a. Waiver Services Summary. Appendix C-3 sets forth the specifications for each service that is offered under this waiver. List the services that are furnished under this waiver in the following table. If case management is not a service under the waiver, complete items C-1-b and C-1-c:
Statutory Services (check each that applies)
Alternate Service Title (if any)
Home Health Aide
Adult Day Health
Expanded Habilitation Services as provided in 42 CFR §440.180(c):
b. Alternate Provision of Case Management Services to Waiver Participants. When case management is not a waiver service, indicate how case management is furnished to waiver participants (check each that applies):
As a Medicaid State plan service under §1915(g)(1) of the Act (Targeted Case Management). Complete item C-1-c.
As an administrative activity. Complete item C-1-c.
c. Delivery of Case Management Services. Specify the entity or entities that conduct case management on behalf of waiver participants:
Qualified agencies that meet Iowa administrative code 441.24 for case management providers, or that meet Iowa Administrative code 321.21 for case management and are approved by the Iowa Department of Elder Affairs to provide case manager or that are certified as Case Manger providers under the Joint Commission on Accreditation of Health Care organizations (JCAHO), the council on Accreditation of Rehabilitation Facilities (CARF) , the Council on Quality and Leadership in Supports for People with
Disabilities, (the Council) or the Council on Accreditation of services for Families and Children (CAO)
Appendix C-2: General Service Specifications
a. Criminal History and/or Background Investigations. Specify the State’s policies concerning conducting criminal history and/or background investigations of individuals who provide waiver services(select one):
Yes. Criminal history and/or background investigations are required. Specify: (a) the types of positions (e.g., personal assistants, attendants) for which such investigations must be conducted; (b) the scope of such investigations (e.g., state, national); and, (c) the process for ensuring that mandatory investigations have been conducted. State laws, regulations and policies referenced in this description are available through the Medicaid or the operating agency (if applicable):
Iowa code requires that any employee of an agency who provides direct services to consumers under Home and Community Based Services is required to have a state and national criminal background check. Personal records are reviewed during provider site visits to ensure checks have been completed. Criminal background checks will be available for employees of consumers who chose the self-direction option but will not be required.
No. Criminal history/background investigations are not required.
b. Abuse Registry Screening. Specify whether the State requires the screening of individuals who provide waiver services through a State-maintained abuse registry (select one):
Yes. The State maintains an abuse registry and requires the screening of individuals through this registry. Specify: (a) the entity (entities) responsible for maintaining the abuse registry; (b) the types of positions for which abuse registry screenings must be conducted; and, (c) the process for ensuring that mandatory screenings have been conducted. State laws, regulations and policies referenced in this description are available through the Medicaid agency or the operating agency (if applicable):
Iowa code requires that all employees of an agency who provides direct services to consumers under Home and Community Based Services is required to be screened for abuseThe Department of Human Services maintains this registry. Personnel records are reviewed during provider site visits to ensure screenings have been conducted. Abuse Screenings will be available for employees of consumers who chose the self direction option but will not be required
No. The State does not conduct abuse registry screening.
No. Home and community-based services under this waiver are not provided in facilities subject to §1616(e) of the Act. Do not complete items c.i – c.ii.
Yes. Home and community-based are provided in facilities subject to §1616(e) of the Act. The standards that apply to each type of facility where waiver services are provided are available through the Medicaid agency or the operating agency (if applicable). Complete items c.i –c.ii.
i. Types of Facilities Subject to §1616(e). Complete the following table for each type of facility subject to §1616(e) of the Act:
Type of Facility
Provided in Facility
Facility Capacity Limit
Residential Care Facilities
Adult day Care, Consumer Directed Attendant Care, Counseling, Home and Vehicle modifications, Home delivered meals, Home health Aide, Homemaker, Interim Medical , Monitoring and Treatment, Nursing, Nutritional Counseling, Personal Emergency Response
According to the Draft Instructions 3.3 if the state does not limit the capacity state : “NA The state does not limit the capacity. The RCF range from anywhere from 5 people to 80 people
ii. Larger Facilities: In the case of residential facilities that serve four or more individuals unrelated to the proprietor, describe how a home and community character is maintained in these settings.
It is required that all consumers receiving waiver services in a Residential Care Facility have a choice of where they live and have full access to community resources and activities. This is assured during the quality assurance process that reviews with consumers to assure that the seven focus areas are met: consumers are productive, consumers use community resources, consumers have relationships, consumers have input into their service plans, consumers maintain good health, consumers are safe, consumers have impact and choice on their services. These focus areas includes such standards that consumers have privacy, have their own rooms and have access to cooking facilities.
iii. Scope of State Facility Standards. By type of facility listed in item C-2-c-I, specify whether the State’s standards address the following topics (check each that applies):
Provision of or arrangement for necessary health services
When facility standards do not address one or more of the topics listed, explain why the standard is not included or is not relevant to the facility type or population. Explain how the health and welfare of participants is assured in the standard area: