Connecticut Statewide Transition Plan for Enhanced Quality in HCBS Programs

The Connecticut Statewide Transition Plan August 6, 2018 3/20/2025 Department of Social Services 1

Background January 2014 CMS published the final rule with the following objectives: To support enhanced quality in HCBS programs Add protections for individuals receiving services Ensure recipients have full access to the benefits of community living Participants are able to receive care in the most integrated setting 3/20/2025 Department of Social Services 2

KEY PROVISIONS Impacts a range of HCBS programs including 1915(c), 1915(i)and 1915(k) Establishes requirements for Home and Community Based Settings Defines person centered planning requirements Provides options to states to combine waiver populations into one waiver Clarifies the timing of waiver amendments and public input requirements Provides CMS additional compliance options for HCBS programs 3/20/2025 Department of Social Services 3

SETTINGS PROVISION OVERVIEW Applies to Residential and Non-Residential settings Requires that the setting: Be integrated in and support full access to the greater community Is selected by the individual from among settings options Ensures the rights of privacy, dignity and respect, freedom from coercion and restraint Optimizes autonomy and independence in making life choices Facilitates choice regarding services and who provides them 3/20/2025 Department of Social Services 4

ADDITIONAL REQUIREMENTS For provider owned and controlled homes the individual such as ABI homes or Residential Care Homes: Has a lease or other legally enforceable agreement providing similar protections Has privacy in their unit including lockable doors, choice of roommates and ability to decorate their unit Has control over their schedule including access to food at any time Can have visitors at any time Is in a setting that is physically accessible 3/20/2025 Department of Social Services 5

MODIFICATIONS Modifications of the additional requirements must be: Supported by specific assessed need Justified in the person-centered service plan Documented in the person-centered service plan 3/20/2025 Department of Social Services 6

SETTINGS PRESUMED NOT TO BE COMMUNITY BASED Settings in a publicly or privately-owned facility providing inpatient treatment Settings on grounds of, or adjacent to, a public institution Settings with the effect of isolating individuals from the broader community of individuals not receiving Medicaid HCBS 3/20/2025 Department of Social Services 7

CONNECTICUTS PLAN Key components included assessment, remediation and monitoring The assessment process identified the following services that required department review for compliance: Adult Day Health Adult Family living Assisted Living Prevocational Service (ABI only) Supported Employment ABI Group Day 3/20/2025 Department of Social Services 8

CONNECTICUTS PLAN Two residential settings were identified as needing additional assessment: Residential Care Homes ABI Provider Owned and/or controlled homes 3/20/2025 Department of Social Services 9

ADULT DAY HEALTH Based on on-site visits, care manager surveys and interviews with ADC participants, DSS concluded that all Adult Day providers meet the settings requirements We worked collaboratively with the association to strengthen some language in the certification standards Five ADC programs were referred to CMS for heightened scrutiny review. The 5 are: St. Mary Home Geer Alzheimer s Resource Center Waveny Hebrew Health 3/20/2025 Department of Social Services 10

ADULT FAMILY LIVING Assessment indicated that most AFL providers are relatives of the client Care Managers complete annual reassessments that includes 10 settings related questions Plan is to continually assess if the AFL setting isolates the participant from the community 3/20/2025 Department of Social Services 11

ASSISTED LIVING CT statute provides Assisted Living as a service, not as a setting The setting is a Managed Residential Community Assisted Living was developed in anticipation of the regulations To assess compliance, we surveyed two individuals in each of the 48 MRCs 83% were pleased with overall quality of care. Some cited health related issues as limiting their abilities to participate 97% felt their choices is respected, staff respect individual needs 96% were positive about activities and their choice to participate 95% approved of food and snack choices DSS has determined that Assisted Living Services comply with the settings requirements 3/20/2025 Department of Social Services 12

PREVOCATIONAL SERVICES 28 site-specific assessments were conducted by Community Options Clinical and Social Work staff. Providers were determined compliant with the HCBS setting rule, and expected to demonstrate: 1. Adherence to the 2-year CMS limit on participation in this service. 2. Services delivery on a 1:1 ratio of Staff-Participant. 3. Consistent practice of community integration activities. Community Options will continue to provide guidance and follow-up as needed. 3/20/2025 Department of Social Services 13

SUPPORTED EMPLOYMENT Site-specific assessments of 15 providers were conducted. A 17-question survey was administered to program participants. 99.7% of participant responses matched program objectives. An additional 7 open-ended questions sought direct participant feedback that documented the significance of: 1. Increased self-esteem through wage earning. 2. Being appreciated by peers and co-workers. 3. Sharing the employment experience with others. 4. Making choices through independence. Community Options will continue to provide guidance and follow-up as needed. 3/20/2025 Department of Social Services 14

ABI GROUP DAY Service is only recently being offered by the provider network Utilized provider network to assist in the development and structure of the service delivery Community engagement opportunities are a core component of the service DSS intends to work with the provider network to further develop and enhance this service to be an integral part of the service plan 3/20/2025 Department of Social Services 15

RESIDENTIAL CARE HOMES Site-specific surveys were conducted at 43 RCHs. A 32-question survey was administered to staff and residents by Community Options Clinical and Social Work staff. DSS has established a workgroup with DPH to improve rental/lease agreements that include eviction protections. Community Options will conduct future setting surveys and work with providers on other areas such as choice, privacy, and options on coming/going policy. 3/20/2025 Department of Social Services 16

ABI Provider Owned and Controlled Homes Site-specific assessments were conducted among 8 providers and 24 residences. No Heightened Scrutiny settings were identified. Providers were asked 30 questions covering choice, community access, living space, staff interaction and privacy. All providers were identified as essentially meeting HCBS requirements with 5 areas requiring attention Community Options will conduct future setting surveys and work with providers on other areas such as choice, privacy, and options on coming/going policy. Site visits will be done as needed 3/20/2025 Department of Social Services 17

RESIDENTIAL CARE HOMES Included only in CHCPE waiver Approximately 250 waiver participants are impacted in 43 sites Community Options staff visited and assessed all 43 sites Met with for profit and not for profit associations several times Interagency workgroup that includes DSS, DPH, representatives of the associations, the state ombudsman and legal services Goal of the group is to modify statutes and regulations related to RCH s to reflect a community based rather than institutional framework 3/20/2025 Department of Social Services 18

RESIDENTIAL CARE HOMES Home has the option of choosing to be recognized as a home and community based setting allowing them to serve residents on the waiver DSS considering rate structure for services similar to Assisted Living waiver services with different levels based on units of service needed Will include a reimbursement for CORE services which are general cleaning, laundry and general homemaker type services If they choose not to participate, waiver participants will be offered other living arrangements that comport with the settings requirements or remain where they are and lose access to their HCBS waiver services. Deadline for completion is March of 2022. DPH envisions adding a section to the RCH license that contains special requirements specific to the HCBS settings requirements and has agreed to meet with representatives of the associations to discuss concerns 3/20/2025 Department of Social Services 19

RESIDENTIAL CARE HOMES Workgroup is currently working on a sample tenancy agreement that offers protections against eviction comparable to those that exist in landlord tenant law Community Options staff will be conducting site visits of RCHs in 2018 Best practice workgroup of for profit and not for profit RCHs currently being convened to develop best practice recommendations around: Privacy concerns, lockable doors, who has key access Freedom to decorate and furnish the unit Control over schedule and access to food Visitor access Any accessibility issues 3/20/2025 Department of Social Services 20

NEXT STEPS We are currently in 30 day comment period Comments will be compiled and included with the submission of the plan to CMS Currently constructing a provider tool kit 3/20/2025 Department of Social Services 21

CONTACT INFORMATION Plan is available at https://portal.ct.gov/- /media/Departments-and-Agencies/DSS/Health-and-Home- Care/Community-Options/CT-STP-Amendment-Final-08-01- 2018.pdf?la=en Or on the DSS web under Community Options Documents and Forms at the bottom of the page Send comments to Kathy.a.bruni@ct.gov by September 2, 2018 Department of Social Services 22