Rappahannock Rapidan Community Services Program Committee Meeting

September 24, 2019 at 1:00 PM

MINUTES Members Present: Ann Baumgardner, Donalda Lovelace, Dawn Klemann, Jack Ledden, Valerie Ward

Staff Present: Jim LaGraffe, Anna McFalls, Ryan Banks, Ray Parks, Paula Stone, Daisy Mills, Valerie Sparks, Jeanette Nord, Sheri Sobkowiak Others present: Robert Weigel, Demaris Miller 1. Call to order

Ann Baumgardner called the meeting to order at 1:01 pm. 2. Agenda Review

The committee consented to adopt the agenda. 3. Follow up on recent activities

Jim LaGraffe, Executive Director noted that, following up to the Board Planning day in August, Katie Snyder, executive coach and consultant, will be attending the October 8th Board Meeting to begin discussions on developing a long-term strategic plan for the organization. Additionally, he reported that the Oxford House in Warrenton is now off the table as there are current code compliance issues. He added, however, that PATH is still interested in it and asked members to keep an eye out if anything becomes available in Fauquier County or northern Culpeper.

4. Quality Assurance Report Anna McFalls, Director, Finance & Administrative Services Division, introduced Daisy Mills, Quality Analyst, after which Ms. Mills briefly described her experience. Valerie Sparks, Quality Analyst, discussed RRCS’ reporting requirements. She also briefly detailed recent program reviews and resulting action plans. Committee members talked about reports regarding client services.

• Closed Session – Discussion Relating to Medical Records

ACTION: Jack Ledden moved that the Board enter closed session for the purpose of discussing issues relating to medical and mental health records. This motion is made pursuant to Virginia Code Section 2.2-3711, Paragraph A, Subsection 16.

After reconvening the open session, committee members were polled, "To the best of your knowledge, do each of you certify that only public business matters lawfully exempted from the open meeting requirements under existing Virginia law, and only such public business matters as were identified in

Program Committee – September 24, 2019 Page 2 the motion by which the closed session was convened were heard, discussed, or considered by the Committee in the closed session just held?" Each Board member present responded as follows:

Ann Baumgardner Yes Donalda Lovelace Yes Dawn Klemann Yes Valerie Ward Yes Jack Ledden Yes Bob Weigel Yes Demaris Miller Yes Marcia Brose Yes

5. Presentation on Organizational Compliance with HCBS community Rule Sheri Sobkowiak provided a presentation on Home and Community Based Services (HCBS), a copy of which is attached.

6. Discussion on Key Performance Indicators for FY20 Committee members consented to context-based presentations at the program committee meeting, while receiving the key performance indicator reports quarterly rather than monthly.

There being no further business, the meeting adjourned at 2:27 pm.

RRCS Developmental Disability Services 9/24/19

Points To Cover

1) Regulatory Agencies2) HCBS3) Future Bridges

DD Waiver Programs Regulatory Agencies

DBHDS, Office of Licensing & Office of Human Rights

Center for Medicaid and Medicare Services (CMS) Home and Community Based Services (HCBS)

Department of Medical Assistance Services (DMAS) Virginia's Medicaidprogram

Department of Justice (DOJ)

Department of Nursing

HUD (for 5 group homes)

External Influences Regulatory Standards

Overall, the regulatory agencies that provide compliance standards are aligned, which enables providers to pave a path towards common goals.

DOJ ~ CMS ~ DMAS ~ HCBS ~ Licensing ~ Human Rights

HCBS Regulations

The requirements are designed to ensure that people withdisabilities living in the community have access to the same kind ofchoice and control over their own lives as those not receivingMedicaid HCBS funding.

Development of HCBS Regulations

Align with federal policy and legislation, supporting inclusion and integration of people with disabilities in the community.

Americans with Disabilities Act

Rehabilitation Act

Developmental Disabilities Act

Individuals with Disabilities Education Act

New Freedom Initiative and Year of Community Living.

This Photo by Unknown Author is licensed under CC BY-NC-ND

HCBS

HCBS compliance is required for providers who offer Home and Community Based Waiver services, which are long term services in the community rather than in an institution. Values that are embedded in

the regulations:

Full Community

Inclusion

Autonomy

Life Choices

HCBS - Interpretation of Regulations

Value based regulations: Challenging: significant variations in what full community

inclusion, autonomy, & making life choices looks like. A couple of the HCBS regulations are clear cut : Example: individuals will have the ability to lock their bedroom doors

for privacy.

HCBS Regulations

The setting is integrated in the greater community;

Provider supports the individual’s full access to the greatercommunity, including opportunities to support people to seekemployment, work in competitive integrated settings, engagein community life;

HCBS Regulations

People are in control of personal resources, andreceive services in the community;

The settings are selected by the individual fromamong different setting options, including non-disability specific options and an option for aprivate unit in a residential setting;

HCBS Regulations

Provider ensures an individual’s rights to privacy, dignity,respect, and freedom from coercion and restraint;

Provider optimizes individual initiative, autonomy, andindependence in making life choices, including dailyactivities, physical environment, and personalassociations; and facilitates individual choice regardingservices and supports and who provides them.

HCBS Regulations

Additional for Residential

Have a lease or other legally enforceable agreement providing similarprotections;

Have privacy in their unit, including lockable doors, choice of roommates andfreedom to furnish or decorate the unit;

Have the right to control his/her own schedule including access to food at anytime;

Have the right to visitors at any time; and Have a setting that is physically accessible. Exceptions can be made to these requirements if supported by a specific need

that is justified in the individual’s person-centered service plan – but this mustrelate to the individual, not the facility.

HCBS

Achieving compliance with broadly stated regulations

2015 submitted 1st provider self assessment

2017 submitted an updated provider self assessment after DMAS issued guidance in HCBS Toolkit documents.

2019 submitted 3rd round of provider self assessment.

This Photo by Unknown Author is licensed under CC BY

HCBS Compliance Deadlines

Statewide compliance must be met by 3/2022.

Provider compliance must be met by 3/2021.

HCBS Levels of Compliance

Full compliance or non compliance No in-between

If a provider does not meet full organizational and settings compliance by 3/2021, all of the people receiving RRCS HCBS services will have 1 year to transition to a different service provider who has achieved full compliance.

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HCBS Organizational & Settings Compliance

Organizational: The organization must have policies and systems in place that show HCBS

compliance. Full organization compliance is required before review of the setting

specific compliance can begin.

Settings: Each program location and accompanying services must meet full

compliance. RRCS – 8 group homes and day support services.

This Photo by Unknown Author is licensed under CC BY-NC-ND

HCBS RRCS – Organizational Compliance

RRCS achieved full Organizational Compliance in August, 2019.

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HCBS Settings

DMAS’ review of an agency’s settings begins after organizational compliance has been achieved.

Review consists of:

Self assessment narratives and evidence.

Reviewers visits programs

Interviews with individuals receiving services

Interviews with other stakeholders

This Photo by Unknown Author is licensed under CC BY-SA

HCBS: RRCS Focus Groups

HCBS regulations touch upon most RRCS Divisions. Internal focus groups were formed to complete projects towards compliance.

Updated and created agency and program policies, procedures, andprotocols.

Quality review of documentation and demonstration of competency ofstaff.

Updated job descriptions for DD staff

HCBS training – all DD staff & people receiving services

Program / organizational culture shift – ongoing.

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HCBS

COMPLIANCE IS CRITICALLY IMPORTANT FOR ……..

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People Living in RRCS Group Homes8 Homes

Home Town / County # of people living in the home

Foxcroft Warrenton 4Airlie Warrenton 2Evergreen Remington 4Remington Remington 4Highpoint * Culpeper 3Canterbury Culpeper 4Locust Grove Locust Grove 5Orange Orange 4

People Receiving Day Support Services –Bridges

Location # of people enrolled in Bridges Elkwood 90

County of residence # of people enrolled in Bridges Culpeper 37Fauquier 30Madison 5Orange 18

Rappahannock 0

RRCS – The Business

DIRECT SUPPORT STAFF Approximately 80 employees

BUDGET Approximately $4,189,774

COMMUNITY Availability of services

Next Steps

Inform stakeholders on HCBS requirements & impact on RRCS DD programs.

Create focus groups to include internal and external stakeholders to participate in program enhancement projects and activities.

Provide ongoing updates on progress towards compliance

Develop and modify as needed, a transition plan for Bridges.

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Bridges

Why is there a focus on Bridges going through a transition?

“CMS has issued guidance on what kinds of settings fall into the category of those that “have the effect of isolating individuals receiving Medicaid-funded HCBS from the broader community.”The guidance explains that these settings are typically designed specifically for people with disabilities (or even people with a certain type of disability). In such settings, the individuals residing within them are primarily or exclusively people with disabilities. They may be designed to provide people with disabilities with many services and activities on-site, and to offer limited, if any, interaction with the broader community.”

For more information, please contact Alison Barkoff, Director of Advocacy, at the Center for Public Representation at abarkoff@cpr-us.org, or Vania Leveille, Senior Legislative Counsel, atvleveille@aclu.org. You can also learn more about the Settings Rule at https://hcbsadvocacy.org/.January 2018. HCBS toolkit

Avoiding Parallel Worlds

Disability life: Primarily with paid staff and disability groups - Group home, Day support, Church group for people with special needs, special Olympics, some “community visits”

to fast food restaurants, library.

LIFE Townhouse with best friend, work at car dealership, sing in Church Choir, local

gym to lift weights, play Bunko with neighbors every Friday night.

Inclusion

“Inclusion is the natural state; anything else is an artificial environment. What could happen if our highest guiding principle was to ensure the natural state of inclusion continues throughout a person’s life. This would require us to hold inclusion as a higher value than services and interventions geared to “help” the person”.

“Yes, many people with disabilities may need more or different, than those without disabilities, but as previously mentioned, our communities are rich with generic (and inclusive) services”.

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Bridges

The team has done an excellent job creating many meaningful experiences for people who receive services, both on-site and in the community.

However, the reality is that there are approximately 90 people who go to one building location, which is a program only for people with Developmental Disabilities.

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Bridges

Transformation from a program to full inclusion; rather than being at aprogram and simply visiting the community.

Have a couple of base location in multiple counties.

The majority of people will be out and about, involved in daily lifeexperiences that are meaningful to each person and side by side withother members of the community.

This Photo by Unknown Author is licensed under CC BY-NC-ND

Community Sites

Some people may remain at a local community location for the majority of the day but still have opportunities to actively engage in the community.

Most people will use this same local community location as a starting and ending point of the day. Most of the day is spent along side other members of the community.

Community Life

Staff

Johnny

Sally

Petunia

Local Gym

Library Volunteer at local hospital

Morning coffee at

local coffee shop

Day Support Service Types

Group Day includes skill-building and support to gain or retain social skills, self-help skills and other necessary skills to enhance independence and increase community integration. Can occur in a center and the community.

Required staff to client ratio: 1:7

Community Engagement provides a wide variety of opportunities to build relationships and natural supports in the community, while utilizing the community as a learning environment. Occurs in the community.

Required staff to client ratio: 1:3

Bridges: Possibilities

Group Day fewer

people & smaller

location

Group Day fewer

people & smaller

location 2 or 3 “mini programs” for people who will primary receive group day services. We are at the beginning stages of identifying locations of mini programs, with integration in mind. People will still have opportunities to go into the community.

Bridges: Possibilities

We are working on the model for the remainder of people who will receive services in the community.

Still need meeting points. People arrive at the meeting points in the morning. Staff andsmall group of people (ideally no more than 3) are then out in the community all day.

Meeting points under review.

Possibly a couple of places in the community not associated with RRCS

Use current RRCS program locations as the meeting point

Bridges Transition – Financial Impact Project

Tier 1 Tier 2 Tier 3 Tier 4

Group Day: ROS $8.60 $11.25 $13.31 $17.34

Group Day: NOVA $10.01 $13.12 $15.55 $20.29

Com. Engagement ROS $14.29 $16.01 $18.38 $22.61

Com. Engagement NOVA $16.19 $18.21 $21.01 $25.98

Bridges Transition – Financial Impact Project

Considerations

Review of each person’s service type: group day, communityengagement, or combination of both.

Determining the number of staff needed to transition to new model.

Projection of Medicaid revenue based on the services and variousreimbursement rates.

Interdepartmental Collaboration

DD Programs and beyond Some examples

Transit: Rides to and from program locations / meet up spots. Use of agency vehicles as community involvement increases.

IT: Phones Devices for documentation purposes. Change methods to capture billing

QA: Review of new policies Finance: Budget impact of changes, billing This Photo by Unknown Author is licensed

under CC BY-NC