Provider Service Expectations Traditional Adult Family Home SPC 202 Provider Subcontract Agreement Appendix N

Provider Service Expectations Traditional Adult Family Home SPC 202 Provider Subcontract Agreement Appendix N Purpose: Define requirements and expecta...
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Provider Service Expectations Traditional Adult Family Home SPC 202 Provider Subcontract Agreement Appendix N Purpose: Define requirements and expectations for the provision of subcontracted, authorized and rendered services. Services shall be in compliance with the Adult Family Home Subcontract Agreement and the provisions of this service expectations document.

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Service Definition

The Adult Family Home (AFH) definitions and standards are described in the Medicaid Waiver Standards for Wisconsin under SPC 202.01, SPC 202.02. Adult family homes of 1-2 beds are places in which the operator provides care, treatment, support, or services above the level of room and board for up to two adults. Services typically include supportive home care, personal care and supervision. Services may also include transportation and recreational/social activities, behavior and social supports, daily living skills training and transportation if provided by the operator or designee of the operator. Includes homes that are the primary domicile of the operator or homes where staff are hired by a third party who also controls the place. Adult family home services also include coordination with other services received by the participant and providers, including health care services, vocational or day services. Adult family homes of 3-4 beds are places where 3-4 adults who are not related to the operator reside and receive care, treatment or services above the level of room and board and that may include up to seven hours of nursing care per resident. Services typically include supportive home care, personal care and supervision. Services may also include behavior and social supports, daily living skills training and transportation performed by the operator or designee of the operator. Includes homes that are the primary domicile of the operator or homes where staff are hired by a third party who also controls the place. Also includes homes specified under s. 50.01 (1) (a) 1 of the Wisconsin Statutes and certified under HFS 82 of the Wisconsin Administrative Code. Traditional owner-occupied adult family home (1-2 bed or 3-4 bed) Sponsor/Operator lives in and home is primary residence. The level of training, expertise, and program development is expected to be at a standard level. Training opportunities for these providers are offered through the MCO. Provider is reimbursed at traditional AFH level using the member’s acuity score. Provider is responsible for obtaining substitute caregiver options for members; provider reimburses substitute caregiver for services. Traditional staffed adult family home (1-2 bed or 3-4 bed) Provider does not live in this home; therefore this home is not the primary residence of provider. The level of training, expertise, and program development is expected to be at a standard level. Training opportunities for these providers are offered through the MCO. Provider is reimbursed at traditional AFH level using the member’s acuity score. Provider is responsible for obtaining substitute caregiver options for members; provider reimburses substitute caregiver for services.

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Standards of Service Provider must follow Medicaid Standards for Adult Family Home Services or DHS 88 Licensed Adult Family Home regulations. These Provider Service Expectations reflect the Standards and regulations. An asterisk* reflects a Medicaid standard and/or DHS regulation reference throughout the document.

As indicated by the State of Wisconsin, Department of Health Services (DHS), WWC shall authorized provision of services in the most integrated residential setting consistent with the member’s long-term care outcomes, and identified needs, and that is cost-effective when compared to alternative services that could meet the same needs and support similar outcomes. Residential care services are services through which a member is supported to live in a setting other than the member’s own home.

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Residential care services are appropriate when:  The member’s long-term care outcomes cannot be cost-effectively supported in the member’s home, or  when the member’s health and safety cannot be adequately safe-guarded in the member’s home; or  Residential care services are a cost-effective option for meeting that member’s long-term care needs. Furthermore, provider will ensure the setting in which the member resides supports integration into the greater community, including opportunities to seek employment and work in competitive settings, engage in community life, control personal resources, and receive services in the community.

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All 1-2 Bed Adult Family Homes shall be certified by a qualified certifying agency. All 3-4 bed Adult Family Homes shall be licensed pursuant to standards established by the Department of Health Services. DHS 88 contains the regulations and standards governing this service and DHS 50 contain the general licensing requirements. *1-2 Bed Adult Family Home providers shall comply with all applicable requirements of the Wisconsin Medicaid Standards, including Article V. Requirements for the Home, VI. Sponsor, Operator, and Staff Qualifications, VIII Sponsor or Operator Responsibilities, Article IX. D-I, Services; and Article X. Resident Rights. *3-4 Bed Adult Family Home providers shall comply with all applicable requirements of DHS Chapter 88.04, 88.07, 88.10, 88.11 and any other regulations related to roles and responsibilities. Service must be provided in a manner which honors member’s rights such as consideration for member preferences (scheduling, choice of provider, direction of work), and consideration for common courtesies such as timeliness and reliability. WWC subcontracted providers of long-term care services are prohibited from influencing members’ choice of long-term care program, provider, or Managed Care Organization (MCO) through communications that are misleading, threatening or coercive. WWC and/or the WI Department of Health Services may impose sanctions against a provider that does so. If any provider considers it in the best interest of a client to learn about other options, they should refer the individual to the ADRC to learn about alternatives; the provider should not provide options/enrollment counseling directly. In addition, the ADRC has the responsibility to inform the customer about his/her rights as a program participant or facility resident, in order to prevent intimidation or coercion of a consumer by a provider. Reference: State of Wisconsin Department of Health Services 2011.0302 Memo: Influencing the Exercise of Participant Freedom of Choice

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Service Description *Physical Environment (Room and Board) – SPC 202.01 and 202.02 In addition to requirements set forth for the physical environment within DHS Chapter 88 or WI Medicaid Standards and Certifying Agency requirements, the following general components of the physical environment must be met: 1. Physical Space- sleeping accommodations in compliance with regulations including access to all common areas of the home and grounds. 2. Furnishings - all common area furnishings and bedroom furnishings (member may bring their own bedroom furniture) including all of the following: bed, mattress with pad, dresser and/or closet, pillows, bedspreads, blankets, sheets, pillowcases, towels and washcloths, window coverings, floor coverings.

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3. Provide a home atmosphere which is safe, warm, stable and accepting of the member. 4. Housekeeping- including laundry service and supplies, cleaning supplies and services, refuse containers/bags and paper goods (toilet paper, paper towel, facial tissue). 5. Home Maintenance - including interior and exterior structure integrity and upkeep, pest control, and refuse disposal 6. Outside Maintenance – including landscaping maintenance, driveway, walkway maintenance, as well as snow and ice removal from all walkways, driveways and overhangs. If a rental, ensuring landlord completes as needed. 7. Home Support Systems- including heating, cooling, air purification, as well as water and electrical systems installation, maintenance and utilization costs. If a rental, ensuring landlord provides and maintains as needed. 8. Fire and Safety Systems- including installation, inspection and maintenance costs. If a rental, ensuring landlord completes as needed. 9. Food and beverages- 3 meals plus snacks, including any special dietary accommodations, as well as consideration for individual preferences and/or cultural or religious customs of the individual resident. For enteral nutrition, refer to section 4.1 under room & board. 10. Telephone and Media Access- access to make and receive calls and acquisition of information and news (e.g. television, newspaper). Cable television and Internet access if the AFH provider purchases this service already for the home. *Program Services (Care and Supervision) – SPC 202.11 and 202.22 1. Supervision- adequate and qualified sponsor/operator/staff to meet the scheduled and unscheduled needs of members 24 hours a day when member is present in the home. 2. Personal and supportive care- assistance with activities of daily living and daily living skills training to achieve optimal independence. 3. Group and individual activities, socialization and community integration activities- including leisure activities, a minimum of one community integration opportunity per week and assistance with socialization with family and other social contacts. 4. Health Monitoring- including coordination of medical appointments and accompanying members to medical service when necessary, reporting medical or significant medication changes to Western Wisconsin Cares Team. 5. Medication Management and Administration- including managing and monitoring the selfadministration of medications. 6. Behavior support strategies to support member’s outcomes, including participation with the MCO in the implementation of Behavior Support Plans (see section 3.4) when applicable. 7. Transportation: This includes providing, arranging, transporting or accompanying a member to leisure and recreational activities, employment and other activities identified in the member’s Plan of Care. *Plan of Care (Service Plan) The level and type of care and supervision required for a member living in a traditional AFH is specified by the Plan of Care, and is completed by the WWC Team, member/member’s guardian and AFH provider to accurately account for the member’s care needs. The Plan of Care covers the level of need, frequency, and type of support required in the following areas:  Personal Care  Medical/Physical Health  Behavioral  Mental Health/AODA  Supervision  Transportation  Daytime Routine  Daily Living Skills A Plan of Care is required prior to admission in a traditional adult family home. The Plan of Care shall be

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reviewed during each Member Centered Plan meeting and updated whenever a change in any provision occurs or when requested by the member or member’s guardian. The WWC Team is responsible for updating the Plan of Care document and ensuring this Plan is signed by required parties and distributed to all IDT members. The WWC Team will obtain the required signatures and provide a copy of the final Plan Of Care to the member, guardian, and AFH Provider. AFH should sign the Plan Of Care when all cares they provide or are expected to provide to the member are sufficiently documented. *Firearms in a Traditional Adult Family Home 1-2 Bed AFH providers shall comply with provisions as established in the WI Medicaid Standards for 1-2 Bed Adult Family Homes, Article V, C 12. Firearms or other dangerous weapons may be kept in an adult family home only when stored and locked in an area that is not accessible to members. Ammunition will be stored and locked separately from firearms. Trigger locks alone do not meet this requirement. Roles of WWC Staff Western Wisconsin Cares acts as the certifying agency when applicable and placing agency for adult family home services. WWC Team (care manager and RN)  Care Manager The care manager is responsible for identifying member service needs using the RAD process and to authorize the service(s) needed to meet the member’s long term care outcomes. The WWC Team coordinates moving member’s belongings and medications at member move in and in the event of the member moving out. The care manager will also coordinate other ancillary services for the member at the time of placement. The care manager is the provider agency’s main point of contact for member specific or related questions, concerns, or information.  RN WWC RNs have an ongoing responsibility to assess and review how the member is doing clinically and educate member/provider on health related issues. WWC RN’s do not provide direct care services, supervision of AFH providers or supervisory visits for nurse delegated tasks. WWC nurses do not delegate tasks to personnel from any provider agency or self directed support. Responsibilities of the WWC team:  The WWC team is responsible to provide member specific training, direction and support as well as monitoring the member’s placement in the adult family home. Monitoring a member’s placement includes informing and updating the member’s schedule, level of supervision, preferences, family involvement, medical, personal care, emotional/mental health/behavioral needs, etc. Monitoring the member’s placement also includes visiting the member at least four times per year with two of these visits occurring in the adult family home to assess the member’s satisfaction with their current living arrangement.  The WWC team is responsible to complete and provide the traditional AFH with a copy of the member’s Plan of Care (POC) prior to the member admission.  The WWC team is also responsible to monitor the services delegated to the AFH documented in the Plan of Care. Provider Network  Residential Coordinator The Residential Coordinator is assigned referrals for members needing various levels of residential services in the Family Care program. The Residential Coordinator works with the team and eligible, subcontracted provider agencies to find appropriate and cost effective residential options when a member need has been identified by the WWC team. The Residential Coordinator is responsible for communicating the care and supervision rate to the provider.  AFH Coordinator

The AFH Coordinator assists the provider in understanding and complying with 1-2 bed AFH Standards and WWC policy and procedure related to the AFH program. The AFH Coordinator is the main point of contact for all issues, questions, or comments regarding the role and responsibility of being a certified 1-2 bed certified AFH provider. Conflicts of Interest

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1-2 Bed Adult Family Home providers will abide by the WI Medicaid Standards for 1-2 bed Adult Family Homes related to Conflict of Interest, Article VI, 5. Traditional Adult Family Home providers will ensure in instances where a conflict of interest exists, but cannot be eliminated the following occurs:  Inform WWC Team and member/member guardian of conflict of interest immediately upon identification of such conflict  Work collaboratively with WWC Team and Guardian to manage conflict  Document conflict of interest in member record, summarizing discussion of conflict with member and others involved and how conflict will be addressed/managed Adult Family Home providers who are also member relatives and/or relative guardians will follow all requirements in place by certifying and/or placing agency. 1-2 Bed Adult Family Homes who are relatives or relative guardians shall comply with WI Medicaid Standards Article VII. Certification of Relatives/Guardians of Residents. WWC does not certify non-relative guardians for paid adult family home services. Respite Care in a 1-2 bed Traditional Adult Family Home Traditional Adult Family Home providers must be approved and contracted to provide WWC funded respite services. 1-2 Bed AFH providers shall comply with all provisions established in the WI Medicaid Standards for 1-2 Bed Adult Family Homes. 1-2 Bed AFH providers providing respite services in the AFH requires an exception notice documented on the AFH certificate.

Units of Service and Reimbursement Guidelines Traditional Adult Family Home services are billed with the indicated SPC and procedure code at the daily rate as defined in Appendix A of the Adult Family Home Agreement and Residential Rate Agreement. The daily rate paid to a Traditional Adult Family Home is comprised of two portions: room & board and care & supervision. Care and Supervision Adult Family Home 1-2 Beds- SPC: 202.11, Procedure code 0240 Adult Family Home 3-4 Beds- SPC: 202.22, Procedure code 0241 Care & Supervision rates are established by WWC using the member’s functional and behavioral acuity. Rates are agreed to between the provider agency and WWC Provider Network department in writing.

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Room and Board SPC: 202.01 (Room & Board) for Adult Family Home 1- 2 Beds SPC: 202.02 (Room &Board) for Adult Family Home 3-4 Beds The room and board portion of the daily rate is a standardized amount for all members established using the member’s Social Security Income. Shared Bedrooms and Enteral Feeding  If a WWC member is placed in a shared bedroom, the room and board portion of the daily rate will be adjusted to pay 100% of the board portion and 70% of the rent portion of the daily rate.  If a member requires enteral/tube feeding, the food portion of the room & board amount is removed from the daily rate. WWC pays the enteral/tube feeding cost separately. The AFH provider and WWC Provider Network shall sign a rate agreement for referred member when a placement occurs. Rate agreements not returned within expected timeframes may result in provider

payments being held until the rate agreement is received. AFH services are billed in daily units. Adult family homes are required to provide for all care needs identified in regulatory language, these provider service expectations, and the Plan of Care or Individual Service Plan. Providers are specifically prohibited from billing for additional services not authorized in the service plan or included in the member specific rate.

Sponsor, Staff and Substitute Care Qualifications & Training

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Caregiver Background Checks Providers will comply with all applicable standards and/or regulations related to caregiver background checks as well as comply with the WWC policy on Caregiver Background Checks. Adult Family Home Providers are independent subcontractors whose responsibility is for the day-to-day supervision, support and care of the WWC member. AFH providers will work collaboratively with guardians, other member care providers, financial representatives, the WWC team and other WWC representatives. 

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1-2 Bed AFH providers must comply with all WI Medicaid Standards for Certified 1-2 Bed Adult Family Homes related to Sponsor, Operator, and Staff Qualifications (Article VI).  3-4 Bed AFH providers must comply with DHS 88.04 regulations related to staff qualifications. Minimum Training Requirements 1-2 Bed AFH providers must comply with all WI Medicaid Standards for Certified 1-2 Bed Adult Family Homes related to Sponsor, Operator, and Staff Qualifications-Training (Article VI, 8). 3-4 Bed AFH providers must comply with DHS 88.04, (5) regulations related to Training. In addition to, or as part of, the minimum regulatory training requirements listed above, Traditional Adult Family Home providers are also expected to have the following training or documented experience: WWC Orientation Training Provided by Adult Family Home Coordinator during certification or entering WWC provider network  Family Care, Western Wisconsin Cares, target groups served  Confidentiality  record keeping, reporting requirements, arranging back up services  Medication management and administration  Member rights and responsibilities  Understanding the principles of person-centered services  Maintaining appropriate personal and professional boundaries with member’s served  Understanding good nutrition, special diets and meal planning  Effective communication skills  Responding with emotional support and empathy  Procedures for handling conflict and complaints  Respecting personal property Member-Specific Training Provided by WWC Team at time of member placement in home  Member-specific information including needs, functional capacities, strengths and abilities, and preferences,  Adapting teaching styles, as applicable, to individual learning style  Preferences in provision of assistance with activities of daily living  Preferences in housekeeping and shopping  Member care plans and individualized care needs  Involvement with and encouragement of natural supports  Respecting cultural, spiritual differences and family relationships  Behavior support techniques and crisis prevention  Skill training techniques and positive practice techniques, for example: visual cueing, shaping,

backward chaining, and self-charting Team to provider communication preferences Assessment and guidance on provider’s direct care ability (transfers, repositioning, range of motion, etc) Traditional Adult Family Homes employing staff will ensure all employees who work with WWC members and substitute caregivers meet the training requirements and expectations listed above. Training records of employees will be made available for review by WWC representatives upon request. Documentation of Required Training 1-2 Bed Traditional Adult Family Homes: Sponsor and any co-sponsor will retain accurate and current training records in the Provider Binder. 3-4 Bed Traditional Adult Family Homes: Sponsor and any co-sponsor will retain accurate and current training records in the Provider Binder or other record keeping system approved by the licensing agency. Should WWC Quality Assurance Department identify a trend or significant occurrence related to Quality Alerts or Critical Incidents, WWC or licensing agency may require as part of a plan correction, evidence of training of specific modules or outside consultant to provide training to agency staff on area of concern. Training records are reviewed annually for 1-2 bed adult family homes as part of the certification renewal process. Substitute Caregivers All substitute caregivers used by Traditional Adult Family Home providers must comply with all applicable provisions established in WI Medicaid Standards for 1-2 Bed Adult Family Homes or DHS 88 Licensed Adult Family Homes. It is the responsibility of the Traditional Adult Family Home to complete, submit to WWC, and retain required substitute caregiver paperwork as defined by WWC and listed below for each substitute caregiver for WWC members. Substitute care cannot begin until all paperwork is completed and WWC has conducted the caregiver background check and provided approval. 1. Substitute Caregiver Checklist; 2. Background Information Disclosure completed and signed/dated by the potential substitute caregiver and caregiver background check results. If the member will be staying at the home of the substitute caregiver, all household members over the age of 18 years must have this form completed. WWC conducts the full caregiver background check for up to four (4) substitute caregivers per AFH. 3. “Expectations and Quality of Care” form with each substitute caregiver; 4. “Substitute Caregiver Home Visit Checklist” if substitute care will be provided in the substitute caregiver’s home. Adult Family Home provider shall conduct a site visit the home of the substitute caregiver. Traditional Adult Family Home provider is responsible for training all substitute caregivers on the member’s support needs (personal care, transferring, ROM, medication administration, etc). This is to be done prior to substitute care being utilized. Traditional Adult Family Home provider is responsible for all transportation to and from substitute care, unless other arrangements are made between adult family home and substitute caregiver. Traditional Adult Family Home provider is responsible for providing each substitute caregiver a complete and current copy of the Member Information Sheet for Substitute Caregivers. The information on this form must be reviewed regularly (at each Member Centered Plan or if there is any significant change with member) and updated with any changes.  

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Supervision and Staff Adequacy All staff employed by Traditional Adult Family Home providers must comply with all applicable provisions established in WI Medicaid Standards for 1-2 Bed Adult Family Homes or DHS 88 Licensed Adult Family Homes. The provider shall maintain adequate staffing/coverage to meet the needs of members referred by WWC and accepted by the AFH for service and in compliance with licensure or certification. Traditional AFH providers with staff: Sponsor/Operator will ensure:



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Staff are supervised and assessed to assure they are working effectively and collaboratively with members by conducting adequate on-site supervision and review.  Performance issues with staff are addressed promptly, WWC teams are kept informed about significant issues that affect the WWC member.  Supervisory staff are involved in assessment, goal planning and tracking, and supervision for WWC members.  Provider staff are working collaboratively and communicating effectively with WWC staff Provider must have a written, formal plan for arranging backup when the assigned care provider is not available.

Referral and Authorization Member referrals for Traditional Adult Family Home (TAFH) services are submitted to the WWC Provider Network Department by the WWC team. The WWC Provider Network Residential Coordinator assists in identifying potential provider matches between the member’s needs and TAFH options. The Residential Coordinator contacts potential provider matches to identify availability and ability of provider to care for member. The Residential Coordinator communicates available options to the WWC team. The WWC team will contact the provider to discuss the member’s needs in depth so both parties are able to determine appropriateness of the referral. This is considered a verbal referral which is an assessment of the services needed for the member cares. Initial Meetings and Pre-placement visits There will be an introductory meeting established by the WWC team to include the member, guardian, and WWC Team. The WWC team schedules and coordinates pre-placement visits between the member and AFH provider. Visits will be scheduled based upon the individual needs of the member and AFH Provider. Preplacement visit may be requested for several hours, during mealtime or overnight. Pre-placement visits may not exceed three (3) days. The WWC team and provider should agree on the length of time for the pre-placement visit. The WWC team authorizes payment for pre-placement visits. Payment for a non-emergency overnight visit is $50 per night. Traditional Adult Family Home provider must accept or decline the referral and rate within two (2) business days or less from receiving the rate information. Upon agreement of placement, WWC team will give provider a written member Plan Of Care detailing supports needed as well as documents from the Member Placement Packet. The WWC team will also provide the most current Member Centered Plan (MCP) and any behavior support plan and/or crisis plan for the member. Services should not commence and will not be reimbursed for until provider network has contacted the AFH provider or vice versa and a rate agreement is complete or in process with an effective date and rate in place. Authorizations for Member Services Current and active authorizations are obtained by accessing the WWC Provider Portal. Providers must sign up with WWC to access the portal. The provider agency is responsible for ensuring only currently employed and authorized staff have access to the WWC provider portal and using the member authorization information available on the portal to bill for services accurately. Questions on active authorizations should be directed to the WWC team. For authorization needs during normal WWC business hours (8:00 a.m.-4:30 p.m.), the provider should contact 1) the WWC team, if not available 2) the WWC team’s Unit Manager, if not available 3) the OnCall Unit Manager. For authorization of services or products after WWC business hours, providers contact the After-Hours Authorization Line at (877) 657-8766.

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Communication, Reporting, and Documentation WWC communicates with Traditional Adult Family Home providers regularly in the following formats:  Quarterly AFH newsletter  Mass notifications via email, fax, or mail  Facilitating distribution and availability of the AFCN training newsletter  Notices for expiring credentialing documents such as insurance, backgrounds checks, etc. Notices are sent to Traditional Adult Family Home providers via email when the provider has email available to ensure timeliness and cost effectiveness of communication. Traditional Adult Family Home providers are required to ensure WWC Provider Network, WWC Care Teams, guardians and other identified members of the interdisciplinary team for a member have accurate and current contact information to include phone numbers, fax numbers, and email addresses at all times. Notification to the AFH Coordinator Provider will notify the WWC AFH Coordinator immediately of:  Any major family illness  Any changes in household occupants  Any future planned relocation or move. The new home environment must be certified before providing service. Member Discretionary Funds Notify WWC Team and legal guardian (if any) if member discretionary funds exceed $200.00 at any one time to arrange for disposition of the excess funds. AFH is barred from handling more than two hundred ($200) dollars of member discretionary funds at any one time. AFH provider will not co-mingle member funds with AFH funds. Behavior Support Planning and Implementation Providers will comply with all aspects of implementation, documentation, communication, reporting and timelines when behavior support plans are in place for a member receiving services. Providers will comply with the WWC Provider Policy on Behavior Support Plans which can be found on the WWC website: www.wwcares.org > Providers > Provider Policy & Procedure Communication of Member Absences from the AFH Providers will comply with the WWC Provider Policy for Member Absences and Change In Condition Reporting in Residential Settings. The provider shall use the WWC Member Absence form which can be found on the WWC website: www.wwcares.org > Providers > Forms Communication of Member Change in Condition Providers will comply with the WWC Provider Policy for member Absences and Change In Condition Reporting in Residential Settings. To communicate a significant member change in condition, provider shall use the WWC Member Change in Condition Notification form, which can be found on the WWC website: www.wwcares.org > Providers> Forms. Member Incidents Provider agencies shall report all member incidents to the WWC team. Providers must promptly communicate with the WWC team regarding any incidents, situations or conditions that have endangered or, if not addressed, may endanger the health and safety of the member. Acceptable means of communicating member incidents to the WWC team would be via phone, fax or email within 24 hours. Additional documentation of incidents may be requested by the WWC team or WWC Quality Assurance. Providers and WWC will comply with the WWC Incident Reporting Policy which is available on the WWC website at: www.wwcares.org > Providers > Provider Policy & Procedure. The provider agency shall give at least 30 days advance notice to the WWC team when it’s unable to provide authorized services to an individual member. The provider agency shall be responsible to

provide authorized services during this time period. The WWC team or designated staff person will notify the provider agency when services are to be discontinued. The WWC team will make every effort to notify the provider at least 30 days in advance. Program Statement All Traditional Adult Family Homes are required to have a program statement. A program statement template is provided by WWC for provider use. The template can be found at www.wwcares.org > Providers > Provider Forms > Traditional Adult Family Homes Traditional Adult Family Home providers shall comply with applicable provisions established in the WI Medicaid Standards for 1-2 bed Adult Family Homes or DHS 88 Licensed Adult Family Homes related to Program Statement requirements. 8.9*  Provider’s program statement shall be provided the potential member for placement, their guardians, and the WWC Team. WWC will facilitate this during the referral process; however, AFH providers should make available a copy at their adult family home site(s).  WWC must give 30 day prior approval to any change in an adult family home provider’s program statement. AFH is responsible to notify residents and their guardians of any change 60 days prior to the change occurring. This provision will apply to both 1-2 bed and 3-4 bed adult family homes. Member Records 1-2 Bed Adult Family Homes will comply with provisions established in WI Medicaid Standards for 1-2 Bed Adult Family Homes Article XI. Records and Reports and with additional requirements as established in this document.  WWC supplies 1-2 Bed AFH providers a member binder with required document tabs at the time of each member placement. All member records indicated shall be stored in the binder system, with the most recent document on top.  WWC representatives will review member records regularly. If provider submits a member 8.10* record document to WWC, provider must also retain this record in the member binder. 3-4 Bed Adult Family Homes will comply with provisions established in DHS88.09- Records (1) Resident Records and with additional requirements as established in this document.  3-4 Bed AFH Providers are required per regulations to have a service agreement with each member accepted to the home, prior to admission. An individual service plan and assessment is required for each member resident within 30 days after placement.  WWC representatives will review member records regularly. If provider submits a member record document to WWC, provider must also retain this record in their member record. Member Cash Logs, Medication Administration Records (MAR), and Health Visit Records Traditional Adult Family Home providers required to retain member financial records (cash log) and/or medication administration records (MAR), as indicated on the member’s Plan of Care, must complete these records as each transaction or administration occurs. Specifically, the MAR is required to be completed at each medication administration/assistance activity.

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Submission Timeframes:  AFH Providers shall submit Cash Log and Medication Administration Record (MAR) documents to WWC by the 5th of the following month from when they were completed.  AFH Providers shall submit Health Visit Records to the WWC Team within 48 hours of the appointment. Submission Instructions: Member documents and records listed above shall be submitted in one of the following ways: Fax to member’s WWC office, Email to the WWC Office Member File, or Mail to the member’s WWC office. Email WWC La Crosse Office: WWC Sparta Office: WWC Blair Office: WWC Mondovi Office:

[email protected] [email protected] [email protected] [email protected]

Fax 608-785-6315 608-785-5330 608-785-5331 608-785-5331

WWC Neillsville Office:

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[email protected]

608-785-5333

Copies of required member records in electronic and/or ‘print and write’ forms are available for providers at: www.wwcares.org > Providers > Provider Forms > Traditional Adult Family Homes.  If the AFH provider utilizes electronic documents, these documents should be stored in a similar manner electronically as the binder system. Document titles should include the name of the document, member name, and date of record. All electronic member documents should be available for WWC representative review. Member Records not completed, not completed as administered, or completed in advance may result in loss of certification or subcontract. The provider must maintain the following documentation for sponsor and/or staff and make available for review by WWC upon request:  Provider meets the required standards for applicable staff qualification, training and programming  Verification of criminal, caregiver and licensing background checks as required  When staff are employed, policy and procedure related to supervision methods by the provider including frequency, intensity and any changes in supervision  Process for responding to complaints, inappropriate practices, or matters qualifying as memberrelated incidents  When staff are employed, policy and procedure regarding work rules, work ethics and reporting variances to the program supervisor  When staff are employed, employee time sheets which support billing to WWC

Quality Assurance Purpose WWC quality assurance activities are a systematic, departmental approach to ensuring and recognizing a specified standard or level of care expected of subcontracted providers. These methodologies are established to review and inspect subcontracted provider performance and compliance.

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WWC will measure a spectrum of outcomes against set standards to elicit the best picture of provider quality. WWC provider quality assurance practices:  establish the definition of quality services;  assess and document performance against these standards; and  detail corrective measures to be taken if problems are detected It is the responsibility of providers and provider agencies to maintain the regulatory and contractual standards as outlined in this section. WWC will monitor compliance with these standards to ensure the services purchased are of the highest quality.

9.2

Resulting action may include recognition of performance at or above acceptable standards, working with the provider to repair and correct performance if it is below an acceptable standard, or action up to termination of services and/or contract should there be failure to achieve acceptable standards and compliance with contract expectations. Quality Performance Indicators  Legal/Regulatory Compliance- evidenced by regulatory review with no deficiencies, type of deficiency and/or effective and timely response to Statement of Deficiency  Education/Training of staff- Effective training of staff members in all aspects of their job, including handling emergency situations. Established procedures for appraising staff performance and for effectively modifying poor performance where it exists.  Performance record of contracted activitieso tracking of number, frequency, and outcomes of assigned WWC Quality Teams related to provider performance o tracking of successful service provision (member achieving goals/outcomes, increased

member independence and community participation, etc.) Contract Compliance- formal or informal review and identification of compliance with WWC contract terms, provider service expectation terms, applicable policies/procedures for WWC contracted providers  Availability and Responsiveness- related to referrals or updates to services, reporting and communication activities with WWC WWC Sources and Activities for Measuring Provider Performance  Member satisfaction surveys  Internal or external complaints and compliments  Onsite review/audits  Statement of Deficiency (SOD)- state regulated entities  Quality Teams- as assigned based on significant incidents, trend in quality concerns or memberrelated incidents, or issued Statement of Deficiency.  Tracking of performance and compliance in relation to the subcontract agreement and appendices  Statistical reviews of time between referral and service commencement Expectations of Providers and WWC for Quality Assurance Activities  Collaboration: working in a goal oriented, professional, and team based approach with WWC representatives to identify core issues to quality concerns, strategies to improve, and implementing those strategies  Responsiveness: actions taken upon request and in a timely manner to resolve and improve identified issues. This may include submitted documents to WWC, responding to calls, emails, or other inquiries, keeping WWC designated staff informed of progress, barriers, and milestones achieved during quality improvement activities  Systems perspective to improvement: approaching a quality concern, trend, or significant incident with the purpose of creating overall improvements that will not only resolve the issue at hand, but improve service and operations as a whole  Member-centered solutions to issues: relentlessly striving to implement solutions with the focus on keeping services member-centered and achieving the goals and outcomes identified for persons served WWC is committed to interfacing with providers to collaboratively and proactively discuss issues identified with processes and assist with implementing improvements and reviewing the impact of the changes as a partner in the mission to serve members. 

9.3

9.4

PSE #:

6.6202.1

Date Issued Document Owner Contract Reference

January 1, 2014 S Strittmater Subcontract Appendix N

DT Approval Date: State Approval Date: Next Review Date:

N/A 8/1/2016

Revision History: Revision #

Date

1

11/1/13

2

11/1/15

Description of Changes/Reason Initial Draft Re-formatted to standard layout, standardized language used, updated to reflect new provider policies and contract language

Requested By Stacey Strittmater Stacey Strittmater

When Staff Instructed