20 CAR Part 621 — Home and Community-Based Services for Clients with Intellectual Disabilities and Behavioral Health Needs Provider Manual

Chapter XV

Subchapter B

20 CAR pt. 621 Home and Community-Based Services for Clients with Intellectual Disabilities and Behavioral Health Needs Provider Manual {#sec-20-car-pt.-621 omnilex-key=us-ar-regs-official--title-20-part-621--20 CAR pt. 621}

Home and Community-Based Services for Clients with Intellectual Disabilities and Behavioral Health Needs Section II

SECTION II - HOME AND COMMUNITY-BASED SERVICES FOR CLIENTS WITH INTELLECTUAL DISABILITIES AND BEHAVIORAL HEALTH NEEDS CONTENTS

200.000 GENERAL INFORMATION 201.000 Introduction 202.000 Arkansas Medicaid Participation Requirements for Home and Community-Based Services 203.000 Provider Certification Requirements 210.000 HOME AND COMMUNITY-BASED SERVICES UNDER ABHSCI 210.100 Partial Hospitalization 210.110 Adult Rehabilitative Day Service 210.120 Supportive Employment 210.130 Supportive Housing 210.140 Adult Life Skills Development 210.150 Peer Support 210.160 Treatment Plan 210.170 Aftercare Recovery Support (for Substance Abuse) 210.180 Therapeutic Communities 210.190 Assertive Community Treatment 220.000 HOME AND COMMUNITY-BASED SERVICES UNDER PASSE 220.100 Behavioral Assistance 220.110 Crisis Stabilization Intervention 220.120 Assertive Community Treatment 220.130 Intensive In-Home (IIH for Children) 220.140 Adult Rehabilitative Day Service 220.150 Peer Support 220.160 Family Support Partners 220.170 Pharmacologic Counseling by RN 220.180 Respite 220.190 Supportive Life Skills Development 220.200 Child and Youth Support Services 220.210 Supportive Employment 220.220 Supportive Housing 220.230 Partial Hospitalization 220.240 Therapeutic Host Homes 220.250 Aftercare Recovery Support (for Substance Abuse) 220.260 Substance Abuse Detox (Observational) 220.270 Therapeutic Communities 220.280 Residential Community Reintegration Program 220.290 CES Supported Employment 220.300 Supportive Living 220.310 Complex Care Homes for IDD 220.320 Adaptive Equipment 220.330 Community Transition Services 220.340 Consultation 220.350 Environmental Modifications 220.360 Supplemental Support 220.370 Respite 220.380 Specialized Medical Supplies 230.000 REIMBURSEMENT 230.100 Method of Reimbursement 230.200 Fee Schedules

Home and Community-Based Services for Clients with Intellectual Disabilities and Behavioral Health Needs Section II

200.000 GENERAL INFORMATION

201.000 Introduction

1-1 -23

Home and Community-Based Services are person-centered care delivered in the home or

community to address a functional deficit or limitation. They are designed to keep clients in their

communities.

The services outlined in this manual are contained in either the 1915(i) State Plan Amendment or

the 1915(c) Community and Employment Supports Waiver for Provider-led Arkansas Shared

Savings Entity (PASSE).

202.000 Arkansas Medicaid Participation Requirements for Home and

Community-Based Services

1-1 -23

Home and Community Based Services are limited to the following populations: PASSE members

and Behavioral Health Adults receiving 1915i HCBS services outside of the PASSE.

203.000 Provider Certification Requirements

1-1 -23

Providers who perform HCBS under this manual must be certified by the Division of Provider

Services and Quality Assurance (DPSQA) or the Division of Developmental Disabilities Services

(DDS) as one of the following:

1. An Outpatient Behavioral Health Agency (OBHA)
2. A Community and Employment Support Waiver Provider (CES Waiver Provider)
3. A Community Support Systems Provider (CSSP)

In addition to certification, providers who perform HCBS under this manual must be enrolled in

Medicaid, and in good standing.

Providers who serve PASSE members must also be credentialed as a home and community-

based provider with the PASSEs.

210.000 HOME AND COMMUNITY-BASED SERVICES UNDER ABHSCI

210.100 Partial Hospitalization 1-1 -23 Partial Hospitalization is an intensive nonresidential, therapeutic treatment program. It can be used as an alternative to and/or a step-down service from inpatient residential treatment or to stabilize a deteriorating condition and avert hospitalization. The program provides clinical treatment services in a stable environment on a level equal to an inpatient program, but on a less than 24-hour basis. The environment at this level of treatment is highly structured and should maintain a staff-to-patient ratio of no more than 1:5 to ensure necessary therapeutic services and professional monitoring, control, and protection. This service shall include at a minimum: intake, individual therapy, group therapy, and psychoeducation. Partial Hospitalization shall be at a minimum of (5) five hours per day, of which 90 minutes must be a documented service provided by a Mental Health Professional. If a client member receives other services during the week but also receives Partial Hospitalization, the client member must receive, at a minimum, 20 documented hours of services on no less than (4) four days in that week. Partial Hospitalization can occur in a variety of clinical settings for adults, similar to adult day cares or adult day clinics. All Partial Hospitalization sites must be certified by the Division of Provider Services and Quality Assurance as a Partial Hospitalization Provider. All medically necessary 1905(a) services are covered for EPSDT eligible individuals in accordance with 1905(r) of the Social Security.

Home and Community-Based Services for Clients with Intellectual Disabilities and Behavioral Health Needs Section II

210.110 Adult Rehabilitative Day Service 1-1 -23 A continuum of care provided to recovering individuals living in the community-based on their level of need. This service includes educating and assisting the individual with accessing supports and services needed. The service assists the recovering individual to direct their resources and support systems. Activities include training to assist the person to learn, retain, or improve specific job skills, and to successfully adapt and adjust to a particular work environment. This service includes training and assistance to live in and maintain a household of their choosing in the community. In addition, transitional services help individuals adjust after receiving a higher level of care. The goal of this service is to promote and maintain community integration. An array of face-to-face rehabilitative day activities providing a preplanned and structured group program for identified clients that aimed at long-term recovery and maximization of self- sufficiency, as distinguished from the symptom stabilization function of acute day treatment. These rehabilitative day activities are person- and family-centered, recovery-based, culturally competent, provide needed accommodation for any disability and must have measurable outcomes. These activities assist the client with compensating for or eliminating functional deficits and interpersonal and/or environmental barriers associated with their chronic mental illness. The intent of these services is to restore the fullest possible integration of the client as an active and productive member of his/her family, social and work community and/or culture with the least amount of ongoing professional intervention. Skills addressed may include: emotional skills, such as coping with stress, anxiety or anger; behavioral skills, such as proper use of medications, appropriate social interactions and managing overt expression of symptoms like delusions or hallucinations; daily living and self-care skills, such as personal care and hygiene, money management and daily structure/use of time; cognitive skills, such as problem solving, understanding illness and symptoms and reframing; community integration skills and any similar skills required to implement a client’s master treatment plan. 210.120 Supportive Employment 1-1 -23 Supportive Employment is designed to help clients acquire and keep meaningful jobs in a competitive job market. The service actively facilitates job acquisition by sending staff to accompany clients on interviews and providing ongoing support and/or on-the-job training once the client is employed. Service settings may vary depending on individual need and level of community integration, and may include the client’s home. Services delivered in the home are intended to foster independence in the community setting and may include training in menu planning, food preparation, housekeeping and laundry, money management, budgeting, following a medication regimen, and interacting with the criminal justice system. 210.130 Supportive Housing 1-1 -23 Supportive Housing is designed to ensure that clients have a choice of permanent, safe, and affordable housing. An emphasis is placed on the development and strengthening of natural supports in the community. This service assists clients in locating, selecting, and sustaining housing, including transitional housing and chemical free living; provides opportunities for involvement in community life; fosters independence; and facilitates the individual’s recovery journey. Supportive Housing includes assessing the client’s individual housing needs and presenting options, assisting in securing housing, including the completion of housing applications and securing required documentation (e.g., Social Security card, birth certificate, prior rental history), searching for housing, communicating with landlords, coordinating the move, providing training in how to be a good tenant, and establishing procedures and contacts to retain housing. Supportive Housing can occur in the following:

Home and Community-Based Services for Clients with Intellectual Disabilities and Behavioral Health Needs Section II

• The individual’s home;

• In community settings such as school, work, church, stores, or parks; and

• In a variety of clinical settings for adults, similar to adult day cares or adult day clinics.

210.140 Adult Life Skills Development

1-1 -23

A service that provides support and training for youth and adults on a one-on-one or group basis.

This service should be a strength-based, culturally appropriate process that integrates the

member into their community as they develop their recovery plan or habilitation plan. This

service is designed to assist members in acquiring the skills needed to support as independent a

lifestyle as possible, enable them to reside in their community (in their own home, with family, or

in an alternative living setting), and promote a strong sense of self-worth. In addition, it aims to

assist members in setting and achieving goals, learning independent life skills, demonstrating

accountability, and making goal-oriented decisions related to independent living.

Topics may include: educational or vocational training, employment, resource and medication

management, self-care, household maintenance, health, socialization, community integration,

wellness, and nutrition. For clients with developmental or intellectual disability, supportive life

skills development may focus on acquiring skills to complete activities of daily living (ADLs) and

instrumental activities of daily living (IADLs), such as communication, bathing, grooming,

cooking, shopping, or budgeting.

210.150 Peer Support

1-1 -23

Peer Support is a consumer centered service provided by individuals (ages 18 and older) who

self-identify as someone who has received or is receiving behavioral health services and thus is

able to provide expertise not replicated by professional training. Peer providers are trained and

certified peer specialists who self-identify as being in recovery from behavioral health issues.

Peer support is a service to work with clients to provide education, hope, healing, advocacy, self-

responsibility, a meaningful role in life, and empowerment to reach fullest potential. Specialists

will assist with navigation of multiple systems (housing, supportive employment, supplemental

benefits, building/rebuilding natural supports, etc.) which impact clients’ functional ability.

Services are provided on an individual or group basis, and in either the client’s home or

community environment.

Peer support may include assisting their peers in articulating their goals for recovery, learning

and practicing new skills, helping them monitor their progress, assisting them in their treatment,

modeling effective coping techniques and self-help strategies based on the specialist's own

recovery experience, and supporting them in advocating for themselves to obtain effective

services.

210.160 Treatment Plan

1-1 -23

A plan that is developed in cooperation with the client to deliver specific mental health services

to restore, improve, or stabilize the client’s mental health condition. Treatment Plans must be

updated annually or more frequently if circumstances or needs change significantly, or if the

client requests.

Treatment Plans can only be developed by the following clinicians:

1. Independently Licensed Clinicians (Masters/Doctoral)
2. Non-independently Licensed Clinicians (Masters/Doctoral)
3. Advanced Practice Nurse (APN)
4. Physician

Home and Community-Based Services for Clients with Intellectual Disabilities and Behavioral Health Needs Section II

210.170 Aftercare Recovery Support (for Substance Abuse) 1-1 -23 A continuum of care provided to recovering members living in the community-based on their level of need. This service includes educating and assisting the individual with accessing supports and services needed. The service assists the recovering client member to direct their resources and support systems. In addition, transitional services to assist individuals adjust after receiving a higher level of care. The goal of this service is to promote and maintain community integration. Meals and transportation are not included in the rate for Aftercare Recovery Support. Aftercare Recovery Support can occur in the following: • The individual’s home; • In community settings such as school, work, church, stores, or parks; and • In a variety of clinical settings for adults, similar to adult day cares or adult day clinics. All medically necessary 1905(a) services are covered for EPSDT eligible members in accordance with 1905(r) of the Social Security Act. 210.180 Therapeutic Communities 1-1 -23 Therapeutic Communities are highly structured residential environments or continuums of care in which the primary goals are the treatment of behavioral health needs and the fostering of personal growth leading to personal accountability. Services address the broad range of needs identified by the person served. Therapeutic Communities employs community-imposed consequences and earned privileges as part of the recovery and growth process. In addition to daily seminars, group counseling, and individual activities, the persons served are assigned responsibilities within the therapeutic community setting. Participants and staff members act as facilitators, emphasizing personal responsibility for one's own life and self-improvement. The service emphasizes the integration of an individual within his or her community, and progress is measured within the context of that community's expectation. Level 1 provides the highest level of supervision, support and treatment as well as ensuring community safety in a facility of no more than sixteen (16) beds o Clients who receive this level of care may have treatment needs that are severe enough to require inpatient care in a hospital but don’t need the full resources of a hospital setting o The emphasis in this level is intensive services delivered using a multi-disciplinary approach including physicians, licensed counselors, and highly trained paraprofessionals. Level 2 provides supervision, support, and treatment, but at a lower level than Level 1 above and can be used as a step down from Level 1 to begin the transition back into a community setting that will not provide twenty-four-hour/seven day (24/7) supervision, service and support o Interventions shift from clinical to addressing the clients educational or vocational needs, socially dysfunctional behavior, and the need for stable housing o Arranging for the full array of clinical and HCBS is critical for successful discharge o Assertive Community Treatment (ACT) would be an ideal step-down service 210.190 Assertive Community Treatment 1-1 -23 Assertive Community Treatment (ACT) is an evidence-based practice provided by a multidisciplinary team providing comprehensive treatment and support services available twenty- four (24) hours a day, seven (7) days a week wherever and whenever needed. Services are

Home and Community-Based Services for Clients with Intellectual Disabilities and Behavioral Health Needs Section II

provided in the most integrated community setting possible to enhance independence and positive community involvement. An individual appropriate for services through an ACT team has needs that are so pervasive and/or unpredictable that it is unlikely that they can be met effectively by other combinations of available community services, or in circumstances where other levels of outpatient care have not been successful to sustain stability in the community. Typically, this service is targeted to individuals who have serious mental illness or co-occurring disorders, multiple diagnoses, and the most complex and expensive treatment needs.

220.000 HOME AND COMMUNITY-BASED SERVICES UNDER PASSE

220.100 Behavioral Assistance 1-1 -23 Behavioral Assistance is a specific outcome oriented intervention provided individually or in a group setting with the child/youth and/or his/her caregiver(s) that will provide the necessary support to attain the goals of the treatment plan. Services involve applying positive behavioral interventions and supports within the community to foster behaviors that are rehabilitative and restorative in nature. The intervention should result in sustainable positive behavioral changes that improve functioning, enhance the quality of life, and strengthen skills in a variety of life domains. Behavioral Assistance is designed to support youth and their families in meeting behavioral goals in various community settings. The service is targeted for children and adolescents who are at risk of out-of-home placement or who have returned home from residential placement and need flexible wrap-around supports to ensure safety and support community integration. The service is tied to specific treatment goals and is developed in coordination with the youth and their family. Behavioral Assistance aids the family in implementing safety plans and behavioral management plans when youth are at risk for offending behaviors, aggressions, and oppositional defiance. Staff provides supports to youth and their families during periods when behaviors have been typically problematic – such as during morning preparation for school, at bedtime, after school, or other times when there is evidence of a pattern of escalation of problem difficult behaviors. The service may be provided in school classrooms or on school busses for short periods of time to help a youth's transition from hospitals or residential settings but is not intended as a permanent solution to problem difficult behaviors at school. 220.110 Crisis Stabilization Intervention 1-1 -23 Crisis Stabilization Intervention is a scheduled face-to-face treatment activity provided to a client who has recently experienced a psychiatric or behavioral health crisis that is expected to further stabilize, prevent deterioration, and serve as an alternative to twenty-four (24) -hour inpatient care. Services are to be congruent with the age, strengths, needed accommodation for any disability and cultural framework of the member and his/her family. Additional needs-based criteria for receiving the service, if applicable (specify): Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration, and scope than those services available to a medically needy client, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. 220.120 Assertive Community Treatment 1-1 -23 Assertive Community Treatment (ACT) is an evidence-based practice provided by a multidisciplinary team providing comprehensive treatment and support services available twenty- four (24) hours a day, seven (7) days a week wherever and whenever needed. Services are provided in the most integrated community setting possible to enhance independence and positive community involvement. An individual appropriate for services through an ACT team has needs that are so pervasive and/or unpredictable that it is unlikely that they can be met

Home and Community-Based Services for Clients with Intellectual Disabilities and Behavioral Health Needs Section II

effectively by other combinations of available community services, or in circumstances where other levels of outpatient care have not been successful to sustain stability in the community. Typically, this service is targeted to individuals who have serious mental illness or co-occurring disorders, multiple diagnoses, and the most complex and expensive treatment needs. 220.130 Intensive In-Home (IIH for Children) 1-1 -23 Intensive In-Home service for children is a team approach that is used to address serious and chronic emotional or behavioral issues for children (youth) who are unable to remain stable in the community without intensive interventions. Services are multifaceted: counseling, skills training, interventions, or resource coordination, and are delivered in the client’s home or in a community setting. The parent or caregiver must be an active participant in the treatment and individualized services that are developed in full partnership with the family. IIH team provides a variety of interventions that are available at the time the family needs. These interventions include “first responder” crisis response, as indicated in the care plan: twenty-four (24) hours per day, seven (7) days per week, three hundred sixty-five (365) days per year. The licensed professional is responsible for monitoring and documenting the status of the client’s progress and the effectiveness of the strategies and interventions outlined in the care plan. The licensed professional then consults with identified medical professionals (such as primary care and psychiatric) and non-medical providers (child welfare and juvenile justice), engages community and natural supports, and includes their input in the care planning process. Intensive In-Home service must be a recognized model of care, clearly outline the duration and scope and be prior approved by a PASSE. 220.140 Adult Rehabilitative Day Service 1-1 -23 A continuum of care provided to recovering individuals living in the community-based on their level of need. This service includes educating and assisting the individual with accessing supports and services needed. The service assists the recovering individual to direct their resources and support systems. Activities include training to assist the person to learn, retain, or improve specific job skills, and to successfully adapt and adjust to a particular work environment. This service includes training and assistance to live in and maintain a household of their choosing in the community. In addition, transitional services to assist individuals adjust after receiving a higher level of care. The goal of this service is to promote and maintain community integration. An array of face-to-face rehabilitative day activities providing a preplanned and structured group program for identified clients that aimed at long-term recovery and maximization of self- sufficiency, as distinguished from the symptom stabilization function of acute day treatment. These rehabilitative day activities are person- and family-centered, recovery-based, culturally competent, provide needed accommodation for any disability and must have measurable outcomes. These activities assist the client with compensating for or eliminating functional deficits and interpersonal and/or environmental barriers associated with their chronic mental illness. The intent of these services is to restore the fullest possible integration of the client as an active and productive member of his/her family, social and work community and/or culture with the least amount of ongoing professional intervention. Skills addressed may include: emotional skills, such as coping with stress, anxiety or anger; behavioral skills, such as proper use of medications, appropriate social interactions and managing overt expression of symptoms like delusions or hallucinations; daily living and self-care skills, such as personal care and hygiene, money management and daily structure/use of time; cognitive skills, such as problem solving, understanding illness and symptoms and reframing; community integration skills and any similar skills required to implement a client’s master treatment plan. 220.150 Peer Support 1-1 -23 Peer Support is a consumer centered service provided by individuals (ages eighteen (18) and older) who self-identify as someone who has received or is receiving behavioral health services

Home and Community-Based Services for Clients with Intellectual Disabilities and Behavioral Health Needs Section II

and thus is able to provide expertise not replicated by professional training. Peer providers are trained and certified peer specialists who self-identify as being in recovery from behavioral health issues. Peer support is a service to work with clients to provide education, hope, healing, advocacy, self-responsibility, a meaningful role in life, and empowerment to reach fullest potential. Specialists will assist with navigation of multiple systems (housing, supportive employment, supplemental benefits, building/rebuilding natural supports, etc.) which impact clients’ functional ability. Services are provided on an individual or group basis, and in either the client’s home or community environment. Peer support may include assisting their peers in articulating their goals for recovery, learning, and practicing new skills, helping them monitor their progress, assisting them in their treatment, modeling effective coping techniques, and self-help strategies based on the specialist's own recovery experience, and supporting them in advocating for themselves to obtain effective services. 220.160 Family Support Partners 1-1 -23 A service provided by peer counselors, of Family Support Partners (FSP), who model recovery and resiliency for caregivers of children and youth with behavioral health care needs or developmental disabilities. FSP come from legacy families and use their lived experience, training, and skills to help caregivers and their families identify goals and actions that promote recovery and resiliency and maintain independence. A FSP may assist, teach, and model appropriate child-rearing strategies, techniques, and household management skills. This service provides information on child development, age-appropriate behavior, parental expectations, and childcare activities. It may also assist the member’s family in securing resources and developing natural supports. Family Support Partners serve as a resource for families with a child, youth, or adolescent receiving behavioral health or developmental disability services. Family Support Partners help families identify natural supports and community resources, provide leadership and guidance for support groups, and work with families on: individual and family advocacy, social support for assigned families, educational support, systems advocacy, lagging skills development, problem solving techniques, and self-help skills. 220.170 Pharmacologic Counseling by RN 1-1 -23 A specific, time limited one-to-one intervention by a nurse with a client and/or caregivers, related to their psycho-pharmacological treatment. Pharmaceutical Counseling involves providing medication information orally or in written form to the client and/or caregivers. The service should encompass all the parameters to make the client and/or family understand the diagnosis prompting the need for the medication and any lifestyle modification required. 220.180 Respite 1-1 -23 Temporary direct care and supervision for a client due to the absence or need for relief of the non-paid primary caregiver. Respite can occur at medical or specialized camps, day-care programs, the member’s home or place of residence, the respite care provider’s home or place of residence, foster homes, or a licensed respite facility. Respite does not have to be listed in the PCSP. The primary purpose of Respite is to relieve the member’s principal care giver of the member with a behavioral health need so that stressful situations are de-escalated, and the care giver and member have a therapeutic and safe outlet. Respite must be temporary in nature. Any services provided for less than fifteen (15) days will be deemed temporary. Respite provided for more than fifteen (15) days should trigger a need to review the PCSP. 220.190 Supportive Life Skills Development 1-1 -23 A service that provides support and training for youth and adults on a one-on-one or group basis. This service should be a strength-based, culturally appropriate process that integrates the

Home and Community-Based Services for Clients with Intellectual Disabilities and Behavioral Health Needs Section II

member into their community as they develop their recovery plan or habilitation plan. This service is designed to assist members in acquiring the skills needed to support as independent a lifestyle as possible, enable them to reside in their community (in their own home, with family, or in an alternative living setting), and promote a strong sense of self-worth. In addition, it aims to assist members in setting and achieving goals, learning independent life skills, demonstrating accountability, and making goal-oriented decisions related to independent living. Topics may include: educational or vocational training, employment, resource and medication management, self-care, household maintenance, health, socialization, community integration, wellness, and nutrition. For clients with developmental or intellectual disability, supportive life skills development may focus on acquiring skills to complete activities of daily living (ADLs) and instrumental activities of daily living (IADLs), such as communication, bathing, grooming, cooking, shopping, or budgeting. 220.200 Child and Youth Support Services 1-1 -23 Child and Youth Support Services are clinical, time-limited services for principal caregivers designed to increase a child’s positive behaviors and encourage compliance with parents at home; working with teachers/schools to modify classroom environment to increase positive behaviors in the classroom; and increase a child’s social skills, including understanding of feelings, conflict management, academic engagement, school readiness, and cooperation with teachers and other school staff. This service is intended to increase parental skill development in managing their child’s symptoms of their illness and training the parents in effective interventions and techniques for working with the schools. Services might include an In-Home Case Aide. An In-Home Case Aide is an intensive, time- limited therapy for youth in the client’s home or, in rare instances, a community-based setting. Youth served may be in imminent risk of out-of-home placement or have been recently reintegrated from an out of-home placement. Services may deal with family issues related to the promotion of healthy family interactions, behavior training, and feedback to the family. 220.210 Supportive Employment 1-1 -23 Supportive Employment is designed to help clients acquire and keep meaningful jobs in a competitive job market. The service actively facilitates job acquisition by sending staff to accompany clients on interviews and providing ongoing support and/or on-the-job training once the client is employed. Service settings may vary depending on individual need and level of community integration, and may include the client’s home. Services delivered in the home are intended to foster independence in the community setting and may include training in menu planning, food preparation, housekeeping and laundry, money management, budgeting, following a medication regimen, and interacting with the criminal justice system. 220.220 Supportive Housing 1-1 -23 Supportive Housing is designed to ensure that clients have a choice of permanent, safe, and affordable housing. An emphasis is placed on the development and strengthening of natural supports in the community. This service assists clients in locating, selecting, and sustaining housing, including transitional housing and chemical free living; provides opportunities for involvement in community life; fosters independence; and facilitates the individual’s recovery journey. Supportive Housing includes assessing the client’s individual housing needs and presenting options, assisting in securing housing, including the completion of housing applications and securing required documentation (e.g., Social Security card, birth certificate, prior rental history), searching for housing, communicating with landlords, coordinating the move, providing training in how to be a good tenant, and establishing procedures and contacts to retain housing. Supportive Housing can occur in the following:

Home and Community-Based Services for Clients with Intellectual Disabilities and Behavioral Health Needs Section II

• The individual’s home; • In community settings such as school, work, church, stores, or parks; and • In a variety of clinical settings for adults, similar to adult day cares or adult day clinics. 220.230 Partial Hospitalization 1-1 -23 Partial Hospitalization is an intensive nonresidential, therapeutic treatment program. It can be used as an alternative to and/or a step-down service from inpatient residential treatment or to stabilize a deteriorating condition and avert hospitalization. The program provides clinical treatment services in a stable environment on a level equal to an inpatient program, but on a less than twenty-four (24) hour basis. The environment at this level of treatment is highly structured and should maintain a staff-to-patient ratio of no more than one to five (1:5) to ensure necessary therapeutic services and professional monitoring, control, and protection. This service shall include at a minimum: intake, individual therapy, group therapy, and psychoeducation. Partial Hospitalization shall be at a minimum of five (5) hours per day, of which ninety (90) minutes must be a documented service provided by a Mental Health Professional. If a client member receives other services during the week but also receives Partial Hospitalization, the client member must receive, at a minimum, twenty (20) documented hours of services on no less than four (4) days in that week. Partial Hospitalization can occur in a variety of clinical settings for adults, similar to adult day cares or adult day clinics. All Partial Hospitalization sites must be certified by the Division of Provider Services and Quality Assurance as a Partial Hospitalization Provider. All medically necessary 1905(a) services are covered for EPSDT eligible individuals in accordance with 1905(r) of the Social Security 220.240 Therapeutic Host Homes 1-1 -23 A home or family setting that that consists of high intensive, individualized treatment for the member whose behavioral health or developmental disability needs are severe enough that they would be at risk of placement in a restrictive residential setting. A therapeutic host parent is trained to implement the key elements of the member’s PCSP in the context of family and community life, while promoting the PCSP’s overall objectives and goals. The host parent should be present at the PCSP development meetings and should act as an advocate for the member. 220.250 Aftercare Recovery Support (for Substance Abuse) 1-1 -23 A continuum of care provided to recovering members living in the community-based on their level of need. This service includes educating and assisting the individual with accessing supports and services needed. The service assists the recovering client member to direct their resources and support systems. In addition, transitional services to assist individuals adjust after receiving a higher level of care. The goal of this service is to promote and maintain community integration. Meals and transportation are not included in the rate for Aftercare Recovery Support. Aftercare Recovery Support can occur in the following: • The individual’s home; • In community settings such as school, work, church, stores, or parks; and • In a variety of clinical settings for adults, similar to adult day cares or adult day clinics. All medically necessary 1905(a) services are covered for EPSDT eligible members in accordance with 1905(r) of the Social Security Act. 220.260 Substance Abuse Detox (Observational) 1-1 -23

Home and Community-Based Services for Clients with Intellectual Disabilities and Behavioral Health Needs Section II

A set of interventions aimed at managing acute intoxication and withdrawal from alcohol or other drugs. Services help stabilize the member by clearing toxins from his or her body. Detoxification (detox) services are short term and may be provided in a crisis unit, inpatient, or outpatient setting. Detox services may include evaluation, observation, medical monitoring, and addiction treatment. The goal of detox is to minimize the physical harm caused by the abuse of substances and prepare the member for ongoing substance abuse treatment. 220.270 Therapeutic Communities 1-1 -23 Therapeutic Communities are highly structured residential environments or continuums of care in which the primary goals are the treatment of behavioral health needs and the fostering of personal growth leading to personal accountability. Services address the broad range of needs identified by the person served. Therapeutic Communities employs community-imposed consequences and earned privileges as part of the recovery and growth process. In addition to daily seminars, group counseling, and individual activities, the persons served are assigned responsibilities within the therapeutic community setting. Participants and staff members act as facilitators, emphasizing personal responsibility for one's own life and self-improvement. The service emphasizes the integration of an individual within his or her community, and progress is measured within the context of that community's expectation. Level 1 provides the highest level of supervision, support and treatment as well as ensuring community safety in a facility of no more than sixteen (16) beds o Clients who receive this level of care may have treatment needs that are severe enough to require inpatient care in a hospital but don’t need the full resources of a hospital setting o The emphasis in this level is intensive services delivered using a multi-disciplinary approach include physicians, licensed counselors, and highly trained paraprofessionals. Level 2 provides supervision, support, and treatment, but at a lower level than Level 1 above and can be used as a step down from Level 1 to begin the transition back into a community setting that will not provide twenty-four-hour/seven day (24/7) supervision, service and support o Interventions shift from clinical to addressing the clients educational or vocational needs, socially dysfunctional behavior, and the need for stable housing o Arranging for the full array of clinical and HCBS is critical for successful discharge o Assertive Community Treatment (ACT) would be an ideal step-down service 220.280 Residential Community Reintegration Program 1-1 -23 The Residential Community Reintegration Program is designed to serve as an intermediate level of care between Inpatient Psychiatric Facilities and home and community-based behavioral health services. The program provides twenty-four (24) hour per day intensive therapeutic care provided in a small group home setting for children and youth with emotional and/or behavior problems which cannot be remedied by less intensive treatment. The program is intended to prevent acute or sub-acute hospitalization of youth, or incarceration. The program is also offered as a step-down or transitional level of care to prepare a youth for less intensive treatment. A Residential Community Reintegration Program shall be appropriately certified by the Department of Human Services to ensure quality of care and the safety of clients and staff. A Residential Community Reintegration Program shall ensure the provision of educational services to all clients in the program. This may include education occurring on campus of the Residential Community Reintegration Program or the option to attend a school off campus if deemed appropriate in accordance with the Arkansas Department of Education.

Home and Community-Based Services for Clients with Intellectual Disabilities and Behavioral Health Needs Section II

220.290 CES Supported Employment 1-1 -23 CES Supported Employment is a tailored array of services that offers ongoing support to members with the most significant disabilities to assist in their goal of working in competitive integrated work settings for at least minimum wage. It is intended for individuals for whom competitive employment has not traditionally occurred, or has been interrupted or intermittent as a result of a significant disability, and who need ongoing supports to maintain their employment. CES Supported Employment includes any combination of the following services: Vocational/job related discovery and assessment, person centered employment planning, job placement, job development, negotiation with prospective employers, job analysis, job carving, training and systematic instructions, job coaching, benefits support, training and planning, transportation, asset development, and career advancement services, extended supported employment supports, and other workplace support services including services not specifically related to job skill training that enable the waiver client to be successful in integrating into the job setting. The service array may also be utilized to support individuals who are self-employed. Transportation between the member's place of residence and the employment site is included as a component of supported employment services when there is no other resource for transportation available. 220.300 Supportive Living 1-1 -23 Supportive living is an array of individually tailored services and activities to enable members to reside successfully in their own home, with family or in an alternative living setting (apartment, or provider owned group home). Supportive living services must be provided in an integrated community setting. Supportive living includes care, supervision, and activities that directly relate to active treatment goals and objectives set forth in the member's PCSP. It excludes room and board expenses, including general maintenance, upkeep, or improvement to the home. Supportive living supervision and activities are meant to assist the member to acquire, retain, or improve skills in a wide variety of areas that directly affect the person’s ability to reside as independently as possible in the community. The habilitation objective to be served by each activity should be documented in the member's PCSP. Examples of supervision and activities that may be provided as part of supportive living include: A. Decision making, including the identification of and response to dangerously threatening situations, making decisions and choices affecting the member’s life, and initiating changes in living arrangements or life activities; B. Money management, including training, assistance or both in handling personal finances, making purchase and meeting personal financial obligations; C. Daily living skills, including training in accomplishing routine housekeeping tasks, meal preparation, dressing, personal hygiene, administration of medication (to the extent permitted by state law), proper use of adaptive and assistive devices and household appliances, training on home safety, first aid, and emergency procedures; D. Socialization, including training and assistance in participating in general community activities and establishing relationships with peers. Activity training includes assisting the member to continue to participate in an ongoing basis; E. Community integration experiences, including activities intended to instruct the member in daily living and community living in integrated settings, such as shopping, church attendance, sports, and participation sports;

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F. Mobility, including training and assistance aimed at enhancing movement within the member's living arrangement, mastering the use of adaptive aids and equipment, accessing and using public transportation, independent travel or movement within the community; G. Communication, including training in vocabulary building, use of augmentative communication devices, and receptive and expressive language; H. Behavior shaping and management, including training and assistance in appropriate expression of emotions or desires, compliance, assertiveness, acquisition of socially appropriate behaviors or reduction of inappropriate behaviors; the supportive living provider is responsible for developing and overseeing the Behavioral Prevention and Intervention Plan; I. Reinforcement of therapeutic services, including conducting exercises reinforcing physical, occupational, speech, behavioral or other therapeutic programs; J. Companion activities and therapies, or the use of animals as modalities to motivate members to meet functional goals established for the member's habilitative training, including language skills, increased range of motion, socialization, and the development of self-respect, self-esteem, responsibility, confidence, an assertiveness; and K. Health maintenance activities, which include tasks that members would otherwise do for themselves or have a family member do, with the exception of injections and IV medication administration. It is not considered administration, with the exception of injections and IV medications, when the paid staff assist the client by getting the medication out of the bottle or blister pack. Supportive living may be provided in clinic setting (physician office, wound clinic) to facilitate appropriate care and follow-up. If health maintenance activity is performed in a hospital setting for supportive care of the individual while receiving medical care, supportive living cannot exceed fourteen (14) consecutive days nor exceed approved prior authorized rate for the service in place prior to hospitalization. 220.310 Complex Care Homes for IDD 1-1 -23 Individuals who receive supportive living and require a higher level of care to acuity may receive supportive living in congregant home settings of no more than eight (8) unrelated persons. Each client residing in the Complex Care Home must be diagnosed with an intellectual disability and a significant co-occurring deficit, which includes without limitation individuals with an intellectual disability and significant: A. Behavioral health needs; or B. Physical health needs. A Provider is required to maintain the client to staff ratio required to meet each client’s needs as provided in their Person Centered Service Plan and ensure client and staff health and safety, but under no circumstances may there be less than a four-to-one (4:1) client to staff ratio in the home at any time. 220.320 Adaptive Equipment 1-1 -23 Adaptive equipment is a piece of equipment, or product system that is used to increase, maintain, or improve functional capabilities of members, whether commercially purchased, modified, or customized. The adaptive equipment services include adaptive, therapeutic, or augmentative equipment that enables a member to increase, maintain, or improve their functional capacity to perform daily life tasks that would not be possible otherwise.

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Consultation by a medical professional must be conducted to ensure the adaptive equipment will

meet the needs of the member.

Adaptive equipment includes enabling technology, such as safe home modifications, that

empower members to gain independence through customizable technologies that allow them to

safely perform activities of daily living without assistance while still providing monitoring and

response for those members, as needed. Enabling technology allows members to be proactive

about their daily schedule and integrates member choice.

Adaptive equipment also includes Personal Emergency Response Systems (PERS), which is a

stationary or portable electronic device used in the member's place of residence and that

enables the member to secure help in an emergency. The system is connected to a response

center staffed by trained professionals who respond to activation of the device. PERS services

may include the assessment, purchase, installation, and monthly rental fee.

Computer equipment, including software, can be included as adaptive equipment. Specifically,

computer equipment includes equipment that allows the member increased control of their

environment, to gain independence, or to protect their health and safety.

Vehicle modifications are also included as adaptive equipment. Vehicle modifications are

adaptions to an automobile or van to accommodate the special needs of the member. The

purpose of vehicle modifications is to enable the member to integrate more fully into the

community and to ensure the health, safety, and welfare of the member. Vehicle modifications

exclude: adaptations or modifications to the vehicle that are of general utility and not of direct

medical or habilitative benefit to the member; purchase, down payment, monthly car payment or

lease payment; or regularly scheduled maintenance of the vehicle.

220.330 Community Transition Services

1-1 -23

Community Transition Services are non-recurring set-up expenses for members who are

transitioning from an institutional or provider-operated living arrangement, such as an ICF or

group home, to a living arrangement in a private residence where the member or his or her

guardian is directly responsible for his or her own living expenses.

Community Transition service activities include those necessary to enable a member to establish

a basic household, not including room and board, and may include:

1. security deposits that are required to obtain a lease on an apartment or home;
2. essential household furnishings required to occupy and use a community domicile,

including furniture, window coverings, food preparation items, and bed/bath linens;

C. set-up fees or deposits for utility or service access, including telephone, electricity, heating

and water;

D. services necessary for the member's health and safety such as pest eradication and one-

time cleaning prior to occupancy; and

E. moving expenses.

Community Transition Services should not include payment for room and board; monthly rental

or mortgage expense; regular food expenses, regular utility charges; and/or household

appliances, or items that are intended for purely diversional/recreational purposes.

220.340 Consultation

1-1 -23

Consultation services are clinical and therapeutic services which assist the individual, parents,

legally responsible persons, responsible individuals, and service providers in carrying out the

member's PCSP. These services are direct in nature. The PASSE will be responsible for

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maintaining the necessary information to document staff qualifications. Staff, who meets the certification criteria necessary for other consultation functions, may also provide these activities. These activities include, but are not limited to: A. Provision of updated psychological and adaptive behavior assessments; allowable providers: psychologist, psychological examiner, speech therapist, physical therapist, occupational therapist within the scope of their practice area; B. Screening, assessing and developing CES waiver services treatment plans; allowable providers: Qualified Developmental Disabled Professional (QDDP), psychologist, psychological examiner, speech therapist, physical therapist, occupational therapist, dietitian, positive behavior support (PBS) specialist, licensed clinical social worker, professional counselor, registered nurse, certified communication and environmental control specialist, board certified behavior analyst (BCBA) within the scope of their practice area; C. Training of direct services staff or family members in carrying out special community living services strategies identified in the member's PCSP as applicable to the consultation specialty; D. Providing information and assistance to the persons responsible for developing the member's PCSP as applicable to the consultation specialty; E. Participating on the interdisciplinary team, when appropriate to the consultant's specialty; F. Consulting with and providing information and technical assistance with other service providers or with direct service staff or family members in carrying out the member's PCSP specific to the consultant's specialty; G. Assisting direct services staff or family members to make necessary program adjustments in accordance with the member's PCSP and applicable to the consultant's specialty; H. Determining the appropriateness and selection of adaptive equipment to include communication devices, computers, and software consistent with the consultant's specialty; I. Training or assisting members, direct services staff, or family members in the set up and use of communication devices, computers, and software consistent with the consultant's specialty; J. Training of direct services staff or family members by a professional consultant in:

1. activities to maintain specific behavioral management programs applicable to the member.
2. activities to maintain speech pathology, occupational therapy, or physical therapy program treatment modalities specific to the member.
3. The provision of medical procedures not previously prescribed but now necessary to sustain the member in the community; K. Training or assisting by advocacy consultants to members and family members on how to self-advocate; L. Rehabilitation counseling; M. The PASSE is responsible for developing a Risk Mitigation Plan for each client that outlines risk factors and action steps that must be taken to mitigate the risk. CES Waiver clients who are at low risk of displaying behaviors that can lead to harm to self, and/or community members must have a Behavioral Prevention and Intervention Plan that is overseen and implemented by the client's supportive living provider. The goal is to keep

Home and Community-Based Services for Clients with Intellectual Disabilities and Behavioral Health Needs Section II

the member in his or her place of residence and avoid an acute placement. Supportive living staff developing, overseeing, and implementing Behavioral Prevention and Intervention Plans must receive training in verbal de-escalation, trauma informed care, verbal intervention training. Behavioral Prevention and Intervention Plan development must be by staff who meet minimum qualification of a Positive Behavior Support Specialist in accordance with CES Waiver standards; N. Screening, assessing, and developing positive behavior support plans, assisting staff in implementation, monitoring, reassessment, and plan modifications; A positive behavior support plan is required when high level of behavioral related risk is identified in the PASSE Risk Mitigation Plan. Allowable providers include Psychologist, Psychological Examiners, Positive Behavior Support (PBS) Specialist, Board Certified Behavior Analyst (BCBA) within the scope of their practice area. licensed clinical social worker and licensed professional counselors; O. Training and assisting members, direct service staff, or family members in proper nutrition and special dietary needs. 220.350 Environmental Modifications 1-1 -23 Modifications made to the member's place of residence that are necessary to ensure the health, welfare, and safety of the member or that enable the member to function with greater independence and without which, the member would require institutionalization. Examples of environmental modifications include the installation of wheelchair ramps, widening doorways, modification of bathroom facilities, installation of specialized electrical and plumbing systems to accommodate medical equipment, installation of sidewalks or pads, and fencing to ensure non- elopement, wandering, or straying of members with decreased mental capacity or aberrant behaviors. Exclusions include modifications or repairs to the home which are of general utility and not for a specific medical or habilitative benefit; modifications or improvements which are of an aesthetic value only; and modifications that add to the total square footage of the home. Environmental modifications that are permanent fixtures to rental property require written authorization and release of current or future liability from the property owner. 220.360 Supplemental Support 1-1 -23 Supplemental Support services meet the needs of the client to improve or enable the continuance of community living. Supplemental Support Services will be based upon demonstrated needs as identified in a member's PCSP as unforeseen problems arise that, unless remedied, could cause a disruption in the member's services or placement, or place the member at risk of institutionalization. 220.370 Respite 1-1 -23 Respite services are provided periodically on a short term basis in accordance with the member’s PCSP. They may be provided in an emergency situation due to the absence of or need for relief to the no-paid primary caregiver. Respite services may include the cost of room and board charges when allowable. Receipt of respite does not necessarily preclude a member from receiving other services on the same day. For example, a member may receive day services, such as supported employment, on the same day as caregiver respite services. When caregiver respite is furnished for the relief of a foster care provider, foster care services may not be billed during the period that respite is furnished. Caregiver respite should not be furnished for the purpose of compensating relief or substitute staff for supportive living services. Caregiver respite services are not to supplant the responsibility of the parent or guardian.

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220.380 Specialized Medical Supplies 1-1 -23 Specialized medical equipment and supplies include: A. Items necessary for life support or to address physical conditions along with ancillary supplies and equipment necessary to the proper functioning of such items; B. Such other durable and non-durable medical equipment not available under the State plan that is necessary to address the member's functional limitations and has been deemed medically necessary by the prescribing physician; C. Necessary medical supplies not available under the State plan. Items reimbursed with Waiver funds are in addition to any medical equipment and supplies furnished under the State plan and exclude those items that are not of direct medical or remedial benefit to the member. All items shall meet applicable standards of manufacture, design, and installation. The most cost effective item should be considered first; Additional supply items are covered as a Waiver service when they are considered essential and medically necessary for home and community care; D. Nutritional supplements; E. Non-prescription medications. Alternative medicines not Federal Drug Administration approved are excluded from coverage; F. Prescription drugs minus the cost of drugs covered by Medicare Part D when extended benefits available under state plan are exhausted.

230.000 REIMBURSEMENT

230.100 Method of Reimbursement 1-1 -23 Home and Community-Based Services outlined in this Manual for the Behavioral Health Adults receiving HCBS services outside of the PASSE are reimbursed on a fee for service basis by Medicaid. Service rates are set on a unit or daily rate basis. A full unit or day must be rendered in order to bill a unit of service. 230.200 Fee Schedules 1-1 -23 Arkansas Medicaid provides fee schedules on the DMS website. The fees represent the fee- for-service reimbursement methodology. Fee schedules do not address coverage limitations or special instructions applied by Arkansas Medicaid before final payment is determined. Procedure codes and/or fee schedules do not guarantee payment, coverage or amount allowed. Information may be changed or updated at any time to correct a discrepancy and/or error. Arkansas Medicaid always reimburses the lesser of the amount billed or the Medicaid maximum.