attachment 1: comments from march 2015 public...

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ATTACHMENT 1: COMMENTS FROM MARCH 2015 PUBLIC COMMENT PERIOD

CommentNumber Theme Comment Commenter Response

Changeto Plan –noted by

X1. Assessment

ActivitiesThe State should look for existing survey andprocesses already in use by other states.

Commenter We agree that this is beneficial andintend to review existing tools.

2. AssessmentActivities

A commenter noted support for the proposed“look-behind” review of the provider self-assessment and noted that it is important tohave checks and balances so that aprovider's information alone is not acceptedwithout verification.

Commenter We agree with this comment.


There is not a description of relocationprocesses. The Plan does not discussrelocation processes for people who arebeing provided services in settings thatcannot come into compliance with theregulations. This is an important process toestablish early with input from multiplestakeholders.

CommenterDevelopmentalDisabilitiesCouncilSCPD

We agree with this comment and willmodify the Plan to note that therelocation process will be tailored toeach individual, and that DMMA/DDDSwill work with the individual and his/herfamily/caregiver, provider, etc. todevelop a smooth transition processthat will protect the health and welfareof participants through the process.

X


Look-behind reviews should include a sitevisit.


We agree with this comment and willmake the necessary modifications tothe Plan.

X(DMMAwill buildin a look-behindprocess

forDSHP)

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X5. Assessment

ActivitiesOn p. 10, the first "bullet" refers to "Statelaws, regulations, policies, etc. and providerpolicies". The recommendation is to include"budgets". If funds or incentives aredisproportionately allocated to restrictive ornon-integrated settings, the Plan isundermined.

DECLASI (2/10)GACEC

Delaware's reimbursementmethodology for HCB services underthe DDDS waiver is a based on thewage scale for the direct supportworkers providing the HCB servicesand related costs. Rates are the samefor all providers and there are noincentive payments. The DMMAbudget for HCB services is currentlyadequate to fund the services atcurrent payment rates. If the ratesneed to be adjusted in order to pay fora change in the way services aredelivered, additional funds can berequested at that time.


Page 10 of the Plan notes: "As available,NCI data will be analyzed by type ofresidence in order to identify non-compliancewith HCB settings." The NCI data alsoaddresses vocational and employmentsettings. It would be preferable to also"mine" the NCI data for information onvocational and employment settings.

DECLASI (2/10)GACEC

DDDS intends to utilize the NCI data tothe greatest extent possible to assistwith the assessment of HCB servicesand settings against the CommunityRule.

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X7. Assessment

ActivitiesOn p. 11, the following sections of theDelaware Code should be added to thereview:A. Employment First Act (codified at 19Del.C. §§740-747), since it overlaps withCMS standards;B. DDDS enabling law (codified at 29 Del.C.§7909A);C. DDDS Advisory Council enabling law(codified at 29 Del.C. §7910) since it is givena central role in assessment;D. Interagency Collaborative Team law(codified at 14 Del.C. §3124) since "reviewwill include residential and non-residentialsettings out of State for which waiver fundsare currently being used" (pp. 14 and 34);E. Nurse Practice Act (codified at 24 Del.C.Ch. 19) since restrictions impact settings inwhich residents receive services; andF. Community-based Attendant Services Act(codified at 16 Del.C. Ch. 94) since DDDSreceives funds under Act and Plan mentionsat p. 26.

DECLASI (2/10)GACEC

The list included in the Plan was notintended to be exhaustive. All relevantAdministrative codes will be reviewed

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X8. Assessment

ActivitiesOn p. 11, the following "Administrative Code"provisions should be added:A. IBSER regulations (16 DE Admin Code3320) which cover AdvoServ; andB. Family Care Home regulations (16 DEAdmin Code 3315) which may cover sharedliving providers; andC. PASRR regulations (16 DE Admin Code20000).

DECLASI (2/10)GACEC

The list included in the Plan was notintended to be exhaustive. All relevantAdministrative codes will be reviewed.


On p. 12, policies to be reviewed shouldinclude PROBIS and HRC. The relevantCMS regulation (42 C.F.R. 441.530)addresses privacy and freedom fromcoercion and restraint. Both the PROBIS andHRC are the main DDDS componentsprotecting such rights.

DECLASI (2/10)GACEC

The policies referenced are included inthe list of "DDDS policies" that will bereviewed against the Community Rule.There is no need to list themindividually.


On p. 13, first paragraph, and p. 19, topentry, the implication is that providers willsubmit a Corrective Action Plancontemporaneously with their self-assessment results. However, the Plan (p.22) gives them 90 days to prepare aCorrective Action Plan which then must bereviewed and approved by the State. The 90-day period is too long to simply develop aCorrective Action Plan. Instead considerchanging to 30-day period.

DECLASI (2/10)GACEC

We agree with this comment and willmodify the Plan to indicate that theCorrective Action Plan must besubmitted within 30 days.

X

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X11. Assessment

ActivitiesThe Plan (p. 13) contemplates a Councilsubcommittee conducting "look- behind"reviews of a sample of provider self-assessment results. The Plan also envisionsthe Council developing "dispute resolutionprocesses for the findings". A fewcommenters recommend that DDDS developand implement the dispute resolutionprocess. The Advisory Council should not becast in the role of arbiter of such disputes.Disputes and appeals should be handled byDDDS and DMMA. Cf. reference on p. 14:"An appeal process will be developed todispute the State's findings of non-compliance." The DDDS Office of QualityImprovement is identified (p. 15) as theagency which monitors compliance with theCommunity Rule for providers with andwithout a Corrective Action Plans.

DECLASI (2/10)GACEC


X


On p. 13, in the first set of bullets, a fewcommenters recommend including IBSERgroup homes which are not neighborhoodgroup homes. The IBSER regulations(§6.2.1) "grandfathered" residences withmore than ten residents and the only agencyregulated by the IBSER regulations operatesits own PROBIS which reduces oversight.

DECLASI (2/10)GACEC

The list included in the Plan was notintended to be exhaustive. All relevantsections of the Administrative Codewill be reviewed.


On p. 20, there are references to changingpolicies but no references to changingstatutes and regulations which will bereviewed per p. 11.

DECLASI (2/10)GACEC


X

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X14. Assessment

ActivitiesPages 22-23 contemplate DDDS submissionof waiver amendments to CMS. Pleaseclarify that DMMA, as the Delaware Medicaidagency, submits such amendments.

DECLASI (2/10)GACEC

We agree with this comment and willmodify the Plan to clarify that DMMAwill submit any amendments to CMS.

X


On pp. 25 and 34, the Plan notes that"DMMA will consider using its ExternalQuality Review Organization (EQRO) todevelop the surveys." This is a rathertentative feature to incorporate in a Plan andsuggests that the State is unsure how it willdevelop the instruments.

DECLASI (2/10)GACEC

The reference to using the EQROconveys that the State is exploring allpossible options to determine the mostappropriate course of action fordeveloping the surveys.


On p. 27, the recommendation is to add theNurse Practice Act, 24 Del.C. Ch. 19, to thelist of Delaware Code provisions to review.

DECLASI (2/10)GACEC

The list included in the Plan was notintended to be exhaustive. All relevantAdministrative codes will be reviewed.


On p. 27, the Plan envisions MCOsdistributing surveys to network providers. Iquestion whether such providers willcomplete the surveys. Query what incentivesexist for providers to complete the surveys?Medicaid MCO reimbursement rates are lowand providers may want to be paid for theirtime. Concomitantly, the Plan has nobenchmark for the percentage of providerswho will complete the surveys. Will 30%,50%, or 70% be sufficient?

DECLASI (2/10)GACEC

We agree with this comment and willmodify the Plan to note thatbenchmarks will be established inaddition to creating a process forfollowing up with providers failing tomeet requested response timeframes.

X


On p. 27, the Plan contemplates providersparticipating in training to learn how tocomplete the surveys. Consistent with thepreceding comment, what incentive exists forproviders to participate in the training.

DECLASI (2/10)GACEC

We agree with this comment and willmodify the Plan to note that DMMA willtake into consideration the need forincentives.

X

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X19. Assessment

ActivitiesOn p. 28, second set of bullets, I recommendinserting a reference to revising "budgets".

DECLASI (2/10)GACEC

We agree with this comment and willmodify the Plan to include as a bulleton page 28:“Develop budget strategies to fundremediation as necessary”.

X


On p. 29, "fair hearing results" could beadded to the list of information related toMCO performance.

DECLASI (2/10)GACEC

We agree with this comment and willmodify the Plan to add analysis of fairhearing results to the list of potentialcompliance monitoring activities.

X


It is unclear how Logisticare, the Medicaidtransportation broker, will be assessed forcompliance with the HCBS Rule. Consistentwith Comment #4 above, transportation canbe integrated or segregated.

DECLASI (2/10)GACEC

Only those services provided in eithera non-residential or residential HCBsetting, per CMS expectations, areaddressed in the Plan. Transportationservices do not fall into this category.


A few commenters questioned the use of theterm "remediation strategy" and insteadrecommend the use of term "CorrectiveAction Plan"

DECLASI (2/10)GACEC

We agree with this comment and willmodify the Plan to refer to CorrectiveAction Plan as appropriate.

X

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X23. Assessment

ActivitiesThere is no requirement (p. 33) that provider"remediation strategies" be shared withDMMA. It would obviously help DMMAassess MCO conformity with the Plan if theMCOs shared the "remediation strategies"submitted by providers with the State. ThePlan (p. 36) otherwise envisions DMMAmonitoring of provider "Corrective ActionPlans". Even this is a less strident standardthan adopted for DDDS providers. DDDSmust approve provider Corrective ActionPlans (p. 13) but there is no analogousrequirement that DMMA approve providerCorrective Action Plans (p. 36).

DECLASI (2/10)GACEC

We agree with this comment and willmodify the Plan to add language,where appropriate, to clarify thatremediation strategies and/orCorrective Action Plans will beapproved by DMMA.

X


On p. 34, first entry, there is a "disconnect"between the action item (changing policiesand procedures) and the proposed end date(a vague "legislative timeframe"). There is noproposed end date for completion of Statepolicy changes.

DECLASI (2/10)GACEC

We agree with this comment and willadd language indicating that anychanges requiring legislative actionmust be taken before 3/17/2019.

X


While DDDS conducts a pilot of its survey (p.21), DMMA conducts no pilot. DMMA couldreconsider this aspect of the Plan.

DECLASI (2/10)GACEC

DMMA will consider conducting a pilot.


The State is encouraged to incorporaterobust assessment standards which do notmerely pay “lip service” to the CMS guidancebut demonstrate that the Statewholeheartedly embraces the underlyingvalues reflected in the guidance.

DECLASI (2/23)GACEC

We are committed to developing arobust process, including standards.We believe that the approach asoutlined in the Plan positions us to dojust this.

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X27. Assessment

ActivitiesThe Plan contemplates both provider andState development of “remediationstrategies” to address identifiedshortcomings. At p. 33 this “targeted”approach to “fixing” specific instances ofnon-conformity with CMS standards is alogical component of the Plan. However, thePlan could be strengthened throughidentification of systemic initiatives designedto increase the State’s capacity to offer anarray of conforming settings. This would beparticularly informative in the context ofemployment.

DECLASI (2/23)GACEC

DMMA is committed to providing awide range of available HCBS. Wepoint you to the Pathways toEmployment program and thePROMISE program as examples ofour commitment to develop andincrease meaningful opportunities foremployment for Medicaid eligiblepersons.


The Plan envisions the Department engagingin a “look-behind” review of a 20% sample ofprovider self-assessments of policies andprocedures. At pp 6 and 13 the Plancontemplates completion of these reviews bya single “sub-working group of the GAC”.Realistically, even if the 7-member DDDSAdvisory Council assembles a “workinggroup” with some additional members, it maybe hard-pressed to conduct a meaningful“look-behind” of numerous providers whichoperate multiple programs. Moreover, thePlan could be strengthened by clarifying thatthe “look-behind” is not comprised solely of amarginally effective “paper” review. The“look-behind” should include onsiteobservation and interviews with programstaff, participants and their representatives

DECLASI (2/23)GACEC

We agree with this comment. The Planindicates that the GAC may create oneor more sub-working groups toconduct specific activities under thePlan. We have addressed look-behindreviews and our intent in a response toa previous comment.

X

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X(including family members).


The Plan contemplates use of participantsurveys to gather information (p 27) as wellas survey-based NCI data (p 3). As asupplement to this planned assessmentprocess, the State could considerestablishing an on-line survey tool (e.g.through Survey Monkey) to allow individualsthe opportunity to comment on specificprograms. Some individuals may be morecomfortable with the ease and anonymity ofcompleting an on-line survey and thequestions could be more targeted to CMSstandards than the NCI survey.

DECLASI (2/23)GACEC

We will explore the use of an onlinesurvey tool as an option for respondingto the participant survey.


Provider and DMMA/DDDS Staff should beasked to think not only about thefacility/setting itself when a self-evaluation isbeing completed, but whether or notcompliance with the rule is applied to eachindividual served.

SCPD The assessment tool will include afocus on the individual.


One commenter asked: who is developingthe assessment tool and will it be availablefor public review before being implemented?

Commenter The GAC and the GCCBA have beendesignated as the SteeringCommittees that will be responsible forthe development of the assessmenttools. These bodies will be augmentedwith additional resources as necessaryto ensure representation of the broadstakeholder group.

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X32. Assessment

ActivitiesThere is concern about the process thatdevelops the survey instruments andprocesses. The Plan could benefit fromgreater description about the surveyinstrument and process. As described, theprocess does not appear to be fullytransparent.

StateRepresentative

As we move forward to flesh out thedetails of the survey process, we willwe seek broad public input.

33. Availability ofOptions

Implementation of the Plan should preservea broad range of choices for housing(including group homes and intentionalcommunities) and employment services(including pre-vocational services such aswork-based facilities/sheltered workshops).Many relatives of participants in pre-vocational services related that thesesettings are safe and provide an importantprotected environment for participants todevelop skills.

MultipleCommenters

We understand and share yourcommitment to making sureparticipants are safe, protected, andhave the services and supports theyneed. The Plan will help to identifywhich of the current services andsettings meet the characteristics ofHCB settings that can be coveredunder an HCBS program. Servicesand settings that do not comply withthe Community Rule have anopportunity to engage in remediationto come into compliance with theCommunity Rule before March 17,2019.

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X34. Availability of

OptionsDMMA should ensure the continuedavailability of current providers such asElwyn, KSI and Chimes and the servicesthey provide. Implementation of the Planshould preserve all currently availableoptions.

MultipleCommentersChimes

The Plan will help to identify which ofthe current services and settings meetthe characteristics of HCB settings thatcan be covered under an HCBSprogram. Services and settings that donot comply with the Community Rulehave an opportunity to engage inremediation to come into compliancewith the Community Rule before March17, 2019.


The Plan should include language thatstipulates the need for all the existingoptions, and it should also be free of any pre-conceived notions, theories or ideas thatwould restrict the choices that should beavailable to all individuals with special needs.New options that enhance or complementthe existing options would certainly bewelcomed.

Commenter The Plan will help to identify which ofthe current services and settings meetthe characteristics of HCB settings thatcan be covered under an HCBSprogram. Services and settings that donot comply with the Community Rulehave an opportunity to engage inremediation to come into compliancewith the Community Rule before March17, 2019.


Many commenters encouraged Delaware toavoid using a “one-size-fits-all” approach toconsidering supports and services for peoplewith disabilities. Not all disabilities are thesame and not all people with disabilities arethe same. What is restrictive for one personis not restrictive for another. Options,including housing options and employmentoptions, need to be based on the needs ofthe individual.

MultipleCommentersChimes ofDelaware


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OptionsMany relatives described the effect thatlosing the option of work-based facilities andsheltered workshop would have on theirfamily members.

MultipleCommenters

All current recipients of day serviceswill continue to receive day services.How services are delivered may ormay not need to be modified based onthe outcome of the assessmentprocess. The assessment tool will bedeveloped using CMS guidelines andinput from stakeholders.


Current employment opportunities are limitedin areas such as Sussex County.

MultipleCommenters

The Department agrees thatemployment opportunities need to beexpanded across all Delawarecounties.


Commenters expressed concerns aboutlimiting group homes to two or threeresidents per home and limiting theavailability of foster family arrangementsthereby forcing persons into higheroccupancy group homes and apartments.

MultipleCommenters

The Community Rule does notspecifically address the size of theresidential settings. The currentapproved DDDS waiver indicates thatwaiver residences will house no morethan four individuals. Nothing in thenew Community Rule requires DDDSto change this.


Several commenters disagreed withsheltered workshops and gated communitiesas viable community options for disabledpersons.

MultipleCommenters


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OptionsPrograms should not mandate a disabled tonon-disabled ratio of participants and shouldallow for the full range of vocational servicesthat currently exists, including facility-basedprevocational programming and supportedemployment.

Commenter The Plan will help to identify which ofthe current services and settings meetthe characteristics of HCB setting thatcan be covered under an HCBSprogram. Services and settings that donot comply with the Community Rulehave an opportunity to engage inremediation to come into compliancewith the Community Rule before March17, 2019.


Integrated, safe, accessible and affordabledisability housing is a challenge in Delawarewith limited options for choice. Private andpublic partnerships for housing options mustbe encouraged and embraced and notdiminished or discouraged in Delaware.

Commenter The Department will continue tomaintain and expand its partnershipswith its housing providers. The Planwill assist in identifying settings thatmeet the characteristics of HCBsettings that can be covered underHCBS programs. The assessment willprovide guidelines to housing partners.

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OptionsThere is concern that some existingprograms, such as group homes with four ormore residents, and sheltered workshops,would be prohibited until the new 2019federal guidelines. You indicated in youremailed statement that 'the Rule does notrequire any of those changes.' Can youensure that this assurance is also containedprominently in the Transition Plan?

StateRepresentative

The current DDDS waiver allows forgroup homes of four or lessindividuals. The Plan will not alter theapproved capacity. The Planassessment will evaluate theexperiences of the individuals in thosegroup home settings. Pre- vocationalservices provided in a shelteredworkshop setting will be evaluated bythe Plan assessment to measurecompliance with the HCB settings thatcan be covered under the HCBSprogram. Services and setting that donot comply with the Rule will have theopportunity to engage in remediationto come into compliance with the Ruleprior to March 17, 2019.


There is a concern as to whether 1) allexisting options will be permitted, that 2)dollars will follow the client, and 3) the client(and/or family) will have a role in selectingwhich option the client obtains, rather than tohave 'the system' make that selection ontheir behalf. If these overriding goals are alsogoals of DDDS, perhaps it would be helpfulto share them (or perhaps other, similaroverarching goals) near the front of thetransition plan, to allay the anxiety thatseveral parties are experiencing.

StateRepresentative

Person centered planning is the basisfor all HCB services, allowing theindividuals and their family to choosetheir services. HCBS funds areindividually allocated and the personchooses what services meet the needsdefined in their plan.

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OptionsThere is concern that DDDS could curtailexisting programs in advance of the 1019deadline, and this is worrisome. Could thePlan be clear regarding what kind ofchanges, if any, would be 'on the table' priorto the 3/17/2019 federal deadline?

StateRepresentative

No services will be curtailed inadvance of 10/19. If services areassessed and are found not be incompliance with the Rule, then theywill have opportunity to come intocompliance.


There is not a discussion of how Delawarewill ensure that individuals have a choice of"non-disability specific" setting and privateunits. Delaware should evaluate its currentcapacity of non-disability specific settingsand develop a plan to increase capacity.Current community services are verysegregated in Delaware and the lack ofcapacity of non-disability specific settings isparticularly acute for non-residentialservices, where the majority of Delaware'scurrent settings are disability specific.


Choice of non-disability settings is aninherent part of the person-centeredplanning process. This is one of thecomponents of the Community Rulethat will be reviewed as part of theassessment of State laws, regulationsand policies as well as providerpractices regarding person-centeredplanning.

47. Barriers toCommunityIntegration

Many commenters described the challengesto community integration that they currentlyface, including the lack of handicappedparking spaces, lack of handicap-accessibleand barriers due to transportation.

MultipleCommenters

We acknowledge this comment.

48. Barriers toCommunityIntegration

Time limits for employment should not beincluded in the Plan in order to facilitatesuccessful job placements.

MultipleCommenters

If we understand the commentcorrectly, there are no time limitscurrently included in the Planassociated with time limits foremployment.

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X49. Characteristics

of WorkEnvironment

The Plan should include a provision thateach work environment is safe for theparticular needs of mentally challengedindividuals. Work environments should bestructured and stress-free.


50. Characteristicsof WorkEnvironment

Remuneration for work performed should befair, but does not need to be minimum wage.

Commenter The Plan evaluates settings not subminimum wage.


Commenters stressed the importance oftraining supervisors and staff in relating topersons with disabilities.

MultipleCommenters

Department agrees with the comment.


The Plan should include a provision givingpersons with disabilities the option to workwith other disabled individuals.


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X53. Characteristics

of WorkEnvironment

The Plan should include a provision fordisabled individuals at any skill level to startin a program and work up to a less restrictiveenvironment.

Commenter By definition, prevocational service isdesigned to meet the needs ofindividuals who may not be ready forcompetitive employment but who havecompetitive employment as their goal.There is no plan to remove this servicefrom the DDDS waiver.

54. Close of PublicCommentPeriod

The advertised time period for publiccomment does not meet the federalstandard. CMS requires "at least a 30-daypublic notice and comment period" [42C.F.R. §441.710(a)(l); 79 Fed Reg. 3033(January 16, 2014]. In contrast, commentson the Plan must be received by 4:30p.m. onMarch 6, 2015.

DECLASI (2/10)GACEC

The end of the public comment periodwas revised to March 9, 2015.

55. Incentives The Plan should be business friendly andshould provide incentives to businesses tohire individuals with disabilities.


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X56. Increase

Capacity forCommunityEmployment

We encourage the State to increase capacityfor community employment. The Plan doesnot really address increasing capacity in anycreative way. New York has ceased newadmissions to sheltered workshops. Itcreated a tax credit for employers to hirepersons with developmental disabilities whoare either unemployed or working insheltered workshops. The State has toassume a higher percentage of individualswith developmental disabilities will qualify forintegrated employment. It needs to expandcapacity/incentives so employers hire them.This needs to be incorporated in the Plan.

DevelopmentalDisabilitiesCouncil

The Department agrees with thecomment.

57. IncreaseCapacity forCommunityEmployment

Reduce the economic uncertainty for serviceproviders in order to encourage innovationand investment to further improve quality andincrease capacity of services. By recognizingthat one service model does not fit all, insistthat DDDS work with providers to createprograms that can be tailored to meetindividuals’ needs.

Commenter The Plan will help to identify which ofthe current services and settings meetthe characteristics of HCB setting thatcan be covered under an HCBSprogram. Services and settings that donot comply with the Community Rulehave an opportunity to engage inremediation to come into compliancewith the Community Rule before March17, 2019. The Department will workwith all providers to developtransition/remediation plans, includinginvestment in quality outcomes.

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X58. Oversight Body A few commenters recommended adding the

State Council for Persons with Disabilities tothe "team". It is a State agency charged withreviewing "all State policies, plans, programs....concerning persons withdisabilities...conducted or assisted...by Statedepartments' and making "recommendationsto ...all State departments...respecting waysto improve the administration of services forpersons with disabilities and for facilitatingthe implementation of new or expandedprograms."

DECLASI (2/10)GACEC

DMMA agrees to take a look at thecomposition of the oversight body andadd members as needed. We will alsoconsider smaller work groups.

59. Oversight Body The Plan (p. 8) mentions that the "oversightbody" will meet "regularly". This is undulyobtuse. It would be preferable to at leastinclude a minimum schedule (e.g. quarterly;monthly).

DECLASI (2/10)GACEC

We agree with this comment and willmodify the Plan to note that theadvisory council will meet, at aminimum, monthly, but will meet morefrequently if necessary depending onthe task at hand.

X

60. Oversight Body The references to "Governor's AdvisoryCouncil" (p. 10) and "GAC'' (seriatim) are notappropriate. The current statute (29 Del.C.§7910) refers to the "Advisory Council to theDivision of Developmental DisabilitiesServices".

DECLASI (2/10)GACEC


X

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X61. Oversight Body On p. 17, last entry, the reference to

"charter" is odd. Councils do not create"charters". The deadline (March 17, 2015) todevelop the operational standards is also tooshort.

DECLASI (2/10)GACEC

Because the Plan is requesting theGAC to perform a role that is specificand time-limited and is somewhatdifferent than what it is supposed to dounder Title 29 of the Delaware Code,we felt that it was important to definethat role via a Charter or other similardocument.

62. Oversight Body On p. 25, the State identifies the Governor'sCommission on Community-BasedAlternatives for Individuals with Disabilitiesas the primary stakeholder group to informthe decision-making regarding assessments.The Commission meets infrequently.Moreover, there is no "end date" forconfirming the Commission's role as theadvisory body for the assessment process(pp. 31-32).

DECLASI (2/10)GACEC

We agree with this comment. DMMAwill discuss with the Commission theimportance of their role inimplementing the Plan and the need tomeet more frequently. 2/23 is intendedto serve as the start and end date forthis task and will modify the Plan tonote this date.

X

63. Oversight Body On p. 32, the reference to the Commissioncreation of a "charter" is odd. A Commissiondoes not create a "charter".

DECLASI (2/10)GACEC

Because the Plan is requesting theCommission to perform a role that isspecific and time-limited and issomewhat different than what it issupposed to do under Executive Order50, we felt that it was important todefine that role via a Charter or othersimilar document.

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X64. Oversight Body The Division of Developmental Disabilities

Services (DDDS) should ensure that theGovernor’s Advisory Council to DDDS andits subgroups, which have been set up toimplement the Transition Plan, continue tobe as representative of all stakeholderswithin the DDDS system as the Focus Groupprocess was. To do so, we recommendincluding additional family members ofindividuals with the most challenging supportneeds currently served in center-basedsettings. We believe that Delaware’s citizensshould be proud of the separate aids,benefits, or services that have beendeveloped to serve those individuals whotruly need them, as determined through aperson-centered planning process. That iswhy we want to make sure that thediscussions in the planning groups don’t ruleout any of these options strictly on the basisof the “Settings that Isolate” guidance postedon the CMS website, which has a completelydifferent emphasis than the guidance onnon-residential services that was issued byCMS on December 15, 2014.

DelARF It is DDDS’s intention to encourage theGAC to create subgroups that includefamily members who represent thevarying support needs of people withinthe DDDS service system and otherkey stakeholders.

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X65. Oversight Body Legislative representation should be added

to the GAC’s work groups, so that costestimates for any changes that are proposedin the DDDS service system can be fullydiscussed, made realistic, and ultimatelyreceive the support of the General Assembly.We are pleased that the Transition Planmakes reference to the rate system inSection 3 in the “matrix” and we think itwould make sense to reflect the existingshortfall in the narrative under Phase 2 and3, as well. We also want to make sure thattransportation is viewed as a necessarysupport for community inclusion, andtherefore, that it be included in the plan andthe financial impact assessment. Above all,we want to be sure that changes proposed tobring the state into compliance do notincrease the funding gap, because that couldresult in a number of unintendedconsequences, including diminished accessto services and additional demand for out-of-home placements by families who haveadults with disabilities living with them.Therefore, we would recommend theinclusion of representation by the GeneralAssembly and the Office of Management andBudget in the plan’s narrative, in Phase 3,and in Section 3 of the matrix.

DelARF DMMA will take a very close look atthe composition of the work groupsand add members when necessary.We will take this request underconsideration.Transportation will be evaluated in thecontext of whether it facilitates theability of consumers to accessresources in the community.

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X66. Oversight Body SCPD recommends that it be added to the

list on p. 8 and p. 31 regarding the“Oversight Body”.

SCPD It is our intent to include as wide arepresentation of stakeholders aspossible in the implementation of thePlan.

67. Oversight Body One commenter asked whether theGovernor’s Commission on CBAID takesprecedence over the Governor’s AdvisoryCouncil.

Commenter No, each group will work with itsstakeholders who are subject matterexperts.

68. Paid Relatives The recommendation was made to makefunding available to allow relatives to serveas paid providers.

Commenter The purpose of the Community Rule isto ensure that HCBS that wereprovided as of March 17, 2013, theeffective date of the Community Rule,are in compliance with the definition of“community”. The Plan does notaddress providing new services orchanging services that are compliantwith the Community Rule.

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X69. Pathways and

PROMISEPrograms

A few commenters questioned the approachof not including the Pathways and PROMISEprograms within the scope of the Plan (p. 3)since the programs were previouslyapproved by CMS after issuance of theJanuary, 2014 CMS regulations.

DECLASI (2/10)GACEC

CMS has made it clear in severalvenues that the Plan requirementsprescribed in the Community Ruleapply only to the existing HCBSprograms operating as of the effectivedate of the Community Rule, March17, 2014. All new programs arerequired to meet the requirementseffective upon approval. For example,section 441.710(a)(3)(i) of theCommunity Rule notes: “Statessubmitting state plan amendments fornew section 1915(i) of the Act benefitsmust provide assurances ofcompliance with the requirements ofthis section for home and community-based settings as of the effective dateof the state plan amendment.”Furthermore, in negotiations with CMSregarding approval of both thePathways and PROMISE programs,CMS notified DMMA that the programswould not be approved unless allrequirements of the Community Rule,including requirements for HCBsettings, were first met. The qualityassurance sections of the Pathwaysapplication approved by CMS includemeasures to monitor the on-goingcompliance of program services andsettings with the Community Rule.

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X70. Person-

CenteredPlanning

The CMS regulations stress the importanceof the "person-centered planning process".The Plan contains some brief references to a"person-centered plan" (pp. 3, 12) but thePlan could benefit from the incorporation ofmore specifics on revamping the currentDDDS ELP plans and DSHP care plans toconform to the federal standards. At aminimum, the matrix on pp. 18-19 couldspecifically highlight the "person-centeredplanning process" as one of the core Statepolicies meriting review.

DECLASI (2/10)GACECDevelopmentalDisabilitiesCouncil

The Essential Lifestyle Plan (ELP) isconsidered a best practice for person-centered planning for personsreceiving HCBS. The ELP has been incontinuous use by DDDS since 1998.The Community Rule makes it clearthat their expectation is that statesmust already be compliant with therequirement for person-centeredplanning as of March 17, 2014, theeffective date of the Community Rule.Since DDDS is already compliant withthis requirement, there is no need toaddress it in the Plan. DDDS continuesto refine the ELP process, as theneeds of our population change.In addition, DMMA’s existing contractwith the MCOs require the MCOs touse a person-centered planningprocess in developing a member’sDSHP Plus LTSS case managementplan, clinical care coordination plan, orMFP transition plan.

71. Person-CenteredPlanning

DDDS should allow families to decide onservices based on their loved one’sindividual needs and through money thatfollows the person.

MultipleCommenters

The intent of the required person-centered planning process is todevelop a plan that is unique to eachindividual using the services that meetthe characteristics of HCBS.

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X72. Person-

CenteredPlanning

Easter Seals fully endorses each individual’sright to choose what his or her services looklike.

Easter Seals Nothing about the Plan will change thebasic right under Medicaid forindividuals to choose among a set ofwaiver-covered services delivered by aset of qualified providers. The Plan willhelp to identify which of the currentservices and settings meet thecharacteristics of HCB settings thatcan be covered under an HCBSprogram. Services and settings that donot comply with the Community Rulehave an opportunity to engage inremediation to come into compliancewith the Community Rule before March17, 2019.

73. PlanImplementation

One commenter recommended that the Planannounce the State’s intent to create ablueprint for how the services and supportssystem will look five years from now andspecify the timeframe within which it will becompleted. People with disabilities, theirfamilies, and our provider networks can bemuch more effective partners in thisendeavor when the road ahead is more well-defined.

University ofDelaware

The Department agrees with thecomment and will engage stakeholdersas the Plan evolves.

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X74. Plan

ImplementationAs Delaware moves forward in its efforts tocomply with the CMS Rule, SCPDencourages the State to strictly follow theOlmstead guidance on integrated versussegregated settings and the CMS guidanceon settings that have the effect of isolatingindividuals receiving HCBS from the broadercommunity.

SCPD In providing HCBS, we are held to therequirements of both the Olmsteaddecision and the Community Rule.

75. Quality ofServices

We are very hopeful that as states, includingthe State of Delaware, begin to implementtheir transition plan, quality of services for allwill improve. The new requirements put forthby CMS include a detailed person-centeredplanning process, rights and protections forthose living in provider-owned settings, and achoice of receiving services in a non-disability setting. These are newrequirements that we believe are criticallyimportant to creating real community optionsand we believe that states can work to makethese options happen in a timely way.

NACDD We acknowledge this comment.

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X76. Service

DefinitionsOn p. 3, the State recites that it is listing "theservice definition from the approved waiver".This is not entirely accurate. For example,the "definitions" of "prevocational services","day habilitation" and "residential habilitation"are partial excerpts from the attached (pp.40-45) service definitions in the DDDSwaiver. "Transportation" references includedin the DDDS waiver service definitions havebeen uniformly omitted from definitions in thePlan. This suggests that transportation willnot be addressed in the Plan. Waiver-fundedtransportation should be included in the Plan.For example, use of integrated transportation(taxi; bus; mileage reimbursement) may bepreferable to use of paratransit or anidentified van with only riders withdisabilities.

DECLASI (2/10)GACEC

The language provided in the Plan areexcerpts from the approved servicedefinitions intended to convey theintent of the definition. Transportationis not a stand-alone service under theDDDS waiver; it is a component part ofresidential habilitation, day habilitationand prevocational services, as allowedby CMS. Transportation will beevaluated in the context of whether itfacilitates the ability of consumers toaccess resources in the community.

77. StakeholderEngagement

We ask that the Division of Medicaid andMedical Assistance ensure that parents areinvolved in the assessment and planningprocess referred to in the Transition Plan.

Multiplecommenters

It is our intent to include as wide arepresentation of stakeholders aspossible in the implementation of thePlan.

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X78. Stakeholder

EngagementThere needs to be further opportunities forsignificant public comment. The February 6thTransition Plan describes the process theState will use to evaluate its current systemand bring it into compliance with the HCBSrules, but it resembles a plan to plan. As theState completes its assessment process andbegins to develop remediation plans forsettings not currently in compliance, thepublic should have an opportunity to giveinput before the revised plan is submitted toCMS for approval.

CommenterDevelopmentalDisabilitiesCouncil

At any point significant changes aremade to the Plan, the Plan will beposted for public comment. The Planwill be updated accordingly.


On p. 10, the Employment First Commissionshould be added as a source of informationand analysis. Per 19 Del.C. §747, theCommission reviews and analyzes data onemployment of persons with disabilities.Apart from the NCI data, the Commissionmay have supplemental information to assistwith assessment of access to integrated,competitive employment.

DECLASI (2/10)GACEC

As the Employment First Commissiondevelops outcome data, it will beincorporated into the process used toevaluate employment services.


The Plan is inconsistent in sometimesreferring to a single GAC work group (p. 12;p. 14) and sometimes referring to multipleGAC work groups (p. 10 at top; p. 20 atbottom).

DECLASI (2/10)GACEC

We agree with this comment. The firstparagraph on page 10 of the Planstates that DDDS will work with theGAC and any work groups convenedby the Council. We will clarify in thePlan that the GAC is intended tooperate as a steering committee.

X

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X81. Stakeholder

EngagementThe Plan should include standards for thecomposition of the Councilsubcommittees/work groups to promoteobjectivity and absence of conflicts. The Plansuggests (p. 42) that DDDS envisionsincluding a single provider representative onthe assessment subcommittee. However,there is nothing in the Plan which wouldpreclude establishment of a subcommitteecomprised of a high percentage of providerswho may have a vested interest in adoptingan anemic assessment instrument. Themembership of the subcommittees wouldostensibly not be limited to the small (sevenmember) Council membership. Perhaps theCouncil could vote to establish a protocol inwhich the Council chair and DDDS directorwould jointly appoint the members of thesubcommittees. Alternatively, the Plan couldinclude some explicit membership standardsto ensure the objectively of thesubcommittees. It would also be prudent toinclude one or more DDDS employees onthe subcommittees.

DECLASI (2/10)GACEC

We agree with this comment. TheGAC will determine the composition ofthe working groups. It is ourexpectation that the groups berepresentative of the majorstakeholder groups. We will addlanguage to this effect. DDDSemployees will attend all GAC andGAC working group meetings both toact as staff to the group and also toprovide expertise.

X


The Transition Plan submitted by the State ofDelaware should be written to accuratelyreflect the public input that is received in thepublic hearings and in written commentsbeing submitted to DMMA.

DelARF It is our intent to accurately reflect allcomments received on the Plan.

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X83. Stakeholder

EngagementThe National Association of Councils onDevelopmental Disabilities (NACDD) ispleased that the State of Delaware will beholding several hearings this week to heartestimony on the Delaware StatewideTransition Plan related to the Centers forMedicare and Medicaid Services (CMS)Home and Community-Based settings rule.The hearings provide an importantopportunity for individuals with disabilities,their families and all those who provide carean opportunity to speak out about the ruleand its impact.

The Department values stakeholderinput.


It is critically important that representatives ofall types of service recipients be involved,including individuals with the mostchallenging support needs. Easter Sealsrecommends that at least five to sevenindividuals/family members and no less thanfive service providers should be included inthe Steering Committee and subsequentwork groups. These should be consumersand providers who represent a range ofservices in order that varied support needsare considered.

Easter Seals It is DDDS’s intention to encourage theGAC to create subgroups that includeself-advocates, family members, andother stakeholders who represent thevarying support needs of people withinthe DDDS service system and otherkey stakeholders.

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X85. Stakeholder

EngagementSCPD is unclear why the only stakeholderfor the following action items on p. 32 is theDelaware Healthcare Facilities Association:· Identify HUD Homes and any financial or

other terms that impact compliance; and· Conduct review of Delaware

landlord/tenant code vis-à-vis the Rule.

At a minimum, the SCPD/Governor’sCommission Housing Committee should beincluded as a stakeholder.

SCPD It is our intent to include as wide arepresentation of stakeholders aspossible in the implementation of thePlan.


One commenter encouraged the State toinvolve legislators and OMB in implementingthe Plan.

Commenter It is our intent to include as wide arepresentation of stakeholders aspossible in the implementation of thePlan.


One commenter expressed concern that thePlan is a “top-down” plan rolling out from afederal bureaucracy.

MultipleCommenters

This is not our intent. It is our intent toinclude as wide a representation ofstakeholders as possible in theimplementation of the Plan.

88. Support of thePlan

Many commenters wrote to express theirsupport of the draft Plan.

MultipleCommentersSCPD

We acknowledge this comment.

89. Support of thePlan

The draft Plan is a good start on the processof transitioning and has positive steps towardthat end.


Department appreciates the comment.

90. TechnicalCorrection

On p. 13, second paragraph, fourthsentence, substitute "indicate" for "indicates".

DECLASI (2/10)GACEC


X

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X91. Technical

CorrectionOn p. 13, final bullet, modify the reference toread "(i) informed consent of the individual orlegal representative. See 42 C.F.R.§441.301(1).

DECLASI (2/10)GACEC


X


On p. 33, the Plan includes a proposed enddate of"9/31/15". There are only 30 days inSeptember.

DECLASI (2/10)GACEC


X


There are multiple references to the“Governor’s Commission on CommunityBased Alternatives for Individuals withDisabilities.” The actual reference should bethe “Governor’s Commission on BuildingAccess to Community Based Services.”

SCPD We acknowledge the comment but wecannot change the name in that this isthe name of the body in ExecutiveOrder 50.

94. Timeline The time line is extended beyond what isreasonable, as written remediation strategieswill not be implemented until February andMay of 2017, leaving insufficient time for theactual implementation, including therelocation of any individuals from settingsthat prove unable to come into compliance.Commenters urged the State to move morequickly and give the HCBS service systemmore time to reach compliance by 2019. TheDelaware system should not wait until 2017to begin the actual transition andtransformation.



X

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X95. Timeline There are some inconsistencies in the time

periods in the matrix. The following areexamples.A. On p. 18, development of the self-assessment instrument has a proposed enddate of 4/24/15. On p. 20, development ofthe self-assessment instrument has an enddate of 5/31/15. On p. 21, development ofthe self-assessment instrument has an enddate of 5/31/15.B. On p. 18, last entry, providers have a7/31/15 end date to complete their self-assessment. In contrast, p. 21 indicates thatonly three providers will complete theassessment as a pilot to identify "bugs" inthe survey instrument by 7/15/15 and arevised survey instrument will be developedby 8/15/15.C. On p. 19, there is a 2/28/16 end date tocomplete a "look-behind" review of a 20%sample of the provider self-assessments. Incontrast, on p. 21, final entry, there is an8/31/16 end date to review a 20% sample ofprovider self-assessments.

DECLASI (2/10)GACEC

A. The provider self-assessment toolsdescribed on pages 18 and 20 & 21are different tools. The tool describedon page 18 with a due date of 4/24/15is the tool for providers to assess theirpolicies and procedures, etc. The toolsfor which the due date is 5/31/15 arefor the providers to use to assess theiractual settings.B. The survey tool on p. 18 with thedue date of 7/31/15 is related to theprovider policies and procedures. Thesurvey tool referred to on page 21 is toassess the individual settings. Theyare two different survey tools.C. The tool referred to on p. 19 withthe due date of 2/28/15 is related tothe provider policies and procedures.The tool referred to on page 21 withthe 8/31/15 due date is related to theHCB settings.

96. Timeline On p. 35, the Plan contemplates a 5-monthperiod (1011/15 to 2/29/16) for providers toconduct a self-assessment and participantsto complete participant surveys. This periodis unnecessarily long.

DECLASI (2/10)GACEC


X

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X97. Timeline The timelines in the plan should be adjusted

so that each phase has sufficient time to befully evaluated and implemented, to ensurethat changes made are based on a thoroughunderstanding of the system that is currentlyin place and a sound fiscal analysis of thechanges that are proposed. Therefore, wesuggest that the plan reduce the amount oftime during which the assessments arecompleted during Phase 2 andcorrespondingly, that the plan increase theamount of time needed for full considerationof the budget impact in both Phase 3 and 4,i.e., for the determination of compliance andimplementation of changes. It might also behelpful to align Phase 4 with the State’s fiscalyear, i.e., to begin it on July 1, 2016 insteadof November 2016.

DelARF We agree with this comment and willmake the necessary modifications tothe Plan.

X

98. Timeline We highly recommend that this Plan includean “end date” for completion of State policychanges.


We agree with this comment and willmodify the Plan to indicate that revisedlanguage for any policies, regulations,etc. that are found not to be compliantwill be developed by 1/31/17.

X

99. Timeline NACDD believes it is very important for all tounderstand that states have up to five yearsto come into compliance with the rules.

NACDD We acknowledge the comment.

attachment 1: comments from march 2015 public...

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