Application for a §1915 (c) hcbs waiver Submitted by



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Service Specification

Service Title:

Personal Emergency Response

Complete this part for a renewal application or a new waiver that replaces an existing waiver. Select one:

X

Service is included in current waiver. There is no change in service specifications.



Service is included in current waiver. The service specifications have been modified.



Service is not included in the current waiver.

Service Definition (Scope):

A personal emergency response system is an electronic devise that transmits a signal to a central monitoring station to summon assistance in the event of an emergency when the consumer is alone. The required components are: an in home medical communications transmitter and receiver; a remote potable activator, a central monitoring station with backup systems staffed by trained attendants at all times, current data files at the central monitoring station containing response protocols and personal, medical and emergency information for each consumer.



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

A unit of service is a one time installation fee or one month of service, maximum units per state fiscal year shall be one initial installation and 12 months of service. The initial one time fee has an upper limit and there is on going monthly fee upper limit, both are subject to change each year. The individuals’ plan of care will address how the consumer health care needs are being met. Services must be authorized in the service plan The Case Manager will monitor the plan.



Provider Specifications

Provider Category(s)

(check one or both):



Individual. List types:

X

Agency. List the types of agencies:


















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




Legally Responsible Person



Relative/Legal Guardian

Provider Qualifications (provide the following information for each type of provider):

Provider Type:

License (specify)

Certificate (specify)

Other Standard (specify)

Agency






The agency shall provide an electronic component to transmit a coded signal via digital equipment over telephone lines to a central monitoring station. The central monitoring station must operate receiving equipment and be fully staffed by trained attendants, 24 hours a day, seven days per week. The attendants must process emergency calls and ensure the timely notification of appropriate emergency resources to be dispatched to the person in need. The agency, parent agency or corporation shall have the necessary legal authority to operate in conformity with federal state and local laws and regulations. There should be a governing authority, which is responsible for establishing policy and ensuring effective control of services and finances. The governing authority shall employ or contract for an agency administration to whom authority and responsibility for overall agency administration are delegated. The agency shall be in compliance with all legislation relating to prohibition of discriminatory practices. The agency also needs to have written policies and procedures


























Verification of Provider Qualifications

Provider Type:

Entity Responsible for Verification:

Frequency of Verification

Agency

Iowa Department of Human Services Iowa Medicaid Enterprise

Verification is done at application and at least every four years.


















Service Delivery Method


Service Delivery Method (check each that applies):



Participant-directed as specified in Appendix E

X

Provider managed




Service Specification

Service Title:

Respite

Complete this part for a renewal application or a new waiver that replaces an existing waiver. Select one:

X

Service is included in current waiver. There is no change in service specifications.



Service is included in current waiver. The service specifications have been modified.



Service is not included in the current waiver.

Service Definition (Scope):

Respite care services are services provided to the consumer that give temporary relief to the usual caregiver and provide all the necessary care that the usual caregiver would provide during that time period. The purpose of respite is to enable the consumer to remain in the consumer’s current living situation. Services provided outside the consumer’s home shall not be reimbursable if the living unit where respite is provided is reserved for another person on temporary leave of absence. Staff to consumer ratios shall be appropriate to the individual needs of the consumer as determined by the consumer’s interdisciplinary team. The interdisciplinary team shall determine if the consumer will receive basic individual respite, specialized respite or group respite. Basic individual respite means respite provide on a staff-to consumer ratio to one or higher to individuals without specialized needs requiring the care of a licensed registered nurse or licensed practical nurse; group respite is respite provided on a staff to consumer ratio of less than one to one; specialized respite means respite provide on a staff to consumer ration of one to one or higher to individuals with specialized medical needs requiring the care, monitoring or supervision of a licensed registered nurse or licensed practical nurse. The payment for respite is connected to the staff to consumer ratio. Respite care is not to be provided to persons during the hours in which the usual caregiver is employed expect when the provider is a camp. Iowa has respite provider for the elderly that are provided at a camp setting.


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

A unit of service is one hour, a maximum of 14 consecutive days of 24-hour respite care may be reimbursed. Basic individual respite, Specialized respite and Group respite has an upper limit reimbursement per hour and a daily limit that they cannot not exceed. The individuals’ plan of care will address how the consumer health care needs are being met. The Case Manager will monitor the plan


Provider Specifications

Provider Category(s)

(check one or both):



Individual. List types:

X

Agency. List the types of agencies:




Home health agencies




Nursing facilities, intermediate care facilities, and hospitals




Group living foster care facilities







Camps






Home care agencies








Adult day care providers







Residential care facilities







Child care facilities







Assisted living programs







Providers enrolled as a respite provider

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



Legally Responsible Person


Relative/Legal Guardian


Provider Qualifications (provide the following information for each type of provider):

Provider Type:

License (specify)

Certificate (specify)

Other Standard (specify)

Home health agencies




Certified to participate in Medicare




Nursing facilities, intermediate care facilities and hospitals







Enrolled as providers of Medicaid

Group living foster care facilities

Licensed by the Department of Human Services according to Iowa code 441 chapters 112 and 114 to 116







Camps


Certified by the American Camping Association





Home care agencies







That meet home care standards and requirements set for in the Iowa Department of Public Health Administrative Rules 641-80.5

Adult day care providers




As certified by the Department of Inspection and appeals as being in compliance with the Iowa Department of Elder Affairs Administrative code 321




Residential care facilities

Licensed by the Iowa Department of Inspections and Appeals







Child care Facilities







Register child care centers, preschools or child development homes registered pursuant to Iowa Administrative Rules 441 chapter 110

Assisted living providers





Certified by the Iowa Department of Inspections and Appeals




Providers







Certified or enrolled as respite providers in one or more waivers

Verification of Provider Qualifications

Provider Type:

Entity Responsible for Verification:

Frequency of Verification

Home health agencies

Iowa Department of Human Services Iowa Medicaid Enterprise

Verified based on the length of the Certification or license or other standards.

Nursing Facilities, intermediate care facilities, and hospitals

The same as above

The same as above

Group living foster care facilities


The same as above

The same as above




Camps

The same as above

The same as above




Home care agencies

The same as above

The same as above




Adult day providers

The same as above

The same as above




Residential care facilities

The same as above

The same as above




Child care facilities

The same as above

The same as above




Assisted living programs

The same as above

The same as above




Providers

The same as above

The same as above

Service Delivery Method

Service Delivery Method (check each that applies):



Participant-directed as specified in Appendix E

X

Provider managed




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