Application for 1915(c) HCBS Waiver: MA.1027.R00.02

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

Service:

Alternate Service Title (if any):

HCBS Taxonomy:

Service Definition (Scope):

Services defined in 42 CFR §440.70 that are provided in addition to home health aide services furnished under the approved State plan. Home health aide services under the waiver differ in nature, scope, supervision arrangements, or provider type (including provider training and qualifications) from home health aide services in the State plan. The differences from the State plan are as follows: 1) Agencies that provide Home Health Aide services under the waiver do not need to meet the requirements for participation in Medicare, as provided in 42 CFR §489.28.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider Specifications:

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service

Service Name: Home Health Aide

Provider Category:

Provider Type:

Homemaker/Personal Care Agencies

Provider Qualifications

License (specify):

Supervision of Home Health Aides must be provided by a Registered Nurse with a valid Massachusetts license.

Certificate (specify):

Individuals employed by the agency providing home health aide services must have either of the following: - Certificate of Home Health Aide Training - Certificate of Certified Nurses Aide Training

Other Standard (specify):

Any not-for-profit or proprietary organization that responds satisfactorily to the Waiver provider enrollment process and as such, has successfully demonstrated, at a minimum, the following - Education, Training, Supervision: Providers must ensure effective training of staff members in all aspects of their job duties, including handling emergency situations. Providers are responsible for ensuring staff are trained on applicable regulations and policies governing waiver service delivery and the principles of participant centered care. Agencies must have established procedures for appraising staff performance and for effectively modifying poor performance where it exists. - Adherence to Continuous QI Practices: Providers must have established strategies to prevent, detect, and correct problems in the quality of services provided and to achieve service plan goals with individual participants by providing effective, efficient services. Providers must have the ability to meet all quality improvement requirements, as specified by the MassHealth agency or its designee and ability to provide program and participant quality data and reports, as required. - Availability/Responsiveness: Providers must be able to initiate services with little or no delay in the geographical areas they designate. - Confidentiality: Providers must maintain confidentiality and privacy of participant information in accordance with applicable laws and policies. - Policies/Procedures: Providers must have policies and procedures that include: Participant Not at Home Policy, Participant Emergency in the Home Policy; and policies that comply with the applicable standards under 105 CMR 155.000 (Department of Public Health regulations addressing patient and resident abuse prevention, reporting, investigation, and registry requirements) for the prevention, reporting and investigation of patient abuse, neglect, and mistreatment, and the misappropriation of patient property by individuals working in or employed by a homemaker agency as well as policies that comply with applicable regulations of the Disabled Persons Protection Commission found at 118 CMR 1.00 to 14.00 (The State’s Division Disabled Persons Protection Commission regulations that describe the purpose, rules, and process regarding abuse allegations for people with disabilities) and the Elder Abuse Reporting and Protective Services Program found at 651 CMR 5.00 et seq (The Executive Office of Elder Affairs’ Elder Abuse Reporting and Protective Services Program regulations). In addition, providers shall ensure that individual home health aides employed by the agency have been CORI checked, and are able to: perform assigned duties and responsibilities; communicate observations verbally and in writing; accept and use supervision; respect privacy and confidentiality; adapt to a variety of situations; and respect and accept different values, nationalities, races, religions, cultures and standards of living.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Every 2 years

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service

Service Name: Home Health Aide

Provider Category:

Provider Type:

Home Health Agencies

Provider Qualifications

License (specify):

Supervision of Home Health Aides must be provided by a Registered Nurse with a valid Massachusetts license.

Certificate (specify):

Individuals employed by the agency providing home health aide services must have either of the following: - Certificate of Home Health Aide Training - Certificate of Certified Nurses Aide Training

Other Standard (specify):

Any not-for-profit or proprietary organization that responds satisfactorily to the Waiver provider enrollment process and as such, has successfully demonstrated, at a minimum, the following - Education, Training, Supervision: Providers must ensure effective training of staff members in all aspects of their job duties, including handling emergency situations. Providers are responsible for ensuring staff are trained on applicable regulations and policies governing waiver service delivery and the principles of participant centered care. Agencies must have established procedures for appraising staff performance and for effectively modifying poor performance where it exists. - Adherence to Continuous QI Practices: Providers must have established strategies to prevent, detect, and correct problems in the quality of services provided and to achieve service plan goals with individual participants by providing effective, efficient services. Providers must have the ability to meet all quality improvement requirements, as specified by the MassHealth agency or its designee and ability to provide program and participant quality data and reports, as required. - Availability/Responsiveness: Providers must be able to initiate services with little or no delay in the geographical areas they designate. - Confidentiality: Providers must maintain confidentiality and privacy of participant information in accordance with applicable laws and policies. - Policies/Procedures: Providers must have policies and procedures that include: Participant Not at Home Policy, Participant Emergency in the Home Policy; and policies that comply with the applicable standards under 105 CMR 155.000 (Department of Public Health regulations addressing patient and resident abuse prevention, reporting, investigation, and registry requirements) for the prevention, reporting and investigation of patient abuse, neglect, and mistreatment, and the misappropriation of patient property by individuals working in or employed by a home health agency as well as policies that comply with applicable regulations of the Disabled Persons Protection Commission found at 118 CMR 1.00 to 14.00 (The State’s Division Disabled Persons Protection Commission regulations that describe the purpose, rules, and process regarding abuse allegations for people with disabilities) and the Elder Abuse Reporting and Protective Services Program found at 651 CMR 5.00 et seq (The Executive Office of Elder Affairs’ Elder Abuse Reporting and Protective Services Program regulations). In addition, providers shall ensure that individual home health aides employed by the agency have been CORI checked, and are able to: perform assigned duties and responsibilities; communicate observations verbally and in writing; accept and use supervision; respect privacy and confidentiality; adapt to a variety of situations; and respect and accept different values, nationalities, races, religions, cultures and standards of living.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Every 2 years

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

Service:

Alternate Service Title (if any):

HCBS Taxonomy:

Service Definition (Scope):

Services that consist of the performance of general household tasks (e.g., meal preparation and routine household care) provided by a qualified homemaker, when the individual regularly responsible for these activities is temporarily absent or unable to manage the home and care for him or herself or others in the home.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider Specifications:

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service

Service Name: Homemaker

Provider Category:

Provider Type:

Homemaker Agencies

Provider Qualifications

License (specify):

Certificate (specify):

Individuals employed by the agency providing homemaker services must have one of the following: - Certificate of Nurse's Aide Training - Certificate of Home Health Aide Training - Certificate of 40-Hour Homemaker Training - Certificate of 60-Hour Personal Care Training

Other Standard (specify):

Any not-for-profit or proprietary organization that responds satisfactorily to the Waiver provider enrollment process and as such, has successfully demonstrated, at a minimum, the following - Education, Training, Supervision: Providers must ensure effective training of staff members in all aspects of their job duties, including handling emergency situations. Providers are responsible for ensuring staff are trained on applicable regulations and policies governing waiver service delivery and the principles of participant centered care. Agencies must have established procedures for appraising staff performance and for effectively modifying poor performance where it exists. - Adherence to Continuous QI Practices: Providers must have established strategies to prevent, detect, and correct problems in the quality of services provided and to achieve service plan goals with individual participants by providing effective, efficient services. Providers must have the ability to meet all quality improvement requirements, as specified by the MassHealth agency or its designee and ability to provide program and participant quality data and reports, as required. - Availability/Responsiveness: Providers must be able to initiate services with little or no delay in the geographical areas they designate. - Confidentiality: Providers must maintain confidentiality and privacy of participant information in accordance with applicable laws and policies. - Policies/Procedures: Providers must have policies and procedures that include: Participant Not at Home Policy, Participant Emergency in the Home Policy; and policies that comply with the applicable standards under 105 CMR 155.000 (Department of Public Health regulations addressing patient and resident abuse prevention, reporting, investigation, and registry requirements) for the prevention, reporting and investigation of patient abuse, neglect, and mistreatment, and the misappropriation of patient property by individuals working in or employed by a homemaker agency as well as policies that comply with applicable regulations of the Disabled Persons Protection Commission found at 118 CMR 1.00 to 14.00 (The State’s Division Disabled Persons Protection Commission regulations that describe the purpose, rules, and process regarding abuse allegations for people with disabilities) and the Elder Abuse Reporting and Protective Services Program found at 651 CMR 5.00 et seq (The Executive Office of Elder Affairs’ Elder Abuse Reporting and Protective Services Program regulations). Homemaker Service Providers must have experience providing services to persons with disabilities. In addition, providers shall ensure that individual homemakers employed by the agency have been CORI checked, and are able to: perform assigned duties and responsibilities; communicate observations verbally and in writing; accept and use supervision; respect privacy and confidentiality; adapt to a variety of situations; and respect and accept people of differing abilities, different values, nationalities, races, religions, cultures and standards of living.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Every two years

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service

Service Name: Homemaker

Provider Category:

Provider Type:

Individual Homemaker

Provider Qualifications

License (specify):

Certificate (specify):

Individuals providing homemaker services must have certification in one of the following: - Certification in Home Health Aide Training - Certification in Nurse's Aide Training - Certification of 40-Hour Homemaker Training - Certification of 60-Hour Personal Care Training

Other Standard (specify):

Individuals who provide Homemaker services must have responded satisfactorily to the Waiver provider enrollment process and must meet requirements for individuals in such roles, including, but not limited to must: have been CORI checked, have life or work experience providing services to individuals with disabilities; can handle emergency situations; can set limits, and communicate effectively with participants, families, other providers and agencies; and have ability to meet legal requirements in protecting confidential information.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Every two years

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

Service:

Alternate Service Title (if any):

HCBS Taxonomy:

Service Definition (Scope):

A range of assistance to enable waiver participants to accomplish tasks that they would normally do for themselves if they did not have a disability. This assistance may take the form of hands-on assistance (actually performing a task for the person) or cuing and supervision to prompt the participant to perform a task. Such assistance may include assistance in bathing, dressing, personal hygiene and other activities of daily living. This service may include assistance with preparation of meals, but does not include the cost of the meals themselves. When specified in the care plan, this service may also include such housekeeping chores as bed-making, dusting and vacuuming, which are incidental to the care furnished, or which are essential to the health or welfare of the individual, rather than the individual's family. Personal care services may be provided on an episodic or on a continuing basis. Personal care under the waiver differs in scope, nature, supervision arrangements, and/or provider type (including provider training and qualifications) from personal care services in the State plan. Personal care under the waiver may include supervision and cuing of participants. All MFP waiver participants are entitled to receive medically necessary State plan services. MassHealth All Provider regulations at 130 CMR 450.140 through 149 detail the ESPDT requirements for MassHealth providers and the MassHealth provider manual for personal care services lists EPSDT screening schedules at Appendix W.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider Specifications:

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service

Service Name: Personal Care

Provider Category:

Provider Type:

Individual Personal Care Worker

Provider Qualifications

License (specify):

Certificate (specify):

Individuals providing personal care services must have one of the following: - Certificate of Home Health Aide Training - Certificate of Nurses Aide Training - Certificate of 60-Hour Personal Care Training

Other Standard (specify):

Individuals who provide Personal Care services must have responded satisfactorily to the Waiver provider enrollment process and must meet requirements for individuals in such roles, including, but not limited to must: have been CORI checked, have life or work experience providing services to individuals with disabilities; can handle emergency situations; can set limits, and communicate effectively with participants, families, other providers and agencies; have ability to meet legal requirements in protecting confidential information; and certification in CPR is required.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Every 2 years

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service

Service Name: Personal Care

Provider Category:

Provider Type:

Personal Care Agencies

Provider Qualifications

License (specify):

Certificate (specify):

Individuals employed by the agency providing personal care services must have one of the following: - Certificate of Home Health Aide Training - Certificate of Nurses Aide Training - Certificate of 60-Hour Personal Care Training

Other Standard (specify):

Any not-for-profit or proprietary organization that responds satisfactorily to the Waiver provider enrollment process and as such, has successfully demonstrated, at a minimum, the following - Education, Training, Supervision: Providers must ensure effective training of staff members in all aspects of their job duties, including handling emergency situations. Providers are responsible for ensuring staff are trained on applicable regulations and policies governing waiver service delivery and the principles of participant centered care. Agencies must have established procedures for appraising staff performance and for effectively modifying poor performance where it exists. - Adherence to Continuous QI Practices: Providers must have established strategies to prevent, detect, and correct problems in the quality of services provided and to achieve service plan goals with individual participants by providing effective, efficient services. Providers must have the ability to meet all quality improvement requirements, as specified by the MassHealth agency or its designee and ability to provide program and participant quality data and reports, as required. - Availability/Responsiveness: Providers must be able to initiate services with little or no delay in the geographical areas they designate. - Confidentiality: Providers must maintain confidentiality and privacy of consumer information in accordance with applicable laws and policies. - Policies/Procedures: Providers must have policies and procedures that include: Participant Not at Home Policy, Participant Emergency in the Home Policy; and that comply with the applicable standards under 105 CMR 155 et seq (Department of Public Health regulations addressing patient and resident abuse prevention, reporting, investigation, and registry requirements) for the prevention, reporting and investigation of patient abuse, neglect, and mistreatment, and the misappropriation of patient property by individuals working in or employed by a personal care agency as well as policies that comply with applicable regulations of the Disabled Persons Protection Commission found at 118 CMR 1.00 to 14.00 (The State’s Division Disabled Persons Protection Commission regulations that describe the purpose, rules, and process regarding abuse allegations for people with disabilities) and the Elder Abuse Reporting and Protective Services Program found at 651 CMR 5.00 et seq(The Executive Office of Elder Affairs’ Elder Abuse Reporting and Protective Services Program regulations). Personal Care Service Providers must have experience providing services to persons with disabilities. In addition, providers shall ensure that individual personal care workers employed by the provider agency have been CORI checked, and are able to: perform assigned duties and responsibilities; communicate observations verbally and in writing; accept and use supervision; respect privacy and confidentiality; adapt to a variety of situations; and respect and accept people of differing abilities, different values, nationalities, races, religions, cultures and standards of living.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Every 2 years

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

Service:

Alternate Service Title (if any):

HCBS Taxonomy:

Service Definition (Scope):

Prevocational Services comprises a range of learning and experiential type activities that prepare a participant for paid or unpaid employment in an integrated, community setting. Services are not job-task oriented but instead, aimed at a generalized result (e.g. attention span, motor skills). The service may include teaching such concepts as attendance, task completion, problem solving and safety as well as social skills training, improving attention span, and developing or improving motor skills. Basic skill-building activities are expected to specifically involve strategies to enhance a participant's employability in integrated, community settings. The amount, duration and scope of Prevocational Services provided to a participant is based on an assessment of the participant's pre-employment needs that arise as a result of his or her functional limitations and/or conditions, including services that enable the participant to acquire, improve, retain/maintain, and prevent deterioration of functioning consistent with the participants interests, strengths, priorities, abilities and capabilities. Services are reflected in the participants individualized service plan and are directed to address habilitative or rehabilitative rather than explicit employment objectives. Prevocational services may be provided one-to-one or in a group format. This service may be provided as a site-based service, in community settings or in a combination of these settings and must include integrated community activities that support the development of vocational skills. Meals provided as part of these services shall not constitute a "full nutritional regimen" (3 meals per day). Documentation is maintained in the file of each individual receiving this service that the service is not available under a program funded under section 110 of the Rehabilitation Act of 1973 or the IDEA (20 U.S.C. 1401 et seq.).

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider Specifications:

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service

Service Name: Prevocational Services

Provider Category:

Provider Type:

Prevocational Service Agencies

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Any not-for-profit or proprietary organization that responds satisfactorily to the Waiver provider enrollment process and as such, has successfully demonstrated, at a minimum, the following: - Education, Training, Supervision: Providers are responsible for ensuring staff are trained on: - Applicable regulations and policies governing waiver service delivery and the principles of participant-centered, community-based care. - Potential cognitive and/or mental health issues as well as physical needs of participants with disabilities - All aspects of their job duties, including handling a range of potential emergency situations. Agencies must have established procedures for appraising staff performance and for effectively modifying poor performance where it exists. - Adherence to Continuous QI Practices: Providers must have established strategies to prevent, detect, and correct problems in the quality of services provided and to achieve service plan goals with individual participants by providing effective, efficient services. Providers must have the ability to meet all quality improvement requirements, as specified by the MassHealth agency or its designee and ability to provide program and participant quality data and reports, as required. - Availability/Responsiveness: Providers must be able to initiate services with little or no delay in the geographical areas they designate. - Confidentiality: Providers must maintain confidentiality and privacy of consumer information in accordance with applicable laws and policies. - Policies/Procedures: Providers must have policies and procedures that comply with applicable regulations of the Disabled Persons Protection Commission found at 118 CMR 1.00 to 14.00 (The State’s Division Disabled Persons Protection Commission regulations that describe the purpose, rules, and process regarding abuse allegations for people with disabilities) and the Elder Abuse Reporting and Protective Services Program found at 651 CMR 5.00 et seq (The Executive Office of Elder Affairs’ Elder Abuse Reporting and Protective Services Program regulations). - Agencies must ensure that staff who provide Prevocational services: have been Criminal Offender Record Information (CORI) checked, have a College degree plus experience in providing community-based services to individuals with disabilities, or at least two years comparable community-based, life or work experience providing services to individuals with disabilities; can handle emergency situations; can set limits, and communicate effectively with participants, families, other providers and agencies; have ability to meet legal requirements in protecting confidential information. Physical Plant: - Understanding and compliance with all required policies, procedures, and physical plant standards relevant to the community setting as established by MRC. - Demonstrated compliance with health and safety, accessibility standards and the ADA, as applicable. Providers licensed, certified and qualified by DDS in accordance with 115 CMR 7.00 ( Department of Developmental Services (DDS) regulations for all DDS supports and services provided by public and private providers and those services subject to regulation by the Massachusetts Rehabilitation Commission, which provide social and pre-vocational supports and work training) will be considered to have met these standards.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Every 2 years

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

Service:

Alternate Service Title (if any):

HCBS Taxonomy:

Service Definition (Scope):

Waiver services provided to participants unable to care for themselves that are furnished on a short-term basis because of the absence or need for relief of those persons who normally provide care for the participant. Respite Care may be provided to relieve informal caregivers from the daily stresses and demands of caring for a Participant in efforts to strengthen or support the informal support system. Respite Care services may be provided in the following locations: - Respite Care in an Adult Foster Care Program provides personal care services in a family-like setting. A provider must meet the requirements set forth by MassHealth and must contract with MassHealth as an AFC provider. - Respite Care in a Hospital is provided in licensed acute care medical/surgical hospital beds that have been approved by the Department of Public Health. - Respite Care in a Skilled Nursing Facility provides skilled nursing care; rehabilitative services such as physical, occupational, and speech therapy; and assistance with activities of daily living such as eating, dressing, toileting and bathing. A nursing facility must be licensed by the Department of Public Health. - Respite Care in a Rest Home provides a supervised, supportive and protective living environment and support services. Rest Homes must be licensed by the Department of Public Health. - Respite Care in an Assisted Living Residence provides personal care services by an entity certified by the Executive Office of Elder Affairs. - Respite care in the home of a Community Respite Provider home which provides personal care services in a home like setting. Provider must meet the site based requirements for respite of the Department of Developmental Services (DDS) - Respite care in DDS Licensed Respite Facilities provides care and supervision in a setting licensed by the Department of Developmental Services. Federal financial participation will only be claimed for the cost of room and board when provided as part of respite care furnished in a facility approved by the State that is not a private residence.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

MFP enhanced funds will not be claimed for any Respite services delivered in non-MFP qualified residential settings.

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider Specifications:

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service

Service Name: Respite

Provider Category:

Provider Type:

DDS Licensed Respite Facilities

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

An organization which meets the Department of Developmental Services (DDS) site-based respite requirements found at 115 CMR 7.00 and 8.00 and that contracts with DDS to provide these services. Department of Developmental Services (DDS) regulations at 115 CMR 7.00 describes the requirements for all DDS supports and services provided by public and private providers and those services subject to regulation by the Massachusetts Rehabilitation Commission, which provide social and pre-vocational supports and work training and 115 CMR 8.00 describes the licensure, certification and enforcement requirements for all DDS residential supports, work/day supports, placement services, or residential site-based respite supports provided by public and private providers.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service

Service Name: Respite

Provider Category:

Provider Type:

Adult Foster Care

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

An organization which meets the requirements of 130 CMR 408.000 (MassHealth Adult Foster Care regulations that define provider eligibility requirements and program rules) and that contracts with MassHealth as the provider of Adult Foster Care.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service

Service Name: Respite

Provider Category:

Provider Type:

Hospital

Provider Qualifications

License (specify):

Licensed by the Department of Public Health in accordance with 105 CMR 130.000 (Department of Public Health Hospital Licensure Regulations that describes the standards for the maintenance and operations of hospitals in Massachusetts).

Certificate (specify):

Other Standard (specify):

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service

Service Name: Respite

Provider Category:

Provider Type:

Skilled Nursing Facility

Provider Qualifications

License (specify):

Licensed by the Department of Public Health in accordance with 105 CMR 153.000 (Department of Public Health Licensure Procedure and Suitability Requirements for Long-Term Care Facilities Regulations that describes the licensure procedures and suitability requirements for long-term care facilities in Massachuesetts).

Certificate (specify):

Other Standard (specify):

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service

Service Name: Respite

Provider Category:

Provider Type:

Rest Home

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service

Service Name: Respite

Provider Category:

Provider Type:

Assisted Living Residence

Provider Qualifications

License (specify):

Certificate (specify):

Certified by the Executive Office of Elder Affairs in accordance with 651 CMR 12.00 (Department of Elder Affairs regulations describing the certification procedures and standards for Assisted Living Residences in Massachusetts).

Other Standard (specify):

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service

Service Name: Respite

Provider Category:

Provider Type:

Community Respite Providers

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

An organization which meets the Department of Developmental Services (DDS) site-based respite requirements found at 115 CMR 7.00 (Department of Developmental Services (DDS) regulations for all DDS supports and services provided by public and private providers and those services subject to regulation by the Massachusetts Rehabilitation Commission, which provide social and pre-vocational supports and work training) and that contracts with DDS to provide these services.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

Service:

Alternate Service Title (if any):

HCBS Taxonomy:

Service Definition (Scope):

Supported employment services consist of intensive, ongoing supports that enable participants, for whom competitive employment at or above the minimum wage is unlikely absent the provision of supports, and who, because of their disabilities, need supports, to perform in a regular work setting. Supported employment may include assisting the participant to locate a job or develop a job on behalf of the participant. 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 supervision and training. 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: 1. Incentive payments made to an employer to encourage or subsidize the employer's participation in a supported employment program; 2. Payments that are passed through to users of supported employment programs; or 3. Payments for training that is not directly related to an individual's supported employment program.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

This service is not for use to provide continuous long-term 1:1 on the job support to enable an individual to complete work activities.

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider Specifications:

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service

Service Name: Supported Employment

Provider Category:

Provider Type:

Community-Based Employment Services Agencies

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Any not-for-profit or proprietary organization that responds satisfactorily to the Waiver provider enrollment process and as such, has demonstrated the experience and ability to successfully provide four components of supported employment programs, including Assessment, Placement, Initial Employment Supports and Extended Employment Supports, as specified by the MassHealth agency and to meet, at a minimum, the following requirements: Program: - Experience providing supported employment services - Demonstrated experience and/or willingness to work effectively with the MassHealth agency or its designee, with the Case Managers responsible for oversight and monitoring of the participants receiving these services, with the participants and their family/significant others; - Adequate organizational structure to support the delivery and supervision of supported employment services, including: - Ability to appropriately assess participants needs; obtain evaluative consultations; provide job development, matching and placement services; ensure necessary supports for employment (coaching/counseling/ training, transportation, accommodations, assistive technology); provide initial and extended supports to maintain job stability and retention, as appropriate; and respond to crisis situations; - Demonstrated ability to produce timely, complete and quality documentation including but not limited to assessments, incident reports, progress reports and program-specific service plans - Demonstrated compliance with health and safety standards, as applicable. - Demonstrated ability to work with and have established linkages with community employers; proven participant marketing/employer outreach strategies; developed employer education materials; plan for regular and on-going employer communication - Demonstrated compliance with health and safety, and Department of Labor standards, as applicable. Staff and Training: - Experience recruiting and maintaining qualified staff; assurance that all staff will be CORI checked; policies/practices which ensure that: - There is a team approach to service delivery - Program management and staff meet the minimum qualifications established by the MassHealth agency and understand the principals of participant choice, as it relates to those with disabilities. Quality: - Providers must have the ability to meet all quality improvement requirements, as specified by the MassHealth agency or its designee and ability to provide program and participant quality data and reports, as required.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Every two years

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

As provided in 42 CFR 440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

Service Title:

Addiction Services

HCBS Taxonomy:

Service Definition (Scope):

Addiction services include an array of person-centered outpatient and intensive outpatient addiction treatment interventions consistent with the individual’s assessed treatment needs, with a rehabilitation and recovery focus designed to promote skills for coping with and managing substance abuse symptoms and behaviors. These services are not otherwise covered in the Medicaid State Plan. Addiction treatment interventions are designed to help individuals achieve changes in their substance abuse behaviors. Addiction interventions include: • Ambulatory detoxification to stabilize the individual’s medical condition under circumstances where neither life nor significant bodily functions are threatened. • Clinically intensive, structured day and/or evening substance use disorder therapeutic interventions. These interventions can be utilized to transition an individual in the continuum of care for an individual being discharged from acute substance abuse treatment, or can be utilized by individuals, who need outpatient services, but who also need more structured treatment for a substance use disorder. Addiction services are provided in Massachusetts Department of Public Health licensed mental health or substance abuse clinic settings.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider Specifications:

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Addiction Services

Provider Category:

Provider Type:

Addiction Service Providers

Provider Qualifications

License (specify):

Services are provided in Massachusetts Department of Public Health-licensed freestanding facilities skilled in addiction recovery treatment in accordance with 105 CMR 164.000 (Department of Public Health regulations regarding the standards for the licensure and operation of all substance abuse treatment programs in Massachusetts); or in Massachusetts Department of Public Health-licensed outpatient departments in acute care hospitals in accordance with 105 CMR 130.000 (Department of Public Health Hospital Licensure Regulations that describe the standards for the maintenance and operations of hospitals in Massachusetts.); or in Massachusetts Department of Public Health-licensed clinics in accordance with 105 CMR 140.00 (Department of Public Health regulations regarding the standards for the licensure of clinics in Massachusetts)

Certificate (specify):

Other Standard (specify):

Detoxification interventions must be provided in an outpatient clinical setting, under the direction of a physician, and designed to stabilize the medical condition of an individual experiencing a serious episode of excessive substance use or withdrawal complications. In accordance with MassHealth’s behavioral health contract requirements, agencies providing clinically intensive, structured day and/or evening substance use disorder therapeutic interventions must employ a multidisciplinary staff that includes a minimum of one fulltime master’s level clinician responsible for the clinical/educational operation of the program and supervision of the staff. The multidisciplinary staff must be trained in the integrated treatment of addictions, co-occurring disorders, biomedical, and related emotional/behavioral problems. All other staff must be bachelors or master’s level trained. A program director must be available to respond to urgent or emergency situations.

Verification of Provider Qualifications

Entity Responsible for Verification:

Department of Public Health and/or MassHealth or its designee.

Frequency of Verification:

Every two years.

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

As provided in 42 CFR 440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

Service Title:

Adult Companion

HCBS Taxonomy:

Service Definition (Scope):

Non-medical care, supervision and socialization, provided to a functionally impaired adult. Companions may assist or supervise the participant with such tasks as meal preparation, laundry and shopping. The provision of companion services does not entail hands-on nursing care. Providers may also perform light housekeeping tasks that are incidental to the care and supervision of the participant. This service is provided in accordance with a therapeutic goal in the service plan.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider Specifications:

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Adult Companion

Provider Category:

Provider Type:

Individual Aide

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Individuals who provide Adult Companion services must have responded satisfactorily to the Waiver provider enrollment process and must meet requirements for individuals in such roles, including, but not limited to must: have been CORI checked, have life or work experience providing services to individuals with disabilities; can handle emergency situations; can set limits, and communicate effectively with participants, families, other providers and agencies; have ability to meet legal requirements in protecting confidential information; and certification in CPR is required.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Every 2 years

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Adult Companion

Provider Category:

Provider Type:

Human Service Agencies

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Any not-for-profit or proprietary organization that responds satisfactorily to the Waiver provider enrollment process and as such, has successfully demonstrated, at a minimum, the following: - Education, Training, Supervision: Providers must ensure effective training of staff members in all aspects of their job duties, including handling emergency situations. Providers are responsible for ensuring staff are trained on applicable regulations and policies governing waiver service delivery and the principles of participant centered care. Agencies must have established procedures for appraising staff performance and for effectively modifying poor performance where it exists. - Adherence to Continuous QI Practices: Providers must have established strategies to prevent, detect, and correct problems in the quality of services provided and to achieve service plan goals with individual participants by providing effective, efficient services. Providers must have the ability to meet all quality improvement requirements, as specified by the MassHealth agency or its designee and ability to provide program and participant quality data and reports, as required. - Availability/Responsiveness: Providers must be able to initiate services with little or no delay in the geographical areas they designate. - Confidentiality: Providers must maintain confidentiality and privacy of consumer information in accordance with applicable laws and policies. - Policies/Procedures: Providers must have policies and procedures that include: Participant Not at Home Policy, Participant Emergency in the Home Policy; and that comply with the applicable standards under 105 CMR 155 et seq (Department of Public Health regulations addressing patient and resident abuse prevention, reporting, investigation, and registry requirements) for the prevention, reporting and investigation of patient abuse, neglect, and mistreatment, and the misappropriation of patient property by individuals working in or employed by a adult companion agency as well as policies that comply with applicable regulations of the Disabled Persons Protection Commission found at 118 CMR 1.00 to 14.00 (The State’s Division Disabled Persons Protection Commission regulations that describe the purpose, rules, and process regarding abuse allegations for people with disabilities) and the Elder Abuse Reporting and Protective Services Program found at 651 CMR 5.00 et seq (The Executive Office of Elder Affairs’ Elder Abuse Reporting and Protective Services Program regulations). - Individuals employed as Adult Companions must meet requirements for individuals in such roles, including, but not limited to must: have been CORI checked, have life or work experience providing services to individuals with disabilities; can handle emergency situations; can set limits, and communicate effectively with participants, families, other providers and agencies; have ability to meet legal requirements in protecting confidential information; and certification in CPR is required.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Every 2 years

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Adult Companion

Provider Category:

Provider Type:

Health Care Agencies

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Any not-for-profit or proprietary organization that responds satisfactorily to the Waiver provider enrollment process and as such, has successfully demonstrated, at a minimum, the following: - Education, Training, Supervision: Providers must ensure effective training of staff members in all aspects of their job duties, including handling emergency situations. Providers are responsible for ensuring staff are trained on applicable regulations and policies governing waiver service delivery and the principles of participant centered care. Agencies must have established procedures for appraising staff performance and for effectively modifying poor performance where it exists. - Adherence to Continuous QI Practices: Providers must have established strategies to prevent, detect, and correct problems in the quality of services provided and to achieve service plan goals with individual participants by providing effective, efficient services. Providers must have the ability to meet all quality improvement requirements, as specified by the MassHealth agency or its designee and ability to provide program and participant quality data and reports, as required. - Availability/Responsiveness: Providers must be able to initiate services with little or no delay in the geographical areas they designate. - Confidentiality: Providers must maintain confidentiality and privacy of consumer information in accordance with applicable laws and policies. - Policies/Procedures: Providers must have policies and procedures that include: Participant Not at Home Policy, Participant Emergency in the Home Policy; and that comply with the applicable standards under 105 CMR 155 et seq (Department of Public Health regulations addressing patient and resident abuse prevention, reporting, investigation, and registry requirements) for the prevention, reporting and investigation of patient abuse, neglect, and mistreatment, and the misappropriation of patient property by individuals working in or employed by a adult companion agency as well as policies that comply with applicable regulations of the Disabled Persons Protection Commission found at 118 CMR 1.00 to 14.00 (The State’s Division Disabled Persons Protection Commission regulations that describe the purpose, rules, and process regarding abuse allegations for people with disabilities) and the Elder Abuse Reporting and Protective Services Program found at 651 CMR 5.00 et seq (The Executive Office of Elder Affairs’ Elder Abuse Reporting and Protective Services Program regulations). - Individuals employed as Adult Companions must meet requirements for individuals in such roles, including, but not limited to must: have been CORI checked, have life or work experience providing services to individuals with disabilities; can handle emergency situations; can set limits, and communicate effectively with participants, families, other providers and agencies; have ability to meet legal requirements in protecting confidential information; and certification in CPR is required.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Every 2 years

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

As provided in 42 CFR 440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

Service Title:

Chore Service

HCBS Taxonomy:

Service Definition (Scope):

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, shoveling snow in order to provide safe access and egress. These services are provided only when neither the participant nor anyone else in the household is capable of performing or financially providing for them, and where no other relative, caregiver, landlord, community/volunteer agency, or third party payer is capable of or responsible for their provision. In the case of rental property, the responsibility of the landlord, pursuant to the lease agreement, is examined prior to any authorization of service.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider Specifications:

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Chore Service

Provider Category:

Provider Type:

Individual Chore Provider

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Individuals who provide Chore services must have responded satisfactorily to the Waiver provider enrollment process and must meet requirements for individuals in such roles, including, but not limited to must: have been CORI checked, have life or work experience providing services to individuals with disabilities; can handle emergency situations; can set limits, and communicate effectively with participants, families, other providers and agencies; have ability to meet legal requirements in protecting confidential information; and certification in CPR is required.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Every 2 years

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Chore Service

Provider Category:

Provider Type:

Chore Provider Agencies

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Any not-for-profit or proprietary organization that responds satisfactorily to the Waiver provider enrollment process and as such, has successfully demonstrated, at a minimum, the following - Education, Training, Supervision: Providers must ensure effective training of staff members in all aspects of their job duties, including handling emergency situations. Providers are responsible for ensuring staff are trained on applicable regulations and policies governing waiver service delivery and the principles of participant centered care. Agencies must have established procedures for appraising staff performance and for effectively modifying poor performance where it exists. - Adherence to Continuous QI Practices: Providers must have established strategies to prevent, detect, and correct problems in the quality of services provided and to achieve service plan goals with individual participants by providing effective, efficient services. Providers must have the ability to meet all quality improvement requirements, as specified by the MassHealth agency or its designee and ability to provide program and participant quality data and reports, as required. - Availability/Responsiveness: Providers must be able to initiate services with little or no delay in the geographical areas they designate. - Confidentiality: Providers must maintain confidentiality and privacy of consumer information in accordance with applicable laws and policies. - Policies/Procedures: Providers must have policies and procedures that include: Participant Not at Home Policy, Participant Emergency in the Home Policy; and that comply with the applicable standards under 105 CMR 155 et seq (Department of Public Health regulations addressing patient and resident abuse prevention, reporting, investigation, and registry requirements) for the prevention, reporting and investigation of patient abuse, neglect, and mistreatment, and the misappropriation of patient property by individuals working in or employed by a chore services agency as well as policies that comply with applicable regulations of the Disabled Persons Protection Commission found at 118 CMR 1.00 to 14.00 (The State’s Division Disabled Persons Protection Commission regulations that describe the purpose, rules, and process regarding abuse allegations for people with disabilities) and the Elder Abuse Reporting and Protective Services Program found at 651 CMR 5.00 et seq (The Executive Office of Elder Affairs’ Elder Abuse Reporting and Protective Services Program regulations). Chore Service Providers must have experience providing services to persons with disabilities. In addition, providers shall ensure that individual chore workers employed by the provider agency have been CORI checked, are able to: perform assigned duties and responsibilities; communicate observations verbally and in writing; accept and use supervision; respect privacy and confidentiality; adapt to a variety of situations; and respect and accept people of differing abilities, different values, nationalities, races, religions, cultures and standards of living.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Every 2 years

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

As provided in 42 CFR 440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

Service Title:

Community Crisis Stabilization

HCBS Taxonomy:

Service Definition (Scope):

Community Crisis Stabilization: Community Crisis Stabilization (CCS) service is provided as an alternative to hospitalization, including short-term psychiatric treatment in a structured, community-based therapeutic environment. CCS provides continuous 24-hour observation and supervision for individuals who do not require inpatient services. CCS provides care where the primary objectives of the active multi-disciplinary treatment include restoration of functioning; strengthening the resources and capacities of the individual, family, and other natural supports; timely return to a natural setting and/or least restrictive setting in the community; development/strengthening of an individualized risk management/safety plan; and linkage to ongoing, medically necessary treatment and support services. CCS staff provide continuous observation of, and support to, individuals with mental health or co-occurring mental health/substance use conditions who might otherwise require treatment in an inpatient psychiatric setting and would benefit from short-term and structured crisis stabilization services. Components of this service include crisis stabilization; initial and continuing bio-psychosocial assessment; psychiatric evaluation and support with managing medication; peer-to-peer support; and mobilization of natural supports and community resources. Federal financial participation is not claimed for the cost of room and board. Community crisis stabilization shall not be provided simultaneously with other waiver services.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider Specifications:

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Community Crisis Stabilization

Provider Category:

Provider Type:

Community Crisis Stabilization Provider

Provider Qualifications

License (specify):

Services are provided in Massachusetts Department of Public-licensed clinic in accordance with 105 CMR 140.00 (Department of Public Health regulations regarding the standards for the licensure of clinics in Massachusetts).

Certificate (specify):

Other Standard (specify):

In accordance with MassHealth’s behavioral health contract requirements providers must employ a multidisciplinary staff with established experience, skills, and training in the acute treatment of mental health and co-occurring mental health and substance use conditions. Providers must maintain appropriate staffing patterns to safely care for all persons 24/7. There must be a psychiatric clinician available for a psychiatric phone consultation within 15 minutes of request and for a face-to-face evaluation within 60 minutes of request, when clinically indicated.

Verification of Provider Qualifications

Entity Responsible for Verification:

Department of Public Health and/or MassHealth or its designee.

Frequency of Verification:

Every two years.

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

As provided in 42 CFR 440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

Service Title:

Community Family Training

HCBS Taxonomy:

Service Definition (Scope):

Community Family Training is designed to provide training and instruction about the treatment regimes, behavior plans, and the use of specialized equipment that supports the waiver participant to participate in the community. Community Family Training may also include training in family leadership, support of self-advocacy, and independence for their family member. The service enhances the skill of the family to assist the waiver participant to function in the community and at home. Documentation in the participant's record demonstrates the benefit to the participant. For the purposes of this service, "family" is defined as the persons who live with or provide care to a waiver participant and may include a parent or other relative. Family does not include individuals who are employed to care for the participant. Community Family Training may be provided in a small group format or the Family Trainer may provide individual instruction to a specific family based on the needs of the family to understand the specialized needs of the waiver participant. The one to one family training is instructional; it is not counseling. Service is available to those waiver participants who either live in the family home or receive less than 24 hours of support per day and regularly visit with their family.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider Specifications:

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Community Family Training

Provider Category:

Provider Type:

Family Training Agencies

Provider Qualifications

License (specify):

If the agency is providing activities where licensure or certification is necessary, the applicant will have the necessary licensure/certifications. For mental health professionals such as Family Therapists, Rehabilitation Counselors, Social Workers, necessary licensure or certification requirements for those disciplines must be met.

Certificate (specify):

Other Standard (specify):

Any not-for-profit or proprietary organization that responds satisfactorily to the Waiver provider enrollment process and as such, has successfully demonstrated, at a minimum, the following - Education, Training, Supervision: Providers must ensure effective training of staff members in all aspects of their job duties, including handling emergency situations. Providers are responsible for ensuring staff are trained on applicable regulations and policies governing waiver service delivery and the principles of participant centered care. Agencies must have established procedures for appraising staff performance and for effectively modifying poor performance where it exists. - Adherence to Continuous QI Practices: Providers must have established strategies to prevent, detect, and correct problems in the quality of services provided and to achieve service plan goals with individual participants by providing effective, efficient services. Providers must have the ability to meet all quality improvement requirements, as specified by the MassHealth agency or its designee and ability to provide program and participant quality data and reports, as required. - Availability/Responsiveness: Providers must be able to initiate services with little or no delay in the geographical areas they designate. - Confidentiality: Providers must maintain confidentiality and privacy of consumer information in accordance with applicable laws and policies. - Policies/Procedures: Providers must have policies and procedures that comply with the applicable standards under 105 CMR 155.000 for the prevention, reporting and investigation of patient abuse, neglect, and mistreatment, and the misappropriation of patient property by individuals working in or employed by a Family Training Agency as well as policies that comply with applicable regulations of the Disabled Persons Protection Commission found at 118 CMR 1.00 to 14.00 and the Elder Abuse Reporting and Protective Services Program found at 651 CMR 5.00 et seq. - Individuals who provide Family Training Services must meet requirements for individuals in such roles, including, but not limited to must: have been CORI checked; can handle emergency situations; can set limits, and communicate effectively with participants, families, other providers and agencies; have ability to meet legal requirements in protecting confidential information. The agency must employ individuals who are able to effectively communicate in the language and communication style of the individual or family for whom they are providing the training. Staff members providing Family Training must have experience in promoting independence and in family leadership.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually or prior to utilization of service

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Community Family Training

Provider Category:

Provider Type:

Individual Family Training Provider

Provider Qualifications

License (specify):

Individuals who meet all relevant state and federal licensure or certification requirements for their discipline.

Certificate (specify):

Relevant competencies and experiences in Family Training.

Other Standard (specify):

Applicants must possess appropriate qualifications to serve as staff as evidenced by interview(s), two personal or professional references, and a Criminal Offense Record Inquiry (CORI). The applicant must have the ability to communicate effectively in the language and communication style of the family to whom they are providing training. The applicant must have experience in providing family leadership, self-advocacy, and skills training in independence.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually or prior to utilization of service

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

As provided in 42 CFR 440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

Service Title:

Community Psychiatric Support and Treatment (CPST)

HCBS Taxonomy:

Service Definition (Scope):

Community Psychiatric Support and Treatment (CPST) includes an array of psychosocial rehabilitation strategies that are part of a comprehensive specialized psychiatric program for adults with significant functional impairments resulting from an identified mental health or substance abuse disorder diagnosis. CPST is not otherwise covered in the Medicaid State Plan. These strategies provide essential therapy to individuals with a long standing history of a psychiatric or substance use disorder and to their families, or to those individuals who are at varying degrees of increased medical risk, or who have behavioral health issues challenging their optimal level of functioning in the community setting. Home and community-based programs utilizing evidence-based strategies under this service must comply with state regulations and policies for the individual strategies. Community programs provided in facilities must comply with any state regulations and policies for the staffing and facility licensure type. These strategies may include: • Assisting the individual and family members, or other formal or informal supports, to identify strategies or treatment options associated with the individual’s mental illness, with the goal of minimizing the negative effects of mental illness symptoms, emotional disturbances or associated environmental stressors which interfere with the individual’s daily living, financial management, housing, academic and/or employment progress, personal recovery or resilience, family and/or interpersonal relationships and community integration. • Individual supportive counseling, solution-focused interventions, emotional and behavioral management and problem behavior analysis with the individual, with the goal of assisting the individual in developing and implementing social, interpersonal, self care, daily living and independent living skills to restore stability, functional gains and to adapt to community living. • Participation in and utilization of strengths-based planning and treatments which include assisting the individual and family members, or other formal or informal supports, with identifying strengths, needs, resources, natural supports and developing goals and objectives to utilize personal strengths, resources and natural supports to address functional deficits associated with their mental illness. These planning and treatment activities are specific to meeting the goals of the service as included in the individual’s plan of care, and are not duplicative of the person-centered planning process as described in Appendix D. • Assisting the individual with effectively responding to or avoiding identified precursors or triggers that would risk their remaining in a natural community location, including assisting the individual and family members, or other formal or informal supports, with identifying a potential psychiatric or personal crisis, developing a crisis management plan and/or, as appropriate, seeking other supports to restore stability and functioning. • Restoration, rehabilitation and support to develop skills to locate, rent and keep a home, handle landlord/tenant negotiations, select a roommate and understand renter’s rights and responsibilities. • Assisting the individual through clinical interventions to develop daily living skills specific to managing their own home, including managing their money, medications and using community resources and other self-care requirements. The strategies may include approaches such as: • Treatment in nonresidential treatment settings that provides clinical, diagnostic, and treatment services on a level of intensity equal to an inpatient program, but on less than a 24-hour basis as a time-limited response to stabilize acute symptoms. • Structured outpatient treatments which combine strategies from behavioral, cognitive, and supportive psychotherapies. • Therapeutic services provided to an individual on a one-to-one basis, to maintain the individual’s safety. • Consultation conducted by outpatient providers in order to facilitate transition to less restrictive home or community-based settings. •Multi-disciplinary team approaches to providing acute, active, ongoing, and long-term community-based psychiatric treatment, assertive outreach, rehabilitation and support. Approaches include assistance to individuals to maximize their recovery, ensure consumer-directed goal setting, assist individuals in gaining a sense of hope and empowerment, and integratration into the community. • Clinically intensive approaches designed to improve functional status, provide stabilization in the community, divert an admission to an inpatient service, or facilitate a rapid and stable reintegration into the community following a discharge from an inpatient service. Such approaches are time-limited, comprehensive, and coordinated multidisciplinary treatment.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider Specifications:

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Community Psychiatric Support and Treatment (CPST)

Provider Category:

Provider Type:

Community Psychiatric Support and Treatment Providers

Provider Qualifications

License (specify):

Services are provided by acute care hospital outpatient departments licensed by the Massachusetts Department of Public Health in accordance with 105 CMR 130.000 (Department of Public Health Hospital Licensure Regulations that describe the standards for the maintenance and operations of hospitals in Massachusetts); or by clinics licensed by Massachusetts Department of Public Health in accordance with 105 CMR 140.00 (Department of Public Health regulations regarding the standards for the licensure of clinics in Massachusetts).

Certificate (specify):

Other Standard (specify):

In accordance with MassHealth’s behavioral health contract requirements, any program utilizing Dialectical Behavior Therapy (DBT) approaches must have a minimum of two DBT-credentialed therapists who oversee the provision of all DBT services. Any program utilizing Program of Assertive Community Treatment approaches must have a one to ten staff client ratio; a full-time team leader with at least a master’s degree in nursing, social work, psychiatric rehabilitation, or psychology; and a psychiatrist on a full-time or part-time basis for a minimum of 20 hours per week for 60 individuals. Community programs provided in facilities must comply with any state regulations and policies for the staffing and facility licensure type. For example, any program licensed as a partial hospitalization program must have a staff-to-patient ratio sufficient to ensure necessary therapeutic services, professional monitoring, control, and protection. A psychiatrist must provide daily psychiatric management and active treatment comparable to that provided by an inpatient setting.

Verification of Provider Qualifications

Entity Responsible for Verification:

Department of Public Health and/or MassHealth or its designee.

Frequency of Verification:

Every two years.

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

As provided in 42 CFR 440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

Service Title:

Day Services

HCBS Taxonomy:

Service Definition (Scope):

Day services/supports provide for structured day activity typically for individuals with pervasive and extensive support needs who are not ready to join the general workforce. Day Services are individually designed around consumer choice and preferences with a focus on improvement or maintenance of the person’s skills and their ability to live as independently as possible in the community. Day Services often include assistance to learn activities of daily living and functional skills; language and communication training; compensatory, cognitive and other strategies; interpersonal skills; recreational/socialization skills and other skills training to prepare the individual to undertake various community inclusion activities. This service may reinforce some aspects of other waiver and state plan services by allowing individuals to continue to strengthen skills, which are necessary for greater independence, productivity and community inclusion. Day Services are provided in a provider operated setting in the community and not in a participant's residence, and do not duplicate any services under the state plan.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider Specifications:

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Day Services

Provider Category:

Provider Type:

Human Service Agencies

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Any not-for-profit or proprietary organization that responds satisfactorily to the waiver provider enrollment process, which includes meeting requirements for staffing qualifications and training, and all prescribed operational policies and procedures, including, but not limited to: Program and Physical Plant: - Understanding and compliance with all required policies, procedures, and physical plant standards - Experience providing functional, community-based services and living skills training and understanding of the philosophy of maximizing independence, participant participation, community integration and a comprehensive blend of services; - Demonstrated experience and/or willingness to work effectively with the MassHealth agency or its designee and with the Case Managers responsible for oversight and monitoring of the participants receiving these services; - Adequate organizational structure to support the delivery and supervision of day services, including:- - Ability to plan and deliver services in the prescribed settings - Demonstrated ability to produce timely, complete and quality documentation including but not limited to assessments, incident reports, progress reports and program-specific service plans - Demonstrated compliance with health and safety, accessibility standards and the ADA, as applicable. Staff and Training: - Demonstrates a team approach to service delivery including the ability to define, track and monitor service interventions that meet participant goals and objectives - Ability to access relevant clinical support as needed - Experience recruiting and maintaining qualified staff; assurance that all staff will be CORI checked; policies/practices which ensure that: - Program management and staff meet the minimum qualifications established by the MassHealth agency and understand the principles of participant choice Quality: - Providers must have the ability to meet all quality improvement requirements, as specified by the MassHealth agency or its designee and ability to provide program and participant quality data and reports, as required. Compliance with the licensure and/or certification standards of another Executive Office of Health and Human Services agency may be substituted for the above qualifications.For example Department of Developmental Services requirements at 115 CMR 7.00 & 8.00 (Department of Developmental Services (DDS) regulations for all DDS supports and services provided by public and private providers and those services subject to regulation by the Massachusetts Rehabilitation Commission, which provide social and pre-vocational supports and work training) or Department of Mental Health requirements at 104 CMR Subpart B (Department of Mental Health regulations for licensing and operational standards for mental health related community programs and which address protection from mistreatment and physical restraints) may be substituted for the above qualifications.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Day Services

Provider Category:

Provider Type:

Rehabilitation Facilities

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

As provided in 42 CFR 440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

Service Title:

Home Accessibility Adaptations

HCBS Taxonomy:

Service Definition (Scope):

Those physical adaptations to the private residence of the participant or the participants family, required by the participant's service plan, 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. This service may also include architectural services to develop drawings and narrative specifications for architectural adaptations, adaptive equipment installation, and related construction as well as subsequent site inspections to oversee the completion of adaptations and conformance to local and state building codes, acceptable building trade standards and bid specifications. 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. Adaptations that add to the total square footage of the home are excluded from this benefit except when necessary to complete an adaptation (e.g., in order to improve entrance/egress to a residence or to configure a bathroom to accommodate a wheelchair). Also excluded are those modifications which would normally be considered the responsibility of the landlord. Home accessibility modifications may not be furnished to adapt living arrangements that are owned or leased by providers of waiver services.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

Lifetime limit of $50,000 per participant. Requests for exceptions to this limit must demonstrate that the exception is essential to the health and safety of the participant and must be approved by MRC and MassHealth.

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider Specifications:

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Home Accessibility Adaptations

Provider Category:

Provider Type:

Architect/Design Agencies

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Any not-for-profit or proprietary organization that becomes qualified through the MRC open procurement process and as such, successfully demonstrates, at a minimum, the following: Providers shall ensure that individual workers employed by the agency have been CORI checked, and are able to perform assigned duties and responsibilities. Staff responsible for architectural drawings must be: Licensed architects, certified designers or draftsmen.

Verification of Provider Qualifications

Entity Responsible for Verification:

Massachusetts Rehabilitation Commission

Frequency of Verification:

Annually, or prior to utilization of service

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Home Accessibility Adaptations

Provider Category:

Provider Type:

Architect/Designer

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Any self-employed provider that becomes qualified through the MRC open procurement process and as such, successfully demonstrates, at a minimum, the following: Staff responsible for architectural drawings must be: Licensed architects, certified designers or draftsmen. Providers shall submit to a CORI check, and must be able to perform assigned duties and responsibilities.

Verification of Provider Qualifications

Entity Responsible for Verification:

Massachusetts Rehabilitation Commission

Frequency of Verification:

Annually, or prior to utilization of service

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Home Accessibility Adaptations

Provider Category:

Provider Type:

Home Accessibility Adaptation Agencies

Provider Qualifications

License (specify):

If the scope of work involves home modifications, agencies and individuals employed by the agencies must possess any licenses/certifications required by the state (e.g., Home Improvement Contractor, Construction Supervisor License, Plumbers license, etc.)

Certificate (specify):

Other Standard (specify):

Any not-for-profit or proprietary organization that becomes qualified through the MRC open procurement process and as such, successfully demonstrates, at a minimum, the following: Providers shall ensure that individual workers employed by the agency have been CORI checked, and are able to perform assigned duties and responsibilities. If the scope of work involves home modifications, agencies and individuals employed by the agencies must possess any appropriate licenses/certifications required by the state (e.g., Home Improvement Contractor, Construction Supervisor License, Plumbers license, etc.)

Verification of Provider Qualifications

Entity Responsible for Verification:

Massachusetts Rehabilitation Commission

Frequency of Verification:

Annually, or prior to utilization of service

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Home Accessibility Adaptations

Provider Category:

Provider Type:

Home Accessibility Adaptation Provider (Self-Employed)

Provider Qualifications

License (specify):

If the scope of work involves home modifications, agencies and individuals employed by the agencies must possess any appropriate licenses/certifications required by the state (e.g., Home Improvement Contractor, Construction Supervisor License, Plumbers license, etc.)

Certificate (specify):

Other Standard (specify):

Any self-employed provider that becomes qualified through the MRC open procurement process and as such, successfully demonstrates, at a minimum, the following: Providers shall submit to a CORI check, and must be able to perform assigned duties and responsibilities. If the scope of work involves home modifications, agencies and individuals employed by the agencies must possess any appropriate licenses/certifications required by the state (e.g., Home Improvement Contractor, Construction Supervisor License, Plumbers license, etc.)

Verification of Provider Qualifications

Entity Responsible for Verification:

Massachusetts Rehabilitation Commission

Frequency of Verification:

Annually, or prior to utilization of service

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

As provided in 42 CFR 440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

Service Title:

Independent Living Supports

HCBS Taxonomy:

Service Definition (Scope):

Independent Living Supports ensures 24 hour seven days a week access to supportive services for persons who have intermittent, scheduled and unscheduled needs for various forms of assistance, but who do not require 24-hour supervision. It provides participants with services and supports in a variety of activities such as: activities of daily living (ADLs) and instrumental activities of daily living (IADLs), support and companionship, and emotional support, and socialization. This service is provided by a site-based provider, and is available to participants who choose to reside in locations where a critical mass of individuals reside who require such support and where providers of such supports are available. Independent Living Supports agencies recruit staff, assess their abilities, train and provide guidance, supervision and oversight for staff. Providers ensure scheduled services as well as intermittent, unscheduled support as needed by the participant. The provision of Independent Living Supports does not entail hands-on nursing care. This service is provided in accordance with a therapeutic goal in the service plan. Independent Living Supports are intended to be provided in a multi-tenant building, including but not limited to such settings as elderly/disabled public housing. The concept is that a provider would secure office space in the building in which staff can be based (thus site-based), would have multiple regular waiver participants and other clients in need of home-based care to whom they provide services in the building, and would have staff who could be available at non-scheduled times to respond to participants who need support for issues that arise unexpectedly. The service provider cannot be the owner of the building in which the services are delivered. To be a qualified residence under MFP, leases should not: include rules and/or regulations from a service agency as conditions of tenancy or include a requirement to receive services from a specific company; require notification of periods of absence, e.g. a person who is absent from a facility for more that 15 consecutive days, or discuss transfer to a nursing facility or hospital; include provisions for being admitted, discharged, or transferred out of or into a facility; or reserve the right to assign apartments and change apartment assignments. Duplicative services, including, but not limited to waiver homemaker, personal care, adult companion, shared home supports, and supportive home care aide services, are not available to participants receiving Independent Living Supports.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider Specifications:

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Independent Living Supports

Provider Category:

Provider Type:

Human Service Agencies

Provider Qualifications

License (specify):

Certificate (specify):

Individuals employed by the agency providing personal care services must have one of the following: - Certificate of Nurse's Aide Training - Certificate of Home Health Aide Training - Certificate of Supportive Home Care Aide Training - Certificate of 60-Hour Personal Care Training

Other Standard (specify):

Human Service Agencies qualified to provide personal care services may apply to become providers of Independent Living Supports. In addition to fulfilling all requirements as a Personal Care service provider the agency must demonstrate the ability to manage both scheduled and unscheduled needs and must be able to initiate services with little or no delay in the designated site. One provider will be selected from the applicants for each designated site.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Independent Living Supports

Provider Category:

Provider Type:

Home Health Agencies

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Home Health Agencies qualified to provide personal care services may apply to become providers of Independent Living Supports. In addition to fulfilling all requirements as a Personal Care service provider the agency must demonstrate the ability to manage both scheduled and unscheduled needs and must be able to initiate services with little or no delay in the designated site. One provider will be selected from the applicants for each designated site.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Independent Living Supports

Provider Category:

Provider Type:

Homemaker/Personal Care Agencies

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Homemaker/Personal Care Agencies qualified to provide personal care services may apply to become providers of Independent Living Supports. In addition to fulfilling all requirements as a Personal Care service provider the agency must demonstrate the ability to manage both scheduled and unscheduled needs and must be able to initiate services with little or no delay in the designated site. One provider will be selected from the applicants for each designated site.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

As provided in 42 CFR 440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

Service Title:

Individual Support and Community Habilitation

HCBS Taxonomy:

Service Definition (Scope):

Services and supports in a variety of activities that may be provided regularly or intermittently, but not on a 24-hour basis, and are determined necessary to prevent institutionalization. These services may include locating appropriate housing, the acquisition, retention or improvement of skills related to personal finance, health, shopping, use of community resources, community safety, and other social and adaptive skills to live in the community. Individual support and community habilitation provide supports necessary for the individual to establish, live in and maintain a household of their choosing in the community. It may include training and education in self-determination and self-advocacy to enable the individual to acquire skills to exercise control and responsibility over the services and supports they receive, and to become more independent, integrated, and productive in their communities. These services must be provided in-person.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider Specifications:

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Individual Support and Community Habilitation

Provider Category:

Provider Type:

Human Service Agencies

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Any not-for-profit or proprietary organization that responds satisfactorily to the Waiver provider enrollment process and as such, has successfully demonstrated, at a minimum, the following - Education, Training, Supervision: Providers must ensure effective training of staff members in all aspects of their job duties, including handling emergency situations. Providers are responsible for ensuring staff are trained on applicable regulations and policies governing waiver service delivery and the principles of participant centered care. Agencies must have established procedures for appraising staff performance and for effectively modifying poor performance where it exists. - Adherence to Continuous QI Practices: Providers must have established strategies to prevent, detect, and correct problems in the quality of services provided and to achieve service plan goals with individual participants by providing effective, efficient services. Providers must have the ability to meet all quality improvement requirements, as specified by the MassHealth agency or its designee and ability to provide program and participant quality data and reports, as required. - Availability/Responsiveness: Providers must be able to initiate services with little or no delay in the geographical areas they designate. - Confidentiality: Providers must maintain confidentiality and privacy of consumer information in accordance with applicable laws and policies. - Policies/Procedures: Providers must have policies and procedures that include: Participant Not at Home Policy, Participant Emergency in the Home Policy; and that comply with the applicable standards under 105 CMR 155.000 et seq (Department of Public Health regulations addressing patient and resident abuse prevention, reporting, investigation, and registry requirements)for the prevention, reporting and investigation of patient abuse, neglect, and mistreatment, and the misappropriation of patient property by individuals working in or employed by a Individual Support and Community Habilitation agency as well as policies that comply with applicable regulations of the Disabled Persons Protection Commission found at 118 CMR 1.00 to 14.00 (The State’s Division Disabled Persons Protection Commission regulations that describe the purpose, rules, and process regarding abuse allegations for people with disabilities.)and the Elder Abuse Reporting and Protective Services Program found at 651 CMR 5.00 et seq (The Executive Office of Elder Affairs’ Elder Abuse Reporting and Protective Services Program regulations). - Individuals who provide Individual Support and Community Habilitation services must meet requirements for individuals in such roles, including, but not limited to must: have been CORI checked, have a College degree plus experience in providing community-based services to individuals with disabilities, or at least two years comparable community-based, life or work experience providing services to individuals with disabilities; can handle emergency situations; can set limits, and communicate effectively with participants, families, other providers and agencies; have ability to meet legal requirements in protecting confidential information; and certification in CPR is required.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Individual Support and Community Habilitation

Provider Category:

Provider Type:

Health Care Agencies

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Any not-for-profit or proprietary organization that responds satisfactorily to the Waiver provider enrollment process and as such, has successfully demonstrated, at a minimum, the following - Education, Training, Supervision: Providers must ensure effective training of staff members in all aspects of their job duties, including handling emergency situations. Providers are responsible for ensuring staff are trained on applicable regulations and policies governing waiver service delivery and the principles of participant centered care. Agencies must have established procedures for appraising staff performance and for effectively modifying poor performance where it exists. - Adherence to Continuous QI Practices: Providers must have established strategies to prevent, detect, and correct problems in the quality of services provided and to achieve service plan goals with individual participants by providing effective, efficient services. Providers must have the ability to meet all quality improvement requirements, as specified by the MassHealth agency or its designee and ability to provide program and participant quality data and reports, as required. - Availability/Responsiveness: Providers must be able to initiate services with little or no delay in the geographical areas they designate. - Confidentiality: Providers must maintain confidentiality and privacy of consumer information in accordance with applicable laws and policies. - Policies/Procedures: Providers must have policies and procedures that include: Participant Not at Home Policy, Participant Emergency in the Home Policy; and that comply with the applicable standards under 105 CMR 155.000 et seq (Department of Public Health regulations addressing patient and resident abuse prevention, reporting, investigation, and registry requirements)for the prevention, reporting and investigation of patient abuse, neglect, and mistreatment, and the misappropriation of patient property by individuals working in or employed by a Individual Support and Community Habilitation agency as well as policies that comply with applicable regulations of the Disabled Persons Protection Commission found at 118 CMR 1.00 to 14.00 (The State’s Division Disabled Persons Protection Commission regulations that describe the purpose, rules, and process regarding abuse allegations for people with disabilities.)and the Elder Abuse Reporting and Protective Services Program found at 651 CMR 5.00 et seq (The Executive Office of Elder Affairs’ Elder Abuse Reporting and Protective Services Program regulations). - Individuals who provide Individual Support and Community Habilitation services must meet requirements for individuals in such roles, including, but not limited to must: have been CORI checked, have a College degree plus experience in providing community-based services to individuals with disabilities, or at least two years comparable community-based, life or work experience providing services to individuals with disabilities; can handle emergency situations; can set limits, and communicate effectively with participants, families, other providers and agencies; have ability to meet legal requirements in protecting confidential information; and certification in CPR is required.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Individual Support and Community Habilitation

Provider Category:

Provider Type:

Support Worker

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Individuals who provide Individual Support and Community Habilitation services must have responded satisfactorily to the Waiver provider enrollment process, and must meet requirements for individuals in such roles, including, but not limited to must: have been CORI checked, have a College degree plus experience in providing community-based services to individuals with disabilities, or at least two years comparable community-based, life or work experience providing services to individuals with disabilities; can handle emergency situations; can set limits, and communicate effectively with participants, families, other providers and agencies; have ability to meet legal requirements in protecting confidential information; certification in CPR is required.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

As provided in 42 CFR 440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

Service Title:

Medication Administration

HCBS Taxonomy:

Service Definition (Scope):

Medication administration is the injection of intramuscular psychotherapeutic medication by qualified personnel and provided in an ambulatory care setting. These services are not otherwise covered in the Medicaid State Plan.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider Specifications:

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Medication Administration

Provider Category:

Provider Type:

Medication Administration Providers

Provider Qualifications

License (specify):

This service can be provided in Massachusetts Department of Public Health licensed outpatient departments in acute care hospitals in accordance with 105 CMR 130.000 (Department of Public Health Hospital Licensure Regulations that describe the standards for the maintenance and operations of hospitals in Massachusetts); or in a Massachusetts Department of Public Health licensed clinic in accordance with 105 CMR 140.00 (Department of Public Health regulations regarding the standards for the licensure of clinics in Massachusetts). Qualified personnel include nurses licensed in accordance with 244 CMR (Board of Registration in Nursing regulations governs the education and practice requirements applicable to nurses practicing in the expanded role), physician assistants license in accordance with 263 CMR (Board of Registration of Physician Assistants regulations describe the settings in which a physician assistant may properly work, the types of clinical activities in which a physician assistant may engage, the level of skill expected of the physician assistant, the nature and extent of the supervision required of the supervising licensed physician, and the allocation of liability for the acts or omissions of a physician assistant)and physicians licensed in accordance with 243 CMR (Board of Registration in Medicine regulations provide directions concerning licensing and the practice of medicine).

Certificate (specify):

Other Standard (specify):

Verification of Provider Qualifications

Entity Responsible for Verification:

Department of Public Health.

Frequency of Verification:

Every two years.

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

As provided in 42 CFR 440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

Service Title:

Occupational Therapy

HCBS Taxonomy:

Service Definition (Scope):

Occupational Therapy services, including the performance of a maintenance program beyond the scope of coverage in the State plan, provided by a licensed occupational therapist. Occupational therapy programs are designed to improve the quality of life by recovering competence, preventing further injury or disability, and to improve the individual’s ability to perform tasks required for independent functioning, so that the individual can engage in activities of daily living. Services must be considered by the therapist to be necessary for the participant either to improve, develop, correct, rehabilitate, or prevent the worsening of physical, cognitive or sensory functions that have been lost, impaired or reduced as a result of acute or chronic medical conditions, congenital anomalies or injuries; or required to maintain or prevent the worsening of function. Services may also include the training and oversight necessary for the participant, family member or other person, to carry out the maintenance program. The provider qualifications specified in the State plan apply. Occupational Therapy services must be authorized by the Case Manager in the service plan. This service is not subject to the Medical Referral Requirements found at 130 CMR 432.415 (MassHealth Therapist Regulations that describe the medical referral requirements necessary as a prerequisite to MassHealth payment) or the requirements for Prior Authorization found in the following regulations: 130 CMR 432.417 (MassHealth Therapist Regulations that describe the prior authorization process for therapy services) or 130 CMR 410.408 (MassHealth Chronic Disease and Rehabilitation Outpatient Hospital Regulations that describe the prior authorization process for therapy services) or 130 CMR 403.413 (MassHealth Home Health Agency Regulations that describe the prior authorization process for therapy services) or 130 CMR 430.601 (MassHealth Rehabilitation Center Regulations that describe the prior authorization process for therapy services). This service can not be provided in Adult Day Health or when the participant is receiving other services that include occupational therapy as part of the program. MassHealth All Provider regulations at 130 CMR 450.140 through 149 detail the ESPDT requirements for MassHealth providers and the MassHealth provider manuals for therapists services lists EPSDT screening schedules at Appendix W.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

These services are subject to the Service Limitations included in 130 CMR 432. 414 (A) and (B) (MassHealth Therapist Regulations that describe the service limitations for therapy treatment per day). No more than one individual treatment and one group therapy session per day may be authorized. Payment will not be made for a treatment claimed for the same date of service as a comprehensive evaluation.

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider Specifications:

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Occupational Therapy

Provider Category:

Provider Type:

Occupational Therapist

Provider Qualifications

License (specify):

Occupational Therapist licensed in accordance with 130 CMR 432.000 (MassHealth Therapist Regulations that define provider eligibility requirements and program rules).

Certificate (specify):

Other Standard (specify):

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Occupational Therapy

Provider Category:

Provider Type:

Chronic Disease and Rehabilitation Inpatient and Outpatient Hospital

Provider Qualifications

License (specify):

The hospital must be licensed as a Chronic Disease and Rehabilitation Inpatient Hospital in accordance with 130 CMR 435.000 (MassHealth Chronic Disease and Rehabilitation Inpatient Regulations that describe the provider eligibility requirements) or as a Chronic Disease and Rehabilitation Outpatient Hospital in accordance with 130 CMR 410.000 (MassHealth Chronic Disease and Rehabilitation Outpatient Regulations that describe the provider eligibility requirements)

Certificate (specify):

Other Standard (specify):

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Occupational Therapy

Provider Category:

Provider Type:

Health Care Agencies

Provider Qualifications

License (specify):

The agency must be licensed as a Group Practice in accordance with 130 CMR 432.404 (MassHealth Therapist Regulations that describe the provider eligibility requirements for in-State therapy providers)or as a Rehabilitation Center in accordance with 130 CMR 430.600 (MassHealth Rehabilitation Center Regulations that define provider eligibility requirements and program rules) or as a Home Health Agency in accordance with 130 CMR 403.000 (MassHealth Home Health Agency regulations that define provider eligibility requirements and program rules). Services must be performed by an Occupational Therapist licensed in accordance with 130 CMR 432.000 (MassHealth Therapist Regulations that define provider eligibility requirements and program rules)

Certificate (specify):

Other Standard (specify):

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

As provided in 42 CFR 440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

Service Title:

Peer Support

HCBS Taxonomy:

Service Definition (Scope):

Peer Support is designed to provide training, instruction and mentoring to individuals about self-advocacy, participant direction, civic participation, leadership, benefits, and participation in the community. Peer support may be provided in small groups or peer support may involve one peer providing support to another peer, the waiver participant, to promote and support the waiver participant's ability to participate in self-advocacy. The one to one peer support is instructional; it is not counseling. The service enhances the skills of the individual to function in the community and/or family home. Documentation in the individual's record demonstrates the benefit to the individual. This service may be self-directed.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

Not to exceed 16 hours per week.

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider Specifications:

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Peer Support

Provider Category:

Provider Type:

Individual Peer Support Specialist

Provider Qualifications

License (specify):

Certificate (specify):

Relevant competencies and experiences in Peer Support.

Other Standard (specify):

Applicants must possess appropriate qualifications to serve as staff as evidenced by interview(s), two personal and or professional references and a Criminal Offense Records Inquiry (CORI). The applicant must have the ability to communicate effectively in the language and communication style of the participant to whom they are providing training; Must have experience in providing peer support, self-advocacy, and skills training and independence; Minimum of 18 years of age; Be knowledgeable about what to do in an emergency; Be knowledgeable about how to report abuse and neglect; Must maintain confidentiality and privacy of consumer information; Must be respectful and accept different values, nationalities, races, religions, cultures and standards of living. Specific competencies needed by an individual provider to meet the support needs of the participant will be delineated in the Support Plan by the Team.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Every 2 years

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Peer Support

Provider Category:

Provider Type:

Peer Support Agencies

Provider Qualifications

License (specify):

Agency needs to employ individuals who meet all relevant state and federal licensure or certification requirements in their discipline.

Certificate (specify):

If the agency is providing activities where certification is necessary, the applicant will have the necessary certifications.

Other Standard (specify):

Any not-for-profit or proprietary organization that responds satisfactorily to the Waiver provider enrollment process and as such, has successfully demonstrated, at a minimum, the following - Education, Training, Supervision: Providers must ensure effective training of staff members in all aspects of their job duties, including handling emergency situations. Providers are responsible for ensuring staff are trained on applicable regulations and policies governing waiver service delivery and the principles of participant centered care. Agencies must have established procedures for appraising staff performance and for effectively modifying poor performance where it exists. - Adherence to Continuous QI Practices: Providers must have established strategies to prevent, detect, and correct problems in the quality of services provided and to achieve service plan goals with individual participants by providing effective, efficient services. Providers must have the ability to meet all quality improvement requirements, as specified by the MassHealth agency or its designee and ability to provide program and participant quality data and reports, as required. - Availability/Responsiveness: Providers must be able to initiate services with little or no delay in the geographical areas they designate. - Confidentiality: Providers must maintain confidentiality and privacy of consumer information in accordance with applicable laws and policies. - Policies/Procedures: Providers must have policies and procedures that include: Participant Emergency in the Home Policy; and that comply with the applicable standards under 105 CMR 155 et seq (Department of Public Health regulations addressing patient and resident abuse prevention, reporting, investigation, and registry requirements) for the prevention, reporting and investigation of patient abuse, neglect, and mistreatment, and the misappropriation of patient property by individuals working in or employed by a Peer Support Agency as well as policies that comply with applicable regulations of the Disabled Persons Protection Commission found at 118 CMR 1.00 to 14.00 (The State’s Division Disabled Persons Protection Commission regulations that describe the purpose, rules, and process regarding abuse allegations for people with disabilities) and the Elder Abuse Reporting and Protective Services Program found at 651 CMR 5.00 et seq (The Executive Office of Elder Affairs’ Elder Abuse Reporting and Protective Services Program regulations). - Individuals who provide Peer Support Services must meet requirements for individuals in such roles, including, but not limited to must: have been CORI checked; can handle emergency situations; can set limits, and communicate effectively with participants, other providers and agencies; have ability to meet legal requirements in protecting confidential information. The agency must employ individuals who are self-advocates and supporters and who are able to effectively communicate in the language and communication style of the individual for whom they are providing the training. Staff members providing Peer Support must have experience in providing peer support, self-advocacy, and skills training and independence.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Every 2 years

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

As provided in 42 CFR 440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

Service Title:

Physical Therapy

HCBS Taxonomy:

Service Definition (Scope):

Physical Therapy services, including the performance of a maintenance program beyond the scope of coverage in the State plan, provided by a licensed physical therapist. Services must be considered by the therapist to be necessary for the participant either to improve, develop, correct, rehabilitate, or prevent the worsening of the physical functions that have been lost, impaired or reduced as a result of acute or chronic medical conditions, congenital anomalies or injuries; or required to maintain or prevent the worsening of function. Services may also include the training and oversight necessary for the participant, family member or other person, to carry out the maintenance program. The provider qualifications specified in the State plan apply. Physical Therapy services must be authorized by the Case Manager in the service plan. This service is not subject to the Medical Referral Requirements found at 130 CMR 432.415 (MassHealth Therapist Regulations that describe the medical referral requirements necessary as a prerequisite to MassHealth payment) or the requirements for Prior Authorization found in the following regulations: 130 CMR 432.417 (MassHealth Therapist Regulations that describe the prior authorization process for therapy services) or 130 CMR 410.408 (MassHealth Chronic Disease and Rehabilitation Outpatient Hospital Regulations that describe the prior authorization process for therapy services) or 130 CMR 403.413 (MassHealth Home Health Agency Regulations that describe the prior authorization process for therapy services) or 130 CMR 430.601 (MassHealth Rehabilitation Center Regulations that describe the prior authorization process for therapy services). This service can not be provided in Adult Day Health or when the participant is receiving other services that include physical therapy as part of the program. MassHealth All Provider regulations at 130 CMR 450.140 through 149 detail the ESPDT requirements for MassHealth providers and the MassHealth provider manuals for therapists services lists EPSDT screening schedules at Appendix W.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider Specifications:

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Physical Therapy

Provider Category:

Provider Type:

Health Care Agencies

Provider Qualifications

License (specify):

The agency must be licensed as a Group Practice in accordance with 130 CMR 432.404 (MassHealth Therapist Regulations that describe the provider eligibility requirements for in-State therapy providers)or as a Rehabilitation Center in accordance with 130 CMR 430.600 (MassHealth Rehabilitation Center Regulations that define provider eligibility requirements and program rules) or as a Home Health Agency in accordance with 130 CMR 403.000 (MassHealth Home Health Agency regulations that define provider eligibility requirements and program rules). Services must be performed by a Physical Therapist licensed in accordance with 130 CMR 432.000 (MassHealth Therapist Regulations that define provider eligibility requirements and program rules).

Certificate (specify):

Other Standard (specify):

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Physical Therapy

Provider Category:

Provider Type:

Chronic Disease and Rehabilitation Inpatient and Outpatient Hospital

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Physical Therapy

Provider Category:

Provider Type:

Physical Therapist

Provider Qualifications

License (specify):

Physical Therapist licensed in accordance with 130 CMR 432.000 (MassHealth Therapist Regulations that define provider eligibility requirements and program rules).

Certificate (specify):

Other Standard (specify):

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

As provided in 42 CFR 440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

Service Title:

Shared Home Supports

HCBS Taxonomy:

Service Definition (Scope):

Shared Home Supports is an option that matches a participant with a Shared Home Supports caregiver. This arrangement is overseen by a Residential Support Agency. The match between participant and caregiver is the keystone to the success of this model. Shared Home Supports includes supportive services that assist with the acquisition, retention, or improvement of skills related to living in the community. This includes such supports as: adaptive skill development, assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs), adult educational supports, social and leisure skill development. Shared Home Supports integrates the participant into the usual activities of the caregivers family life. In addition, there will be opportunities for learning, developing and maintaining skills which may include the areas of ADLs, IADLs, social and recreation activities, and personal enrichment. The Residential Support Agency provides regular and ongoing oversight and supervision of the caregiver. The caregiver lives with the participant at the residence of the caregiver or the participant. Shared Home Supports provides daily structure, skills training and supervision, but does not include 24-hour care. Shared Home Supports agencies recruit caregivers, assess their abilities, coordinate placement of participant or caregiver, train and provide guidance, supervision and oversight for caregivers and provider oversight of participants living situations. The caregiver may not be a legally responsible family member. Duplicative waiver and state plan services are not available to participants receiving Shared Home Supports services. Shared Home Supports services are not available to individuals who live with their immediate family unless the family member is not legally responsible for the individual and is employed as the caregiver, or the immediate family member (grandparent, parent, sibling or spouse) is also eligible for shared home supports and had received prior authorization, as applicable. Payment is not made for the cost of room and board, including the cost of building maintenance, upkeep and improvement. The method by which the costs of room and board are excluded from payment is specified in Appendix I-5. Shared Home Supports may be provided to no more than two participants in a home.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider Specifications:

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Shared Home Supports

Provider Category:

Provider Type:

Residential Support Agencies

Provider Qualifications

License (specify):

115 CMR 7.00 (Department of Developmental Services Standards for all Services and Supports) and 115 CMR 8.00 (Department of Developmental Services Certification, Licensing and Enforcement Regulations) or 104 CMR Chapter 28 (Department of Mental Health regulations governing Licensing and Operational Standards for Community Programs).

Certificate (specify):

Residential Support Agencies Provider employees must have a High School diploma, GED or relevant equivalencies or competencies.

Other Standard (specify):

Residential Support Agencies must be licensed by the Department of Developmental Services. Residential Support Agencies Provider employees must possess appropriate qualifications as evidenced by interview(s), two personal or professional references and a Criminal Offense Records Inquiry (CORI), be age 18 years or older, be knowledgeable about what to do in an emergency; be knowledgeable about how to report abuse and neglect, have the ability to communicate effectively in the language and communication style of the participant, maintain confidentiality and privacy of the consumer, respect and accept different values, nationalities, races, religions, cultures and standards of living.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Services Organization

Frequency of Verification:

every two years

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

As provided in 42 CFR 440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

Service Title:

Skilled Nursing

HCBS Taxonomy:

Service Definition (Scope):

Services listed in the service plan that are within the scope of the State's Nurse Practice Act and are provided by a Registered Nurse or a Licensed Practical Nurse with a valid Massachusetts license. Skilled nursing services under the waiver differ in nature, scope, supervision arrangements, or provider type (including provider training and qualifications) from skilled nursing services in the State plan. The differences from the State plan are as follows: 1) Agencies that provide Skilled Nursing services under the waiver do not need to meet the requirements for participation in Medicare, as provided in 42 CFR §489.28. MassHealth All Provider regulations at 130 CMR 450.140 through 149 detail the ESPDT requirements for MassHealth providers and the MassHealth provider manual for nursing services lists EPSDT screening schedules at Appendix W.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

This service is limited to one Skilled Nursing visit per week. The State may grant exceptions to the limit on a temporary basis to facilitate transitions to a community setting, to ensure that an individual at risk for medical facility admission is able to remain in the community, or to otherwise stabilize a participants medical condition.

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider Specifications:

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Skilled Nursing

Provider Category:

Provider Type:

Home Health Agencies

Provider Qualifications

License (specify):

Skilled Nursing services must be performed by a Registered Nurse or a Licensed Practical Nurse with a valid Massachusetts license.

Certificate (specify):

Other Standard (specify):

Any not-for-profit or proprietary organization that responds satisfactorily to the Waiver provider enrollment process and as such, has successfully demonstrated, at a minimum, the following - Education, Training, Supervision: Providers must ensure effective training of staff members in all aspects of their job duties, including handling emergency situations. Providers are responsible for ensuring staff are trained on applicable regulations and policies governing waiver service delivery and the principles of participant centered care. Agencies must have established procedures for appraising staff performance and for effectively modifying poor performance where it exists. - Adherence to Continuous QI Practices: Providers must have established strategies to prevent, detect, and correct problems in the quality of services provided and to achieve service plan goals with individual participants by providing effective, efficient services. Providers must have the ability to meet all quality improvement requirements, as specified by the MassHealth agency or its designee and ability to provide program and participant quality data and reports, as required. - Availability/Responsiveness: Providers must be able to initiate services with little or no delay in the geographical areas they designate. - Confidentiality: Providers must maintain confidentiality and privacy of consumer information in accordance with applicable laws and policies. - Policies/Procedures: Providers must have policies and procedures that include: Participant Not at Home Policy, Participant Emergency in the Home Policy; and that comply with the applicable standards under 105 CMR 155 et seq (Department of Public Health regulations addressing patient and resident abuse prevention, reporting, investigation, and registry requirements) for the prevention, reporting and investigation of patient abuse, neglect, and mistreatment, and the misappropriation of patient property by individuals working in or employed by a Home Health Agency as well as policies that comply with applicable regulations of the Disabled Persons Protection Commission found at 118 CMR 1.00 to 14.00 (The State’s Division Disabled Persons Protection Commission regulations that describe the purpose, rules, and process regarding abuse allegations for people with disabilities) and the Elder Abuse Reporting and Protective Services Program found at 651 CMR 5.00 et seq (The Executive Office of Elder Affairs’ Elder Abuse Reporting and Protective Services Program regulations). - Individuals who provide Skilled Nursing Services must meet requirements for individuals in such roles, including, but not limited to must: have been CORI checked; experience providing services to individuals with disabilities; can handle emergency situations; can set limits, and communicate effectively with participants, families, other providers and agencies; have ability to meet legal requirements in protecting confidential information.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Skilled Nursing

Provider Category:

Provider Type:

Homemaker/Personal Care Agencies

Provider Qualifications

License (specify):

Skilled Nursing services must be performed by a Registered Nurse or a Licensed Practical Nurse with a valid Massachusetts license.

Certificate (specify):

Other Standard (specify):

Any not-for-profit or proprietary organization that responds satisfactorily to the Waiver provider enrollment process and as such, has successfully demonstrated, at a minimum, the following - Education, Training, Supervision: Providers must ensure effective training of staff members in all aspects of their job duties, including handling emergency situations. Providers are responsible for ensuring staff are trained on applicable regulations and policies governing waiver service delivery and the principles of participant centered care. Agencies must have established procedures for appraising staff performance and for effectively modifying poor performance where it exists. - Adherence to Continuous QI Practices: Providers must have established strategies to prevent, detect, and correct problems in the quality of services provided and to achieve service plan goals with individual participants by providing effective, efficient services. Providers must have the ability to meet all quality improvement requirements, as specified by the MassHealth agency or its designee and ability to provide program and participant quality data and reports, as required. - Availability/Responsiveness: Providers must be able to initiate services with little or no delay in the geographical areas they designate. - Confidentiality: Providers must maintain confidentiality and privacy of consumer information in accordance with applicable laws and policies. - Policies/Procedures: Providers must have policies and procedures that include: Participant Not at Home Policy, Participant Emergency in the Home Policy; and that comply with the applicable standards under 105 CMR 155 et seq (Department of Public Health regulations addressing patient and resident abuse prevention, reporting, investigation, and registry requirements) for the prevention, reporting and investigation of patient abuse, neglect, and mistreatment, and the misappropriation of patient property by individuals working in or employed by a Home Health Agency as well as policies that comply with applicable regulations of the Disabled Persons Protection Commission found at 118 CMR 1.00 to 14.00 (The State’s Division Disabled Persons Protection Commission regulations that describe the purpose, rules, and process regarding abuse allegations for people with disabilities) and the Elder Abuse Reporting and Protective Services Program found at 651 CMR 5.00 et seq (The Executive Office of Elder Affairs’ Elder Abuse Reporting and Protective Services Program regulations). - Individuals who provide Skilled Nursing Services must meet requirements for individuals in such roles, including, but not limited to must: have been CORI checked; experience providing services to individuals with disabilities; can handle emergency situations; can set limits, and communicate effectively with participants, families, other providers and agencies; have ability to meet legal requirements in protecting confidential information.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

As provided in 42 CFR 440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

Service Title:

Specialized Medical Equipment

HCBS Taxonomy:

Service Definition (Scope):

Specialized Medical Equipment includes: (a) devices, controls, or appliances, specified in the plan of care, that enable participants to increase their ability to perform activities of daily living; (b) devices, controls, or appliances that enable the participant to perceive, control, or communicate with the environment in which they live; (c) items necessary for life support or to address physical conditions along with ancillary supplies and equipment necessary to the proper functioning of such items; (d) such other durable and non-durable medical equipment not available under the State plan that is necessary to address participant functional limitations; and, (e) necessary medical supplies not available under the State plan. In addition to the acquisition of the Specialized Medical Equipment itself this service may include: - Evaluations necessary for the selection, design, fitting or customizing of the equipment needs of a participant - Customization, adaptations, fitting, set-up, maintenance or repairs to the equipment or devices - Temporary replacement of equipment - Training or technical assistance for the participant, or, where appropriate, the family members, guardians, or other caregivers of the participant on the use and maintenance of the equipment or devices. 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. This service does not include vehicle modifications or home accessibility adaptations.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider Specifications:

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Specialized Medical Equipment

Provider Category:

Provider Type:

Pharmacies

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Any not-for-profit or proprietary organization that responds satisfactorily to the Waiver provider enrollment process and as such, has successfully demonstrated, at a minimum, the following: - Providers shall ensure that individual workers employed by the agency have been CORI checked, and are able to perform assigned duties and responsibilities. - Providers of specialized medical equipment and supplies must ensure that all devices and supplies have been examined and/or tested by Underwriters Laboratory (or other appropriate organization), and comply with FCC regulations, as appropriate.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Every 2 years

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Specialized Medical Equipment

Provider Category:

Provider Type:

Medical Equipment Suppliers

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Any not-for-profit or proprietary organization that responds satisfactorily to the Waiver provider enrollment process and as such, has successfully demonstrated, at a minimum, the following: - Providers shall ensure that individual workers employed by the agency have been CORI checked, and are able to perform assigned duties and responsibilities. - Providers of specialized medical equipment and supplies must ensure that all devices and supplies have been examined and/or tested by Underwriters Laboratory (or other appropriate organization), and comply with FCC regulations, as appropriate.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Every 2 years

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Specialized Medical Equipment

Provider Category:

Provider Type:

Assistive Technology Agencies

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Any not-for-profit or proprietary organization that responds satisfactorily to the Waiver provider enrollment process and as such, has successfully demonstrated, at a minimum, the following: - Providers shall ensure that individual workers employed by the agency have been CORI checked, and are able to perform assigned duties and responsibilities. - Providers of specialized medical equipment and supplies must ensure that all devices and supplies have been examined and/or tested by Underwriters Laboratory (or other appropriate organization), and comply with FCC regulations, as appropriate. Staff providing services must have: - Bachelors degree in a related technological field and at least one year of demonstrated experience providing adaptive technological assessment or training; or - A bachelors degree in a related health or human service field with at least two years of demonstrated experience providing adaptive technological assessment or training; or - Three years of demonstrated experience providing adaptive technological assessment or training. Individuals providing services must also have: - Knowledge and experience in the evaluation of the needs of an individual with a disability, including functional evaluation of the individual in the individuals customary environment. - Knowledge and experience in the purchasing, or otherwise providing for the acquisition of assistive technology devices by individuals with disabilities. - Knowledge and/or experience in selecting, designing, fitting, customizing, adapting, applying, maintaining, repairing, or replacing assistive technology devices. - Knowledge and/or experience in coordinating and using other therapies, interventions, or services with assistive technology devices. - Knowledge and/or experience in training or providing technical assistance for an individual with disabilities, or, when appropriate, the family of an individual with disabilities or others providing support to the individual. - Knowledge and/or experience in training and/or providing technical assistance for professionals or other individuals whom provide services to or are otherwise substantially involved in the major life functions of individuals with disabilities.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Every 2 years

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Specialized Medical Equipment

Provider Category:

Provider Type:

Individual Assistive Technology Provider

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Individuals who provide Assistive Technology services must have responded satisfactorily to the Waiver provider enrollment process and must meet requirements for individuals in such roles, including, but not limited to must: have been CORI checked and communicate effectively with participants, families, other providers and agencies; have ability to meet legal requirements in protecting confidential information. Individuals providing services must have: - Bachelors degree in a related technological field and at least one year of demonstrated experience providing adaptive technological assessment or training; or - A bachelors degree in a related health or human service field with at least two years of demonstrated experience providing adaptive technological assessment or training; or - Three years of demonstrated experience providing adaptive technological assessment or training. Individuals providing services must also have: - Knowledge and experience in the evaluation of the needs of an individual with a disability, including functional evaluation of the individual in the individuals customary environment. - Knowledge and experience in the purchasing, or otherwise providing for the acquisition of assistive technology devices by individuals with disabilities. - Knowledge and/or experience in selecting, designing, fitting, customizing, adapting, applying, maintaining, repairing, or replacing assistive technology devices. - Knowledge and/or experience in coordinating and using other therapies, interventions, or services with assistive technology devices. - Knowledge and/or experience in training or providing technical assistance for an individual with disabilities, or, when appropriate, the family of an individual with disabilities or others providing support to the individual. - Knowledge and/or experience in training and/or providing technical assistance for professionals or other individuals whom provide services to or are otherwise substantially involved in the major life functions of individuals with disabilities.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Every 2 years

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

As provided in 42 CFR 440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

Service Title:

Speech Therapy

HCBS Taxonomy:

Service Definition (Scope):

Speech Therapy services, including the performance of a maintenance program beyond the scope of coverage in the State plan, provided by a licensed speech therapist. Services must be considered by the therapist to be necessary for the participant either to improve, develop, correct, rehabilitate, or prevent the worsening of speech/language communication and swallowing disorders that have been lost, impaired or reduced as a result of acute or chronic medical conditions, congenital anomalies or injuries; or required to maintain or prevent the worsening of function. Services may also include the training and oversight necessary for the participant, family member or other person, to carry out the maintenance program. The provider qualifications specified in the State plan apply. Speech Therapy services must be authorized by the Case Manager in the service plan. This service is not subject to the Medical Referral Requirements found at 130 CMR 413.419 (MassHealth Speech and Hearing Center Regulations that describe the medical referral requirements necessary as a prerequisite for MassHealth payment)or the requirements for Prior Authorization found in the following regulations: 130 CMR 413.408 (MassHealth Speech and Hearing Center Regulations that describes the prior authorization process for therapy services) or 130 CMR 432.417 (MassHealth Therapist Regulations that describe the prior authorization process for therapy services) or 130 CMR 410.408 (MassHealth Chronic Disease and Rehabilitation Outpatient Hospital Regulations that describe the prior authorization process for therapy services) or 130 CMR 403.413 (MassHealth Home Health Agency Regulations that describe the prior authorization process for therapy services) or 130 CMR 430.601 (MassHealth Rehabilitation Center Regulations that describe the prior authorization process for therapy services).. This service can not be provided in Adult Day Health or when the participant is receiving other services that include speech therapy as part of the program. MassHealth All Provider regulations at 130 CMR 450.140 through 149 detail the ESPDT requirements for MassHealth providers and the MassHealth provider manuals for therapists services lists EPSDT screening schedules at Appendix W.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

These services are subject to the Service Limitations included in 130 CMR 413. 418 (A) and (B)(MassHealth Speech and Hearing Center Regulations that describe the prior authorization process for therapy services). No more than one individual treatment and one group therapy session per day may be authorized. Payment will not be made for a treatment claimed for the same date of service as a comprehensive evaluation.

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider Specifications:

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Speech Therapy

Provider Category:

Provider Type:

Speech/Language Therapist (Speech/Language Pathologist)

Provider Qualifications

License (specify):

Speech/Language Therapist licensed in accordance with 130 CMR 432.000 (MassHealth Therapist Regulations that define provider eligibility requirements and program rules).

Certificate (specify):

Other Standard (specify):

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Speech Therapy

Provider Category:

Provider Type:

Chronic Disease and Rehabilitation Inpatient and Outpatient Hospital

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Speech Therapy

Provider Category:

Provider Type:

Health Care Agencies

Provider Qualifications

License (specify):

The agency must be licensed as a Speech and Hearing Center Group Practice in accordance with 130 CMR 413.404 (MassHealth Speech and Hearing Center Regulations that describe the provider eligibility requirements) or as a Group Practice in accordance with 130 CMR 432.404 (MassHealth Therapist Regulations that describe the provider eligibility requirements for therapy providers) or as a Rehabilitation Center in accordance with 130 CMR 430.600 (MassHealth Rehabilitation Center Regulations that define provider eligibility requirements and program rules) or as a Home Health Agency in accordance with 130 CMR 403.000 (MassHealth Home Health Agency regulations that define provider eligibility requirements and program rules). Services must be performed by a Speech/Language Therapist licensed in accordance with 130 CMR 432.000 (MassHealth Therapist Regulations that define provider eligibility requirements and program rules).

Certificate (specify):

Other Standard (specify):

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

As provided in 42 CFR 440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

Service Title:

Supportive Home Care Aide

HCBS Taxonomy:

Service Definition (Scope):

Supportive Home Care Aides perform personal care and/or homemaking services in accordance with waiver definitions, in addition to providing emotional support, socialization, and accompanying the participant to community activities and appointments. These services are provided to Participants with Alzheimer’s Disease/Dementia or behavioral health needs.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider Specifications:

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Supportive Home Care Aide

Provider Category:

Provider Type:

Human Services Agencies

Provider Qualifications

License (specify):

Certificate (specify):

Individuals employed by the agency to provide supportive home care aide services must have one of the following: - Certificate of Home Health Aide Training - Certificate of Nurse's Aide Training

Other Standard (specify):

Any not-for-profit or proprietary organization that responds satisfactorily to the Waiver provider enrollment process and as such, has successfully demonstrated, at a minimum, the following - Education, Training, Supervision: Providers must ensure effective training of staff members in all aspects of their job duties, including handling emergency situations. Providers are responsible for ensuring staff are trained on applicable regulations and policies governing waiver service delivery and the principles of participant centered care. Agencies must have established procedures for appraising staff performance and for effectively modifying poor performance where it exists. - Adherence to Continuous QI Practices: Providers must have established strategies to prevent, detect, and correct problems in the quality of services provided and to achieve service plan goals with individual participants by providing effective, efficient services. Providers must have the ability to meet all quality improvement requirements, as specified by the MassHealth agency or its designee and ability to provide program and participant quality data and reports, as required. - Availability/Responsiveness: Providers must be able to initiate services with little or no delay in the geographical areas they designate. - Confidentiality: Providers must maintain confidentiality and privacy of consumer information in accordance with applicable laws and policies. - Policies/Procedures: Providers must have policies and procedures that include: Participant Not at Home Policy, Participant Emergency in the Home Policy; and that comply with the applicable standards under 105 CMR 155 et seq (Department of Public Health regulations addressing patient and resident abuse prevention, reporting, investigation, and registry requirements) for the prevention, reporting and investigation of patient abuse, neglect, and mistreatment, and the misappropriation of patient property by individuals working in or employed by a Homemaker/Personal Care Agency as well as policies that comply with applicable regulations of the Disabled Persons Protection Commission found at 118 CMR 1.00 to 14.00 (The State’s Division Disabled Persons Protection Commission regulations that describe the purpose, rules, and process regarding abuse allegations for people with disabilities) and the Elder Abuse Reporting and Protective Services Program found at 651 CMR 5.00 et seq (The Executive Office of Elder Affairs’ Elder Abuse Reporting and Protective Services Program regulations). - Individuals who provide Supportive Home Care Aide Services must meet requirements for individuals in such roles, including, but not limited to must: have been CORI checked; experience providing services to individuals with disabilities; can handle emergency situations; can set limits, and communicate effectively with participants, families, other providers and agencies; have ability to meet legal requirements in protecting confidential information; certification in CPR is required. In addition to the required certificate, individual Supportive Home Care Aides must have completed at least one of the following: - An additional 12 hours of training in the area of serving participants with behavioral health needs; or - The 12-hour training developed by the Alzheimers Association, Massachusetts Chapter on serving participants with Alzheimer's disease or related disorders. If the service involves transporting the participant, the Supportive Home Care Aide must have a valid driver’s license and vehicle insurance.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Every 2 years

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Supportive Home Care Aide

Provider Category:

Provider Type:

Homemaker/Personal Care Agencies

Provider Qualifications

License (specify):

Certificate (specify):

Individuals employed by the agency to provide supportive home care aide services must have one of the following: - Certificate of Home Health Aide Training - Certificate of Nurses Aide Training

Other Standard (specify):

Any not-for-profit or proprietary organization that responds satisfactorily to the Waiver provider enrollment process and as such, has successfully demonstrated, at a minimum, the following - Education, Training, Supervision: Providers must ensure effective training of staff members in all aspects of their job duties, including handling emergency situations. Providers are responsible for ensuring staff are trained on applicable regulations and policies governing waiver service delivery and the principles of participant centered care. Agencies must have established procedures for appraising staff performance and for effectively modifying poor performance where it exists. - Adherence to Continuous QI Practices: Providers must have established strategies to prevent, detect, and correct problems in the quality of services provided and to achieve service plan goals with individual participants by providing effective, efficient services. Providers must have the ability to meet all quality improvement requirements, as specified by the MassHealth agency or its designee and ability to provide program and participant quality data and reports, as required. - Availability/Responsiveness: Providers must be able to initiate services with little or no delay in the geographical areas they designate. - Confidentiality: Providers must maintain confidentiality and privacy of consumer information in accordance with applicable laws and policies. - Policies/Procedures: Providers must have policies and procedures that include: Participant Not at Home Policy, Participant Emergency in the Home Policy; and that comply with the applicable standards under 105 CMR 155 et seq (Department of Public Health regulations addressing patient and resident abuse prevention, reporting, investigation, and registry requirements) for the prevention, reporting and investigation of patient abuse, neglect, and mistreatment, and the misappropriation of patient property by individuals working in or employed by a Homemaker/Personal Care Agency as well as policies that comply with applicable regulations of the Disabled Persons Protection Commission found at 118 CMR 1.00 to 14.00 (The State’s Division Disabled Persons Protection Commission regulations that describe the purpose, rules, and process regarding abuse allegations for people with disabilities) and the Elder Abuse Reporting and Protective Services Program found at 651 CMR 5.00 et seq (The Executive Office of Elder Affairs’ Elder Abuse Reporting and Protective Services Program regulations). - Individuals who provide Supportive Home Care Aide Services must meet requirements for individuals in such roles, including, but not limited to must: have been CORI checked; experience providing services to individuals with disabilities; can handle emergency situations; can set limits, and communicate effectively with participants, families, other providers and agencies; have ability to meet legal requirements in protecting confidential information; certification in CPR is required. In addition to the required certificate, individual Supportive Home Care Aides must have completed at least one of the following: - An additional 12 hours of training in the area of serving participants with behavioral health needs; or - The 12-hour training developed by the Alzheimer's Association, Massachusetts Chapter on serving participants with Alzheimers disease or related disorders. If the service involves transporting the participant, the Supportive Home Care Aide must have a valid driver’s license and vehicle insurance.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Every 2 years

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Supportive Home Care Aide

Provider Category:

Provider Type:

Home Health Agencies

Provider Qualifications

License (specify):

Certificate (specify):

Individuals employed by the agency to provide supportive home care aide services must have one of the following: - Certificate of Home Health Aide Training - Certificate of Nurses Aide Training

Other Standard (specify):

Any not-for-profit or proprietary organization that responds satisfactorily to the Waiver provider enrollment process and as such, has successfully demonstrated, at a minimum, the following - Education, Training, Supervision: Providers must ensure effective training of staff members in all aspects of their job duties, including handling emergency situations. Providers are responsible for ensuring staff are trained on applicable regulations and policies governing waiver service delivery and the principles of participant centered care. Agencies must have established procedures for appraising staff performance and for effectively modifying poor performance where it exists. - Adherence to Continuous QI Practices: Providers must have established strategies to prevent, detect, and correct problems in the quality of services provided and to achieve service plan goals with individual participants by providing effective, efficient services. Providers must have the ability to meet all quality improvement requirements, as specified by the MassHealth agency or its designee and ability to provide program and participant quality data and reports, as required. - Availability/Responsiveness: Providers must be able to initiate services with little or no delay in the geographical areas they designate. - Confidentiality: Providers must maintain confidentiality and privacy of consumer information in accordance with applicable laws and policies. - Policies/Procedures: Providers must have policies and procedures that include: Participant Not at Home Policy, Participant Emergency in the Home Policy; and that comply with the applicable standards under 105 CMR 155 et seq (Department of Public Health regulations addressing patient and resident abuse prevention, reporting, investigation, and registry requirements) for the prevention, reporting and investigation of patient abuse, neglect, and mistreatment, and the misappropriation of patient property by individuals working in or employed by a Homemaker/Personal Care Agency as well as policies that comply with applicable regulations of the Disabled Persons Protection Commission found at 118 CMR 1.00 to 14.00 (The State’s Division Disabled Persons Protection Commission regulations that describe the purpose, rules, and process regarding abuse allegations for people with disabilities) and the Elder Abuse Reporting and Protective Services Program found at 651 CMR 5.00 et seq (The Executive Office of Elder Affairs’ Elder Abuse Reporting and Protective Services Program regulations). - Individuals who provide Supportive Home Care Aide Services must meet requirements for individuals in such roles, including, but not limited to must: have been CORI checked; experience providing services to individuals with disabilities; can handle emergency situations; can set limits, and communicate effectively with participants, families, other providers and agencies; have ability to meet legal requirements in protecting confidential information; certification in CPR is required. In addition to the required certificate, individual Supportive Home Care Aides must have completed at least one of the following: - An additional 12 hours of training in the area of serving participants with behavioral health needs; or - The 12-hour training developed by the Alzheimers Association, Massachusetts Chapter on serving participants with Alzheimers disease or related disorders. If the service involves transporting the participant, the Supportive Home Care Aide must have a valid driver’s license and vehicle insurance.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Every 2 years

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

As provided in 42 CFR 440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

Service Title:

Transportation

HCBS Taxonomy:

Service Definition (Scope):

Service offered in order to enable waiver participants to gain access to waiver and other community services, activities and resources, as specified by the service plan. This service is offered in addition to medical transportation required under 42 CFR §431.53 and transportation services under the State plan, defined at 42 CFR §440.170(a), and does not replace them. Transportation services under the waiver are offered in accordance with the participant's service plan. Whenever possible, family, neighbors, friends, or community agencies which can provide this service without charge are utilized.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider Specifications:

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Transportation

Provider Category:

Provider Type:

Transportation Provider Agencies

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Any not-for-profit or proprietary organization that responds satisfactorily to the Waiver provider enrollment process and as such, has successfully demonstrated, at a minimum, the following: - Driver and Vehicle Requirements: Verification of valid driver’s license, liability insurance, written certification of vehicle maintenance, age of vehicles; passenger capacity of vehicles; RMV inspection; seat belts; list of safety equipment; air conditioning and heating; first aid kits; snow tires in winter; and two-way communication. - Education, Training, Supervision: Providers must ensure effective training of staff members in all aspects of their job duties, including handling emergency situations. Established procedures for appraising staff performance and for effectively modifying poor performance where it exists. - Adherence to Continuous QI Practices: Providers must have established strategies to prevent, detect, and correct problems in the quality of services provided and to achieve service plan goals with individual participants by providing effective, efficient services. Providers must have the ability to meet all quality improvement requirements, as specified by the MassHealth agency or its designee and ability to provide program and participant quality data and reports, as required. - Availability/Responsiveness: Providers must be able to initiate services with little or no delay in the geographical areas they designate. - Confidentiality: Providers must maintain confidentiality and privacy of consumer information in accordance with applicable laws and policies. - Policies/Procedures: Providers must have policies and procedures that include: Participant Not at Home Policy, Participant Emergency in the Home Policy; and that comply with the applicable standards under 105 CMR 155 et seq (Department of Public Health regulations addressing patient and resident abuse prevention, reporting, investigation, and registry requirements) for the prevention, reporting and investigation of patient abuse, neglect, and mistreatment, and the misappropriation of patient property by individuals working in or employed by a transportation agency as well as policies that comply with applicable regulations of the Disabled Persons Protection Commission found at 118 CMR 1.00 to 14.00 (The State’s Division Disabled Persons Protection Commission regulations that describe the purpose, rules, and process regarding abuse allegations for people with disabilities) and the Elder Abuse Reporting and Protective Services Program found at 651 CMR 5.00 et seq (The Executive Office of Elder Affairs’ Elder Abuse Reporting and Protective Services Program regulations). Providers must ensure that staff who transport must: have been CORI checked; experience providing services to individuals with disabilities; can handle emergency situations; and communicate effectively with participants, families, other providers and agencies.

Verification of Provider Qualifications

Entity Responsible for Verification:

Administrative Service Organization

Frequency of Verification:

Annually

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Service Type:

As provided in 42 CFR 440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

Service Title:

Vehicle Modification

HCBS Taxonomy:

Service Definition (Scope):

Adaptations or alterations to an automobile or van that is the waiver participants primary means of transportation in order to accommodate the special needs of the participant. Vehicle Modifications 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. Examples of Vehicle Modifications include: - Van lift - Tie downs - Ramp - Specialized seating equipment - Seating/safety restraint The following are specifically excluded Vehicle Modifications: 1. Adaptations or improvements to the vehicle that are of general utility, and are not of direct medical or remedial benefit to the individual. 2. Purchase or lease of a vehicle 3. Regularly scheduled upkeep and maintenance of a vehicle, except upkeep and maintenance of the adaptations. Modifications to a paid caregivers vehicle or provider agency vehicle are excluded. Funding for adaptations to a new van or vehicle purchased/leased by an individual and/or family can be made available at the time of purchase/lease to accommodate the special needs of the participant. The need for Vehicle Modifications must be documented in the service plan and is subject to MRC rules. 1. The Case Manager must receive in advance for his/her review and recommendation the following information: a proposal detailing the request for funding and the completed Vehicle Modification Funding Request Form. 2. If the Case Manager recommends the proposal for funding, the request is then forwarded to MRC for review and recommendation of funding.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

Cost not to exceed $25,000 over three year period.

Service Delivery Method (check each that applies):

Specify whether the service may be provided by (check each that applies):

Provider Specifications:

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Vehicle Modification

Provider Category:

Provider Type:

Independent Vehicle Modification Contractors

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Any Independent Vehicle Modification Contractor who becomes qualified through the MRC open procurement process and as such, successfully demonstrates, at a minimum, the following: Providers shall ensure that individual responsible for vehicle modifications are skilled in applicable mechanical, electrical, welding or electronics trades, and that they have current applicable licenses and/or certifications.

Verification of Provider Qualifications

Entity Responsible for Verification:

Massachusetts Rehabilitation Commission

Frequency of Verification:

Annually or prior to utilization of service

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Vehicle Modification

Provider Category:

Provider Type:

Vehicle Modification Agencies

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Any not-for-profit or proprietary organization that becomes qualified through the MRC open procurement process and as such, successfully demonstrates, at a minimum, the following: Providers shall ensure that individual staff responsible for vehicle modifications are skilled in applicable mechanical, electrical, welding or electronics trades, and that they have current applicable licenses and/or certifications.

Verification of Provider Qualifications

Entity Responsible for Verification:

Massachusetts Rehabilitation Commission

Frequency of Verification:

Annually or prior to utilization of service