Risk Assessment, Mitigation & MonitoringRefresher, Exceptions, & Extended Waiver

Eligibility (EWE)

Presentedby

Medicaid APD Services and Supports Policy Unit

November 7, 2018

Aging and People with Disabilities

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Agenda

• Risk Assessment

(RA)

• Exceptions

• Extended Waiver

Eligibility (EWE)

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Risk Assessment

• Last training Jan. 2017, click to view full

PowerPoint

– Why assess risks?

– RA policy review

– Risk mitigation

– Risk monitoring

▪ Working these in with your Direct contacts

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Federal Requirements

• Identify specific risk

factors

• Identify ways to

mitigate/minimize risks

• Identify a back-up plan

• Monitor identified

risks/back-up plan

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Assessing for Risks to….

• Ensure consumer health and safety.

• Provide resources and information so

consumers can make an informed choice.

• Minimize identified risks.

• The goal is to reduce identified risks;

– i.e.: from High Risk to Low or No Risk.

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Secretary of State Audit

• Utilize APD' s current RA tool to identify clients most at

risk for fraud, neglect and abuse.

• Future changes to RA expectations coming in 2019.

• Today’s focus:

– Understanding current RA expectations.

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APD-PT-12-007

Frequency requirements for monitoring risks:

• No risk, low, or moderate risk factors = Two times per

year (one contact every six months)

• One or two high risk factors = quarterly (minimum of

one contact every three months)

• Three or more high risk = monthly

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Capturing Identified Risks

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How to Assess for Risks

• It’s important to select the appropriate risk

level for each risk identified in the RA.

• Assessing for risks should occur during

the assessment process.

• Includes determining if risks are being

reduced or mitigated.

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Risk Levels

• No Risk:

– Has plan and supports

in place and/or no risk

identified.

• Low Risk:

– Has plan and supports

in place but is

dependent on others

who are immediately

available.

• Moderate Risk:

– Has plan in place, but

is dependent on others

who are NOT

immediately available.

• High Risk:

– No plan in place and is

dependent on others,

but has no supports

available.

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Examples of “No Risk” Level

Physical: No physical assistance is needed.

Safety/Cleanliness of residence/Facility: No apparent

safety or cleanliness risks.

Access to care: No barriers to finding caregivers / doctors

/dental / equipment etc.

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Examples of “Low Risk” Level

Physical: Would need help to exit home but almost always

has help available.

Safety/Cleanliness of residence/Facility: Older home with

deferred maintenance, exterior paint and roof integrity

questionable. Heating and plumbing systems working but

beyond life expectancy.

Access to care: Has HCW but no back-up and access to

workers for area is difficult.

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Examples of “Moderate Risk” Level

Physical: Would need help to easily exit home and has

some help but not constantly available.

Safety/Cleanliness of residence/Facility: Older home

with roof leaking, temporary repairs made, but repairs are

needed. No means to make repairs.

Access to care: Has HCW but no back-up and access to

workers for area is difficult.

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Examples of “High Risk” Level

Physical: Cannot exit home without help and has no help

available.

Safety/Cleanliness of residence/Facility: Older home

with roof leaking, heating, electrical, and plumbing failing or

inoperable.

Access to care: Chooses to remain in rural home but

HCW / IHCAs are unavailable or unwilling to provide care.

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Risk Mitigation Examples

• Risk mitigation means taking an action which lowers the

risk.

– Risk: Consumer’s paid provider answers all

questions for them.

– Mitigation: A non-paid family member is found to act

as consumer employer representative and monitor

that care is provided as expected.

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Risk Mitigation Examples

• Risk: Consumer has

unpredictable care needs and

would benefit from ‘just in

case’ type assistance.

• Mitigation: Consumer tours

various settings and chooses

to move to an AFH.

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Risk Mitigation Examples

• Risk: Consumer is on oxygen and experiences frequent

power outages.

• Mitigation: Neighbor’s power usually goes out at same

time and has a generator that consumer can plug into

when outages happen and a back-up canister that does

not require power is in place for emergencies.

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Consumers in Facilities

• Per APD-PT-12-007, consumers living in Community Based

Care (CBC) Facility or a Nursing Facility (NF) are not

currently required to have a RA.

• One of our core goals in OAR 411-015-0000, is as follows:

– To assure that services paid by the Department, and the

setting in which they are provided are safe and adequate.

– Staff have a legal and moral responsibility to evaluate

risks anytime a consumer lives or is considering to live in

a CBC facility or a NF.

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Consumers in Facilities

• Risk mitigation: Follow similar rules as for in-home

monitoring. The higher the risk the higher the monitoring

frequency.

• As appropriate:

– Engage facility staff/management in problem solving

– Engage Licensing

– Engage Adult Protective Services

– Complete Report of Serious Event (ROSE) SDS 307A

reports per APD-PT-12-010 guidelines

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Risk Monitoring

• Risk monitoring is when the CM contacts the

consumer/representative to discuss the previously

identified risks to discuss mitigation progress, changes

or strategies.

• Risk monitoring MUST be a Direct contact.

• The CM needs to determine if an in-person contact is

needed or if a phone call is sufficient.

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Wrapping Up Risk Topic

• RAs and mitigation are not optional activities. They are

required elements of Case Management.

• People may make choices that keep them at risk but we still

have an obligation to inform and offer safer options.

• Lowering risks reduces harm and workload by decreasing

monitoring and preventing crisis situations.

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In-Home ServicesException Requests

APD-PT-18-046

Aging and People with Disabilities

2018

Scott Spencer; Exceptions Coordinator

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Decision Making Authority

• Tier 2 users = managers, lead workers, QA

• Tier 2 users can approve, partially deny or completely

deny plans with

– ADLs ≤ 73 hours

– IADLs ≤ 35 hours

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Just a reminder for Tier 2 users

Process for Tier 3 Exception Requests

• Tier 3 = CO staff

• Please let us know if you support the request

– If not, please include commentary explaining why the hours are

not support in your submission email

• Please make sure the 514 is filled out completely

• Please make sure the plan in OA is set up correctly

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Managers or supervisors must review

exception Tier 3 requests

514 Process for Tier 2 Exception Requests

• For new Tier 2 requests, please save the signed 514 locally.

• A signed 514 is no longer required for renewals ≤ the number of

exception hours previously approved.

– As long as the consumer agrees to the hours being authorized

and their agreement is recorded in the narration.

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• OAR 411-030-0071(9) is in the

process of being amended to reflect

this policy change.

– If the consumer does not agree

to receiving the same or fewer

number of hours, the consumer

should complete and sign a new

514 request.

For renewals of

plans that are

greater than 108

hours*, please

use this

template

Process for Tier 2 Exception Requests

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The following is a renewal of the current

service plan. The hours are (choose one):

same/fewer when compared to the current

service plan.

Type of request: (In-home Hourly, Shift

Service, Spousal Pay, ICP)

Consumer Name:

Consumer Prime:

Branch:

Case Manager:

Dates:

Allowed Hours:

Exception Hours:

Total Hours:

Providers:

VDQ?: Y/N

I have reviewed this request for

appropriateness: Yes or No

*CO reserves the right to

review any renewal for

appropriateness, which

includes Tier 2 approvals.

Case Manager Initiated Requests

• CMs who determine a need for exception hours, an exception to the

hourly cap, or shift services, are required to initiate the request if the

consumer is unable to.

• In this case:

– The CM may complete the 514 without the consumer’s signature.

– The request must have consent (verbally or in writing) from the

consumer prior to submission.

– The 514 must indicate that the CM is requesting the exception.

• If the consumer would like to propose a different number of hours from

the CM, they can proceed with a request through the normal process.

– The consumer must sign the 514 for any exception request they

initiate.

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New In-Home Exceptions Request Form

• Reformatted the section that requests the reason for the in-home

hours exception request

• Consumer’s or authorized representative’s printed name along with

their signature

• CM’s name, email and branch number

• The in-home provider information field was edited to improve clarity

• A brief explanation about Shift Services

The amended 514 is attached and will be updated on the CM Tools

Website Exceptions page

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We have updated the 514

New 514 Form – Page 1

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This page is for

the consumer

or CM to

complete

New 514 Form – Page 2

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This page is

for the

consumer or

CM to

complete

New 514 Form – Page 3

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This page is for

the consumer

or CM to

complete too

New 514 Form – Page 4

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This will be

translated into top

6 consumer

languages

Most of this

page is for LO

to fill out

A Few Things To Remember

• Exception hours and Hourly Cap hours must be based on

need.

• Timeframes for requests are in rule now and must be

followed.

– LO must submit the 514 within 3 business days of receipt of the

514 from the consumer.

– CO has no more than 30 days from the date of receipt of the 514

and any supporting documentation to make a determination.

– In emergency situations CO will make a decision within 2 business

days of receipt of the application (please make it clear that it’s an

emergency in your email).

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Before You Submit the Request

• Review every request!

– Consumers can request any number of hours they feel they need.

– We will only approve the minimum number of hours to meet the

consumer’s needs.

• Indicate in the email to CO (not on the 514) if the request is

appropriate.

– If not, please indicate what alternate plan you suggest (this helps

speed up the review process).

• Make sure all of the required documentation is included.

• Make sure the plan is set up and ready for approval in

Oregon ACCESS.

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Aging and People with Disabilities

Extended Waiver Eligibility (EWE)

411-015-0030

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Clarification on EWE

• Depending on the date of submission for the EWE

request and the benefit end date there may need for an

ADMIN extension.

– This is a Tier 2 extension and may be completed locally.

• If EWE is approved, there is no approved Benefit or

Service Plan in OA at this time.

– In OA it is critical each step be narrated clearly.

– This should include the decision, effective dates, actions taken or

actions that need to be taken as well as next steps.

– The coding will be completed by the Mainframe (MF) Business

Analysts.

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Required Forms and Steps

• CM completes EWE Assessment Form and the EWE

Planning Form following the instructions on page two of

the form.

– This includes clearly documenting the specific steps (local and

state resources and/or actions) that will be taken to safely

transition the consumer off LTSS over the next six months.

NOTE: The EWE Planning form requires a

consumer/rep and CM signature.

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Requirements and Steps

• If approved the supervisor/lead must send the request

including all required forms to

APD.EWE.Request@State.OR.US.

– In the subject line note that this is an EWE request

– In the body of the email be sure to include:

• Consumer’s Prime

• Consumer’s First and Last Name

• Branch Number

• Prior SPL

• Care Setting Type (i.e. AFH, ALF, RCF, In-Home or NF)

• Indicate the benefit and service plan types the consumer is

currently receiving

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Process at Central Office

• The EWE Policy Analyst will review the case.

• If approved and coded by the Mainframe Analysts complete

the appropriate step below:

– In-Home: the voucher for 10 hours per pay period may

be created.

– CBC: the 512 should be touched (should match the

effective date). Verify the base rate or level 1 is being

paid.

– NF: the POC in MMIS should be updated.

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Mainframe

• CMs only need to update

the MF when there is a

financial change.

• If any service related

case descriptors are

removed or changed

there will be an error in

payment.

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Resource Links

• CAPS Risk Assessment, Monitoring, & Documentation Netlink

• Procedures for Risk Assessments, Monitoring & Documentation

• Risk Assessment Worksheet and Guidelines

• Exceptions Webpage

• Extended Waiver Eligibility (EWE) Webpage

• Program Analyst Contact List

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