limited to, the Maryland Board of Nursing, until the 30th day after the date by which the state of emergency is terminated and the catastrophic health emergency is rescinded by the Governor of Maryland. Age Requirement Individuals 16 years of age or older, including family members, neighbors and certified babysitter, that meet revised qualifications can provide direct support for Waiver program services that normally require that the direct support professional be 18 years of age or older. This individual direct support staff would have to be determined qualified by: (1) the participant or the participant’s legal representative if the participant is enrolled in the self-directed services delivery model; or (2) the provider if the participant is enrolled in the traditional services delivery model. Expedited hiring, training and on-boarding of direct support professionals Waiver of High School or GED Requirement Direct Support Professionals do not need to have a high school diploma or GED certificate in order to provide Waiver program services during this emergency. Legally-Responsible Family Members Legally-responsible family members (spouses and parents of minor children) and relatives may provide services under both the self-directed and traditional service delivery models. Tracking Legally-Responsible Family Members The authority to hire and pay spouses and parents of minor children will terminate after the state of emergency ends. Providers are encouraged to track spouses and parents of minor children separately in their employment systems. Background Checks A provider who chooses to utilize non-traditional staff in direct support positions must initiate appropriate background checks, and MVA checks (if driving), but may place the staff person on the schedule immediately after performing an abbreviated background check using the name, birthdate, and social security number of the potential new hire. Training Requirements To expedite the hiring of staff and their ability to work with participants immediately, the DDA will temporarily waive all but the most essential staff training requirements for direct support staff under both the self-directed and traditional service delivery models. The essential training requirements that will still be required, prior to working with a participant,

during this crisis are: (1) completion of online CPR & First Aid training; (2) training on the participant’s person-centered plan to whom the staff will provide direct care; (3) basic condensed training in fundamental rights, including abuse, neglect, restraints, and seclusion; and (4) condensed training in DDA’s Policy on Reportable Incidents and Investigations (PORII). All training completed must be documented in the personnel record. In an effort to expedite service delivery during the pandemic, training requirements may be waived for family members willing to provide services to participants until 60 days following the end of

the State of Emergency. For new employees, agencies that utilize abbreviated training formats for the purpose of accelerating the onboarding of direct support professionals must ensure that all employees meet pre-existing annual training requirements within 120 days of onboarding. For current employees,

annual training requirements for direct support professionals, who have previously completed all training requirements, will be extended ninety days.

CPR & First Aid Training

Provider agencies may choose to provide on-line training, such as CPR and First Aid, in lieu of inperson training. Training may also be conducted by telephone or electronic means (e.g., Skype or Zoom). Appropriate (full) CPR/first aid certification must be obtained if the staff person maintains a direct support position 90 days after the end of the state of emergency. Staff without current CPR/first aid may provide direct support as long as they are working with a

nurse or at least one other direct support person who has CPR/first aid certifications. CPR and First Aid Certifications current as of March 13, 2020, but expiring between March 13, 2020 and the end of the state of emergency shall not be required to be renewed until 90 days after the end of the state

of emergency.

MTTP/Medication Technician Training

The MTTP/Medication Technician requirements have not changed at this time with some exceptions. All staff who are responsible for administering medication must have medication administration training. Direct Support Professionals who have taken and passed MTTP course may begin administering medications immediately and MTTP licenses current as of March 13, 2020, but expiring between March 13, 2020 and the end of the state of emergency shall not be

required to be renewed until 90 days after the end of the state of emergency.

Nursing Required Training

Temporarily waive requirement that a registered nurse receive training from DDA regarding delegating nursing until the state of emergency is terminated.

Waiving the Health Screen and PPD test Providers may waive the basic health screen and PPD skin test as a condition of employment for all direct support professionals serving individuals enrolled in Medicaid or a waiver program,

including legally-responsible family members. Training in Participant’s Person-Centered Plan, Nursing Care Plan, and Behavior Plan. All direct support professionals must receive training on the participant’s PCP, Nursing Care Plan,

and Behavior Plan for whom they are rendering these services. Training on the PCP must consist of basic health and safety support needs for that participant, including, but not limited to, the aspiration, dehydration, constipation and seizures. MANDT training requirements shall be suspended at this time and are not required unless the staff person maintains a direct support position 90 days after the end of the state of emergency. All direct support professional staff assigned to support an individual with a behavior support plan shall receive training on the plan by another direct support professional DSP who has experience supporting the individual or a supervisor, prior to working independently with the individual.

Policy on Reportable Incidents and Investigation (PORII) Training

The PORII training may be provided in a condensed form and must include, at minimum, the definitions of reportable and serious reportable incidents and the agency’s procedures for reporting.

Exception to Maryland Professional Licenses

Among other things, this Executive Order: (1) permits any person who holds a valid, unexpired license as a health care practitioner in another U.S. state to practice within the scope of that license in the State of Maryland; and (2) permits expedited reinstatement of inactive licenses of health care practitioners.

Provider Organizations:

The staff person hired may be placed in a direct support position immediately upon completion of the above requirements.

If provider agencies need to share staff, a written document can be accepted from a Direct Support Professional’s primary employer stating that they have required training and background checks in order for them to work for a different agency. These employees must still receive specific training regarding the participant’s needs and services as set forth in the participant’s person-centered and, if applicable, nursing care plan and behavior plan (including crisis intervention, if

necessary), including services to be provided in accordance with the person-centered plan and site-specific emergency response training. This training may be condensed at the discretion of the provider and must be documented and kept with personnel records. Providers are encouraged to work with families to explore the availability of natural supports, if needed. Providers are encouraged to utilize all staff in the provision of direct support. This includes management and clerical staff, as examples. The training expectations for this staff is the same as

described in this section. Special Considerations for Participants Enrolled in Self-Directed Services Delivery Model: A participant, with the assistance of their person-centered planning teams (Team) will be able to hire caregivers they deem to be responsible including family members, neighbors and other trusted

individuals. The Fiscal Management Services providers (FMS) are given authority to compensate new caregivers at staff rates already included in the participant’s budget, approved by DDA. The requirement that staff be a Certified Medication Technician (CMT) if performing delegated nursing tasks shall temporarily be suspended for Self-Directing participants. The team can elect to either defer any nursing delegation home visit or utilize telecare/remote nursing assistance options. Current certification in CPR and First Aid can be temporarily waived with respect to legally responsible family members providing services to participants enrolled in the self-directed services

delivery model.

Modify Provider Types

N/A

Modify Licensure/Requirements for Waiver Settings

Provider and Staff Licensing and Certification Requirements Pursuant to the Governor’s authority under the Constitution and Laws of Maryland, on March 12, 2020, the Governor issued an Executive Order extending the expiration date of all licenses, permits, registrations, and other authorizations issued by any agency of the State of Maryland, including, but not limited to, the Maryland Board of Nursing, until the 30th day after the date by which the state of emergency is terminated and the catastrophic health emergency is rescinded by the Governor of Maryland. You may read the Executive Order Setting Limitations and Staff Ratios Community Living – Group Home, Supported Living, and Shared Living 1. Maximum number of individuals served in a service location may be exceeded to address staffing shortages or accommodate use of other sites as non-quarantine or quarantine sites 2. Staffing ratios as required by licensure, service definition and/or a participant’s personcentered plan may be exceeded due to staffing shortages Day Habilitation and Community Development Services 1. Staffing ratios as required by licensure, service definition, and/or a participant’s personcentered plan may be exceeded due to staffing shortages. 2. The requirement to provide services in the community is suspended Community Development Services 1. The requirement that no more than four (4) people can be supported at a time is suspended. 2. The requirement to provide services in the community is suspended.

Modification LOC Eval and Re-Eval Processes

Level of care recertification may be postponed up to one year past the original due date when conditions do not allow the Coordinator of Community Services to complete the process.

Increase Payment Rates

The following service rates may be increased up to 50% of the current rate for supporting participants that tested positive for the COVID-19 virus, and therefore are required to be isolated. These services are: Community Living – Group Home, Supported Living, Shared Living, Personal Supports, and Nursing Services (e.g. Nurse Health Case Management & Delegation Services, Nurse Consultation, and Nurse Health Case Management).

Modifications of ISP

The State may temporarily modify requirements such as: 1. Processes for completing the person-centered plan such as in-person attendance of person-centered plan development and monitoring meetings. The State will allow the option for virtual or remote visits to be conducted in lieu of a face-to-face meetings; 2. Retroactive approval date for service needs identified to mitigate harm or risk directly related to COVID-19 impacts; 3. The use of e-signatures that meets privacy and security requirements will be added as a method for signing to indicate approval of the plan; and 4. Services may start while waiting for the signature dated the day of the meeting/agreement to be returned. The State will ensure the person-centered plan service authorization within PCIS2 or LTSSMaryland is modified to allow for additional supports/and or services to respond to the COVID-19 pandemic. The specificity of such services including amount, duration and scope will be appended as soon as possible to ensure that the specific service is delineated accordingly to the date it began to be received. Person-Centered Plans that are due to expire within the next 60 days require case management contact to the participant using allowable remote contact methods to verify with the participant or representative that the current assessment and services, including providers, remain acceptable and approvable for the upcoming year.

Modify Incident Reporting/Med Management Safeguards

Incident Reporting The requirement to conduct an investigation of any incident of deviation in staffing as outlined in a participant’s person-centered plan may be suspended, if deemed necessary by the Department. The requirement to submit an incident report for any deviation in staffing as outlined in a participant’s person-centered plan may be suspended. If this requirement is suspended, providers still must report any incidents in which staffing shortages result in a failure to provide care, if deemed necessary by the Department. Allow for entry of incidents into the DDA incident reporting systems (i.e. PCIS2) outside of typical time frames in instances in which staff shortages due to COVID-19 occur. Response to incidents will not be impacted.

Allow Payment for Services During Acute Care Hospital/Short Term Institutional Stay

Allow payment for the following services for purposes of supporting waiver participants who are in an acute care hospital or receiving a short-term institutional stay. These services will be focused on providing personal, behavioral and communication supports not otherwise provided in that setting. They will not be duplicative of hospital or short-term institutional services. Community Living – Group Home Supported Living Personal Supports Community Development Services Day Habilitation

Inclusion of Retainer Payments

Maryland may allow for payments for COVID-19 related retainer payments for the following services that include personal assistance when participants are not receiving planned services under either the self-directed services delivery model or the traditional services delivery model. The retainer payment time limit may not exceed the lesser of 30 consecutive days or the number of days for which the State authorizes a payment for “bed-hold” in nursing facilities. The State confirms that retainer payments are for direct care providers who normally provide services that include habilitation and personal care, but are currently unable to due to health and safety risk; State mandates; complications experienced during the COVID-19 pandemic because the waiver participant is sick due to COVID-19; the waiver participant is sequestered and/or quarantined based on local, State, federal and/or medical requirements/orders. Traditional Service Delivery Model 1. Employment Services, Supported Employment, Community Development Services, Career Exploration, and Day Habilitation, up to 80% of the rate. 2. Personal Supports, up to a maximum of 120 hours within the authorized limit, unless otherwise authorized by the DDA 3. Community Living – Group Home 4. Supported Living Self-Directed Service Delivery Model 1. Employment Services, Supported Employment, Community Development Services, Career Exploration, and Day Habilitation for a maximum of 120 hours unless otherwise authorized by the DDA. 2. Personal Supports for a maximum of 120 hours up to the authorized limit, unless otherwise authorized by the DDA. Retainer payment will occur on a case by case basis when the provider or participant self-directing services is directly impacted by COVID-19. Retainer payments will not be authorized when a self-directed staff or provider is providing services to the participant. The State will implement a distinguishable process to monitor payments to avoid duplication of billing. Self-Directed participants and providers must produce supporting documentation of the participant being unable to be supported, displaced, or other circumstances related to the COVID19 crisis, and must notify the Coordinator of Community Services, resume habilitative services, and document when the participant is back in their services.

Institute/Expand Opportunities for Self-Direction

N/A

Increase Factor C

N/A

Other Changes Necessary

Waiving certain self-directed budget modification requirements 1. Fiscal Management Services (FMS) providers can authorize budget modification in accordance with a participant’s current authorized budget for: a. Changes within current services authorized by DDA, and b. Changes from current service authorized to a new service. 2. FMS can authorize up to $2000 above the authorized budget to support any of the following (1) increased need in services (e.g., Personal Supports, Community Development Services); (2) increase Support Broker hours, (3) Staff Recruitment; and (4) Personal Protective Equipment/Supplies. Requests more than $2000 above the authorized budget must be approved by the DDA. Transition Delay The DDA’s highest priority is the health and safety of the people we support, our staff, and the many people working in our provider network. The most important focus now is responding to the COVID-19 outbreak. The Deputy Secretary of DDA is delaying the full transition to LTSSMaryland until after this crisis has passed, there is time for recovery, and our service system is ready to move forward. The delay will allow providers, CCSs, and other stakeholders needed prep time given the pandemic and allow for shifting resources to pandemic response. The transition included moving from Supported Employment/Employment Discovery and Customization to the new Employment Services, Day Habilitation Service grouping (i.e. small and large groups), and the new Community Living-Enhanced Supports. No prior authorization or person-centered plan change is required for people to continue to receive current services through the legacy PCIS2 authorization and billing system. The DDA will ensure PCP revisions occur for anyone who desires a service change. All current services including Supported Employment and Employment Discovery and Customization Services may continue past June 30, 2021, with the new corresponding services (i.e. Job Development, On-Going, and Discovery) beginning based on the PCP processes. Employment services (i.e. Job Development, On-Going, and Discovery) noted within the LTSSMaryland PCP detailed services authorization will be authorized in PCIS2 as Supported Employment and/or Employment Discovery and Customization. Audits and Fiscal Reporting Temporarily extend all associated deadlines with audits and fiscal reporting requirements This temporary allowance will terminate in keeping with the timeframe laid out in Section F of the General Information section of this document. Flexibility in Performance of Required Activities The Department requests flexibility with respect to deadlines and timetables for performance of required activities conducted by the Department, providers, and contracted entities. These reports and activities include but are not limited to quarterly and annual quality reports, CMS 372, and Evidentiary reports. The Department proposes to extend the deadline for submission of evidencebased reports for 90 days past the original due date.

Addendum

HCBS Regulations

Not comply with the HCBS settings requirement at 42 CFR 441.301(c)(4)(vi)(D) that individuals are able to have visitors of their choosing at any time, for settings added after March 17, 2014, to minimize the spread of infection during the COVID-19 pandemic.

Services

Add Electronic Method of Service Delivery

case management, personal care services that only require veral cueing; monthly monitoring, in-home habilitation, Other: Electronic method of service delivery (e.g., telephonic) allowing services to continue to be provided remotely in the home and community settings including:

The following services based on needs of the participant and scope of services:

• Behavioral Support Services including Brief Support Implementation Services

• Case Management (i.e. Coordination of Community Services)

• Community Development Services

• Day Habilitation

• Employment Discovery and Customization

• Employment Services

• Personal Supports

• Supported Employment

• Nursing Services

Add Home Delivered Meals

N/A

Add Medical Supplies, Equipment and Appliances

N/A

Add Assistive Technology

N/A

Conflict of Interest

Other Changes Necessary

Provider Qualifications

Allow Spouses and Parents of Minor Children to Provide Personal Care Servcies

Allow a Family Member to be Paid to Render Services to an Individual

Allow Other Practitioners in Lieu of Approved Providers Within the Waiver

Modify Service Providers for Home-Delivered Meals to Allow for Additional Providers, Including Non-Traditional Providers

N/A

Processes

Allow an Extension for Reassessments and Reevaluations for up to One Year Past the Due Date

Allow the Option to Conduct Evaluations, Assessments, and Person-Centered Service Planning Meetings Virtually/Remotely in lieu of Face-to-Face Meetings

Adjust Prior Approval/Authorization Elements Approved in Waiver

Adjust Assessment Requirements

Add an Electronic Method of Signing Off on Required Documents Duch As The Person-Centered Service Plan

Maryland Appendix K - Application (PDF)

Maryland Appendix K - Approval Letter (PDF)