CFR 42 §441.301(c)(6) Transition Plan For Home And .

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State of Alaska Department of Health and Social ServicesSenior and Disabilities ServicesCFR 42 §441.301(c)(6) Transition Plan forHome and Community-Based Services SettingsVersion 1 - Original March 17, 2015Version 2 draft for public comment - September 14, 2015Version 2 final - October 16, 2015Version 3 draft for public comment - February 9, 2016Version 3 final – March 24, 2016Updated Systemic Assessment and Remedial Actions - December 23, 2016Approved by CMS December 28, 2016Version 4 Draft for public comment – April 8, anHCBS/HCBStransitionAlaska Settings Transition Plan version 4 –Narrative parts 1-4 (April 6, 2018) - page 1

TABLE OF CONTENTSTABLE OF CONTENTS . 2LIST OF TABLES . 4LIST OF FIGURES . . 4INTRODUCTION . . 5PART 1 -EDUCATIONAL ACTIVITIES FOR PROVIDERS, RECIPIENTS, AND OTHERSTAKEHOLDERS .6PART 2 – SYSTEMIC ANALYSIS OF STATE COMPLIANCE WITH NEW FEDERALREGULATIONS 10Review of the SDS Mission, Vision, and Principles . 10Systemic Review of State Statutes and Regulations . 12Overview and Internal Review of Waiver Programs 13Voluntary Provider Self-Assessment of Settings 15PART 3 – ACTIVITIES TO ACHIEVE SETTINGS COMPLIANCEMandatory Provider Self-Assessment of Settings 17Self-Assessment Results 18Validation of Self-Assessment Results and Settings Verification: Sample Group . 20Analysis of Non-Sampled Self-Assessments 20Remediation Plans 23Summary of Validation and Remediation Process . . 26Alaska Settings Transition Plan version 4 –Narrative parts 1-4 (April 6, 2018) - page 2

Heightened Scrutiny .27Ongoing Monitoring . 29Communication with Recipients about Options When a Provider Will Not BeCompliant 32Building Statewide Capacity 33Amendments to Regulations and Conditions of Participation 36PART 4 – INPUT FROM THE PUBLIC: SUMMARY OF PUBLIC COMMENT AND SDS RESPONSE(to be developed after public comment ends) . . 40APPENDICESAppendix A – Systemic Assessment of Alaska Statutes and Regulations . 47Appendix B – Settings Qualities Checklist and Exploratory Questions for HBCSettings . 79Appendix C – Voluntary Provider Self-Assessment of Settings Tool .86Appendix D– Evidence of Public Information and Opportunity for PublicComment . . 107Alaska Settings Transition Plan version 4 –Narrative parts 1-4 (April 6, 2018) - page 3

LIST OF TABLESTable 1. Home and community-based services settings educational activitiesoffered by SDS to providers, recipients, and other stakeholdersTable 2. Additional Settings that Need to Comply with CMS Settings RegulationsHistorical ContextTable 3. Initial Compliance Status by Setting Type, Alaska, 5/31/17Table 4. Detailed Timeline for Amendments to Regulations and COPsTable 5. Alaska Settings Transition Plan Updated TimelineLIST OF FIGURESFigure A. Flow of Self-Assessment ResultsFigure B: Settings Remediation Plan Flow Chart for ProvidersAlaska Settings Transition Plan version 4 –Narrative parts 1-4 (April 6, 2018) - page 4

INTRODUCTIONThe Alaska Department of Health and Social Services, Senior and Disabilities Services (SDS)now submits for public review and comment the fourth version of its Transition Plan (“Plan”) inaccordance with CFR 42 §441.301(c)(6). This describes what SDS and providers have beenworking on to ensure that Alaska’s HCBS settings achieve compliance with the elements of thefinal rule. The State has described how compliance has been assessed; what the outcomes are;what educational strategies have been used; how providers have achieved compliance throughremediation strategies; and what collaborative strategies will be used to ensure ongoingcompliance after the deadline of March 22, 2019.This Plan reflects careful consideration and analysis of feedback from CMS since Alaska earnedinitial approval in December, 2016. In March, 2016, the State of Alaska submitted a draft of theSettings Transition Plan for a 30-day public comment period, summarized and responded to thepublic comments, and then submitted the draft to CMS. CMS reviewed the draft and providedadditional feedback, requesting that the state make several technical corrections to the systemicassessment and remediation section. These changes did not necessitate another public commentperiod. The State completed the technical corrections and then resubmitted an updated versionof the Plan to CMS on December 23, 2016.On December 28, 2016, CMS granted Initial Approval to the State and listed remaining stepsthat would need to be completed and documented in the next version of the Plan in order toreceive final approval. Those steps are addressed in this Plan.Alaska Settings Transition Plan version 4 –Narrative parts 1-4 (April 6, 2018) - page 5

Part 1EDUCATIONAL ACTIVITIES FOR PROVIDERS, RECIPIENTS,AND OTHER STAKEHOLDERSThe Division of Senior and Disabilities Services (SDS) found that the best approach to initiallyassessing the settings aspects of Alaska’s home and community-based services (HCBS) programwas to work with the stakeholder community to gain an understanding of the potential impact ofthe new federal regulations on service delivery. As SDS began reviewing state regulations andpolicies, it implemented concurrently a process of sharing information about the new regulationsand of gaining feedback from stakeholders through series of contacts that included on-linewebinars, interactive community forums, and informative updates via SDS E-Alerts, the emailnetwork used to send notices and other information to providers. Later, Alaska’s HCBS Settingsweb page was developed more extensively, with multiple resources added.The educational activities and learning opportunities offered to providers regarding home andcommunity-based services settings are shown in the following table:Table 1. Home and community-based services settings educational activities offered bySDS to providers, recipients, and other 2014MarchApril19SDS E-AlertAnnounced finalization of new CMSregulations and key areas of change1WebinarFirst information-sharing webinar: Overviewof new CMS regulations4SDS E-AlertApril 1 webinar materials made available10WebinarSecond information-sharing webinar andannouncement of community forumsJune27SDS E-AlertInvitation to community forums in Fairbanks,Kenai, Anchorage, Juneau, and statewide byteleconferenceAlaska Settings Transition Plan version 4 –Narrative parts 1-4 (April 6, 2018) - page 6

Community Statewide teleconferenceSDS E-AlertUpdates/ clarifications of CMS regulations;evaluation using Provider Self-Assessment ofSettings Survey2SDS E-AlertProvider Self-Assessment of Settings Surveyand FAQs released with October 31 due date15WebinarQ & A on Provider Self-Assessment ofSettings Survey16SDS E-AlertProvider Self-Assessment of Settings Surveydue date extended to November 1421WebinarQ & A on Provider Self-Assessment ofSettings Survey27SDS E-AlertAdditional FAQs on CMS regulationsreleased7SDS E-AlertProvider Self-Assessment of Settings reminder10SDS E-AlertOpen letter from SDS Director21SDS E-AlertSave the Date for public comment26SDS E-AlertTransition Plan available for public comment30WebinarQ&A on Transition PlanSDS E-AlertRevised Transition Plan available for publiccommentWebinarQ&A on revised Transition PlanSDS E-Alert, Online PublicNotice, Tribal Consultationletters and emails, ads inthree newspapers, and flyersdistributed via advocacyTransition Plan Version 3 available for publiccomment until March 11, 2016September 15OctoberNovemberInteractive forum for information on newregulations, ideas from stakeholders, Q&A2015JanuarySeptember 15292016February10Alaska Settings Transition Plan version 4 –Narrative parts 1-4 (April 6, 2018) - page 7

organizationsFebruary17WebinarTransition Plan Presentationsto two advocacy groups(AgeNet and AlaskaAssociation forDevelopmental Disabilities)Submit Transition PlanVersion 3 to CMSSDS performs initial reviewof Provider Settings SelfAssessment and 2nd levelSample onsite reviews, andoffers technical assistanceMarch 10March 1231April,2016 –June,2017Q&A on Transition Plan Version 3Q&A on Transition Plan Version 3Public comment incorporated and plansubmittedIndividual providers receive technicalassistance from Settings Compliance Team2017MarchJuly ber18SDS updated SettingswebsiteSDS provides technicalassistance for settings innon-sample groupE Alert sent about SDSwebinar for ISW providersOrientation for prospectiveproviders in ALHsSDS added information toSettings web page for ISWapplicantsSDS webinar for ISW waiverprovidersSDS added remediationresources to websiteInform public more efficiently about CMSfinal settings rule and associated informationIndividual providers receive technicalassistance from Settings Compliance TeamInform potential providers under theIndividual Supports Waiver of webinarInformation is aligned between DHSSDivisionsISW waiver providers are knowledgeableabout settings rule and remediationMore information about remediation isavailable to public2018February22February26Webinar about settingsrequirements at AlaskaAssociation onDevelopmental DisabilitiesmeetingSDS settings training withDHCS Residential Licensingand Office of Long TermSettings information spread to large networkof agencies serving those with disabilitiesStrengthen staff of other divisions that will bemonitoring compliance in settingsAlaska Settings Transition Plan version 4 –Narrative parts 1-4 (April 6, 2018) - page 8

February28April8Care OmbudsmanBreakout session on settingsEducation for advocatesduring annual conferenceSDS E-Alerts, Online PublicNotice, Tribal Consultationletters and emails, ads inAnnouncing upcoming Public Commentnewspapers, Webinars, flyers period for STPdistributed via advocacyorganizationsAlaska Settings Transition Plan version 4 –Narrative parts 1-4 (April 6, 2018) - page 9

Part 2SYSTEMIC ANALYSIS OF STATE COMPLIANCE WITH NEW FEDERAL REGULATIONSTo evaluate compliance with federal requirements for home and community-based settings, SDSundertook a comprehensive review of its service philosophy and state regulations, beforebeginning the work of assessing all settings in Alaska.Review of the SDS Mission, Vision, and PrinciplesIn the 1970s, Alaska embraced the concepts of choice, inclusion, and independence embodied inthe Social Security Act by joining the national movement toward deinstitutionalization bydeveloping community alternatives. This philosophy is formalized in the SDS Mission, Visionand Service Principles. Periodically, as new materials such as the Americans with DisabilitiesAct and the Olmstead decision inform the home and community-based system of service, SDSreviews its philosophy and enriches statewide advocacy for recipients by incorporating thevalues advanced in those materials.The assessment of state compliance with the new regulations began with a review of SDSphilosophy embedded in its Mission, Vision and Service Principles. This philosophy guides thedevelopment of regulations and policies and, as a result, is incorporated in the practices of boththe State and the service providers. Because Alaska providers share this philosophy, SDS andthe providers are able to work in concert to maintain a well-balanced and responsive home andcommunity-based system.SDS concludes that its philosophy reflects the values promoted by the new requirements forhome and community-based settings.Alaska Settings Transition Plan version 4 –Narrative parts 1-4 (April 6, 2018) - page 10

State of Alaska Department of Health and Social ServicesSenior and Disabilities ServicesMission, Vision, and PrinciplesMISSION: Senior and Disabilities Services promotes health, well-being and safety forindividuals with disabilities, seniors and vulnerable adults by facilitating access to qualityservices and supports that foster independence, personal choice and dignity.VISION: Choice, safety, independence and dignity in home and community-based livingSERVICE PRINCIPLES: Senior and Disabilities Services is person-centered and incorporatesthis value into the following service principles: We and our partners are responsible and accountable for the efficient and effectivemanagement of services. We and our partners foster an environment of fairness, equality, integrity andhonesty. Individuals have a right to choice and self-determination and are treated withrespect, dignity and compassion. Individuals have knowledge of and access to community services. Individuals are safe and served in the least restrictive manner. Quality services promote independence and incorporate each individual’s culture andvalue system. Quality services are designed and delivered to build communities where all membersare included, respected and valued. Quality services are delivered through collaboration and community partnerships. Quality services are provided by competent, trained caregivers who are chosen byindividuals and their families.Alaska Settings Transition Plan version 4 –Narrative parts 1-4 (April 6, 2018) - page 11

Systemic Review of State Statutes and RegulationsTo gauge the extent to which current state regulations ensure compliance with federal setting requirements, SDSreviewed the state statutes and regulations governing Medicaid waiver services, assisted living home licensing,foster care licensing, and the home and community-based services provider standards in the SDS Conditions ofParticipation. After submitting a revised review of the statutes, regulations and Conditions of Participation anda robust plan for achieving compliance, Alaska received Initial Approval from CMS in December, 2016.SDS has now amended state regulations and policies applicable to waiver services so that they are moreconsistent with the new federal regulations, supporting integrated settings, full access to the community, andrecipient initiative, autonomy, and independence. Amendments to SDS regulations and Conditions ofParticipation are outlined in Part 3, the State Plan for Achieving Compliance section. These amendments toregulations and COPs became effective November 5, 2017.The Department of Health and Social Services established a stakeholder group called the Interagency SettingsCompliance Committee (ISCC), whose mission is to ensure that the State is not only in compliance with theCMS settings rule but also that the rule is ingrained in the practice of HCBS providers. The STP coordinator atthe Division of Senior and Disabilities Services is staffing this committee and monitoring the timeline for theplan and overseeing milestones needed to achieve compliance in the state’s systemic assessment andremediation part of the plan. This includes acting as the liaison between the ISCC and SDS leadership asneeded.The purpose of this committee is to: Evaluate State Statute and Regulations to ensure compliance with CMS RuleDevelop interagency policies that increase oversight and compliance to rule and improve outcomes forconsumersEngage stakeholder community on regulation changes and department updatesMembership in the ISCC includes: Division of Senior and Disabilities Services (SDS)Division of Health Care Services (DHCS)Office of Children’s Services (OCS)Office of the Long Term Care Ombudsman (LTCO)Division of Pioneer HomesDepartment of Law (DoL)The systemic review of State statutes and regulations relevant to settings is attached asAppendix A.Alaska Settings Transition Plan version 4 –Narrative parts 1-4 (April 6, 2018) - page 12

Overview and Internal Review of Waiver ProgramsAlaska currently operates four home and community based services waiver programs: Intellectual andDevelopmental Disabilities (IDD), serving those who experience only intellectual or developmental disabilitiesand who meet the level of care for an Intermediate Care Facility for Individuals with Intellectual Disabilities(ICF/IID); Alaskans Living Independently (ALI), serving those 21 who experience only physical disabilitiesand meet the nursing facility level of care (NFLOC); Adults with Physical and Developmental Disabilities(APDD), for those 21 who have both physical and developmental disabilities and meet NFLOC; and Childrenwith Complex Medical Conditions (CCMC), serving those up to age 21 who meet NFLOC.Alaska recently submitted an application to CMS for a new waiver, the Individual Supports Waiver, andacknowledges that approval is contingent upon all settings for this waiver being compliant, so the new waiver isnot addressed in this Plan.In addition to the systemic regulatory review for CMS, SDS conducted an internal review of its certification andcompliance activities to determine which services and settings in each of its four waivers (IDD, ALI, APDD,and CCMC) would need to be evaluated for compliance with the federal settings requirements. Through thisinternal review, SDS determined that because the following services are provided in private homes, these homescan be presumed compliant but will be monitored, with remedial actions taken if service providers are found tohave a stake in home ownership (such as individually owned homes providing foster care): Care coordination (all waivers)Respite (in home) (all waivers)Chore (all waivers)Environmental Modifications (all waivers)Intensive Active Treatment (IDD, APDD, CCMC)Nursing Oversight and Care Management (IDD, CCMC)Specialized Medical Equipment (all waivers)Meals (home-delivered) (all waivers)Specialized Private Duty Nursing (IDD, APDD)Privately owned or rented homes and apartments of people living with family members, friends, or roommatesmeet the HCBS settings requirements if they are integrated in typical community neighborhoods where peoplewho do not receive HCBS also reside. Settings where individuals reside in the home of an unrelated paidprofessional staff will not be considered an individual's private home, and will be assessed and validated forcompliance with the federal HCBS rule like other provider-owned or controlled settings. Settings where thebeneficiary lives in a private residence owned by an unrelated caregiver (who is paid for providing HCBSservices to the individual), are considered provider owned or controlled settings and will be evaluated as such.Additionally, SDS found that the following services are provided in settings that will need to comply with theCMS settings regulations:Alaska Settings Transition Plan version 4 –Narrative parts 1-4 (April 6, 2018) - page 13

Table 2. Additional Settings that Need to Comply with CMS Settings RegulationsSetting typeSettingWaiverPopulationLicensed assistedliving homeResidential habilitationGroup homeIDD, APDDLicensed foster homeResidential habilitation,Family home habilitation(child)IDD, CCMC,APDDFamily home e CategoryLicensed assistedliving homeResidential supportedlivingALI, APDDProvider-owned,leased or operatedhousingSupported livingIDD, APDDFacility-basedDay habilitationIDD, APDD,CCMCFacility-basedAdult dayALI, APDDEmployment siteSupported employment *IDD, APDDFacility-basedMeal, congregateAll four waivers* The Supported Employment service has two billing codes and rates, Group and Individual, but theservice is the sam

additional feedback, requesting that the state make several technical corrections to the systemic assessment and remediation section. These changes did not necessitate another public comment period. The State completed the technical corrections and then resubmitted an updated version of the Plan to CMS on December 23, 2016.

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