317:40-9-1. Self-directed services (SDS)
(a) Applicability. This Section applies to SDS provided through Home and Community-Based Services (HCBS) Waivers operated by the Oklahoma Human Services (OKDHS) Developmental Disabilities Services (DDS).
(b) Member option. Traditional service delivery methods are available for eligible members who do not elect to self-direct services.
(c) General information. SDS are an option for members receiving HCBS through the In-Home Supports Waiver for Adults, In-Home Supports Waiver for Children, and the Community Waiver when the member lives in a non-residential setting. SDS provides members the opportunity to exercise choice and control in identifying, accessing, and managing specific Waiver services and supports in accordance with his or her needs and personal preferences. SDS are Waiver services OKDHS DDS specifies may be directed by the member or representative using employer and budget authority.
(1) SDS may be directed by:
(A) An adult member, when the member has the ability to self-direct;
(B) A member's legal representative including a parent, spouse or legal guardian; or
(C) A non-legal representative who the member or legal representative freely chooses.
(2) The person directing services:
(A) Is eighteen (18) years of age or older;
(B) Complies with DDS and Oklahoma Health Care Authority (OHCA) rules and regulations;
(C) Completes required DDS training for self-direction;
(D) Signs an agreement with DDS;
(E) Is a member or legal representative approved to act in a representative capacity;
(F) Demonstrates knowledge and understanding of the member's needs and preferences; and
(G) Does not serve as the Self-Directed (SD) habilitation training specialist (HTS) for the member when he or she is directing the member's services.
(d) The SDS program includes:
(1) The SDS budget. A Plan of Care (POC) is developed to meet the member's needs without SDS consideration. The member may elect to self-direct part or the entire amount identified for traditional HTS services. This amount is under the member's control and discretion in accordance with this policy and the approved POC, and is the allocated amount that may be used to develop the SDS budget. The SDS budget details the specific spending plan.
(A) The SDS budget is developed annually at the time of the annual plan and updated. Individuals who participate in the budget development include, the member, case manager, parent, legal guardian, and others the member invites to participate.
(B) Payment may only be authorized for goods and services (GS) not covered by SoonerCare, or other generic funding sources, and must meet service necessity criteria, per Oklahoma Administrative Code (OAC) 340:100-3-33.1.
(C) The member's SDS budget includes the actual cost of administrative activities including fees for financial management services (FMS) subagent, background checks, workers' compensation insurance, and the amount identified for SD-HTS, SD Job Coaching, and Self-directed goods and services (SD-GS).
(D) The SDS budget is added to the POC to replace any portion of traditional HTS services to be self-directed.
(E) The member's employment services costs, excluding transportation services, cannot exceed limits set forth in OKDHS Appendix D-26, Developmental Disabilities Services Rates Schedule, per POC year.
(2) The SD-HTS supports the member's self-care and the daily living and leisure skills needed to reside successfully in the community. Services are provided in community-based settings in a manner that contributes to the member's independence, self-sufficiency, community inclusion, and well-being. SD-HTS services must be included in the approved SDS budget. Payment is not made for routine care and supervision that is typically provided by a family member or the member's spouse. SD-HTS services are provided only during periods when staff is engaged in purposeful activity that directly or indirectly benefits the member. SD-HTS services are limited to a daily average of no more than nine (9) hours per day, per OAC 340:100-5-35. At no time are SD-HTS services authorized for periods when staff is allowed to sleep. Legally responsible persons may not provide services, per OAC 340:100-3-33.2. Other family members providing services must be employed by provider agencies per OAC 340:100-3-33.2. For the purpose of this rule, family members include parents, siblings, step-parents, step siblings, and anyone living in the same home as the member. Payment does not include room and board, maintenance, or upkeep or improvements to the member's or family's residence. An SD-HTS:
(A) Is eighteen (18) years of age and older;
(B) Passes a background check, per OAC 340:100-3-39;
(C) Demonstrates competency to perform required tasks;
(D) Completes required training, per OAC 340:100-3-38 et seq.;
(E) Signs an agreement with DDS and the member;
(F) Is physically able and mentally alert to carry out the job's duties;
(G) Does not work as an SD-HTS more than forty (40) hours in any week;
(H) Does not implement prohibited procedures, per OAC 340:100-5-58;
(I) Provides services to only one (1) member at any given time. This does not preclude providing services in a group setting where services are shared among group members; and
(J) Does not perform any job duties associated with other employment, including on-call duties, at the same time they are providing SD-HTS services.
(3) SD-Job Coaching services:
(A) Are pre-planned, documented activities related to the member's identified employment outcomes. This includes training at the work site and support by job coach staff who have completed DDS sanctioned training per OAC 340:100-3-38.2;
(B) Promote the member's capacity to secure and maintain integrated employment at the member's chosen job, provided the job pays at or more than minimum wage, or the member is working to achieve minimum wage;
(C) Provide active participation in paid work. Efforts are made in cooperation with employers, and an active relationship with the business is maintained, to adapt normal work environments to fit the member's needs;
(D) Are available for individual placements. Individual placement is one member receiving job coaching services who:
(i) Works in an integrated job setting;
(ii) Is paid at or more than minimum wage;
(iii) Does not receive services from a job coach who is simultaneously responsible for continuous job coaching for a group;
(iv) Is employed by a community employer; and
(v) Has a job description that is specific to the member's work; and
(E) Is authorized when on-site supports by a certified job coach are provided more than twenty (20 percent of the member's compensable work time. Job coaching services rate continues until a member reaches twenty (20) percent or less job coach intervention for four (4) consecutive weeks, at which time stabilization services begin.
(F) Are based on the amount of time the member is compensated by the employer, except per OAC 317:40-7-11;
(G) For members in individual placements, the Personal Support Team (Team):
(i) Evaluates the job coaching services need at least annually; and
(ii) Documents a plan for fading job coaching services as the member's independence increases.
(H) In order to participate in individual placement, the individual is found ineligible for services funded through the Department of Rehabilitation Services or have a closed case; and
(I) An SD-Job Coach:
(i) Is eighteen (18) years of age;
(ii) Passes a background check per OAC 340:100-3-3;
(iii) Demonstrates competency to perform required tasks;
(iv) Completes required training per OAC 340:100-3-38 et seq.;
(v) Signs an agreement with DDS and the member;
(vi) Is physically able and mentally alert to carry out job duties;
(vii) Does not work more than forty (40) hours in any week as an SD-Job Coach or SD-HTS;
(viii) Does not implement restrictive or intrusive procedures per OAC 340:100-5-57;
(ix) Provides services to only one member at any given time; and
(x) Does not perform any job duties associated with other employment including on-call duties at the same time he or she is providing SD-Job Coaching services; and
(4) SD-GS are incidental, non-routine, and promote the member's self-care, daily living, adaptive functioning, general household activities, meal preparation, and leisure skills needed to reside successfully in the community. SD-GS do not duplicate other services authorized in the member's POC. These SD-GS must be included in the Individual Plan (Plan) and approved SDS budget. SD-GS must meet the requirements listed in (A) through (F) of this paragraph.
(A) The item or service is justified by a licensed professional's recommendation.
(B) The item or service is not prohibited by federal or state statutes and regulations.
(C) The item or service meets one (1) or more of the criteria listed in (i) through (iii) of this subparagraph. The item or service:
(i) Increases the member's functioning related to the disability;
(ii) Increases the member's safety in the home environment; or
(iii) Decreases dependence on other SoonerCare funded services.
(D) SD-GS may include, but are not limited to:
(i) Fitness items that can be purchased at retail stores;
(ii) Short duration camps lasting fourteen (14) consecutive calendar days or less;
(iii) A food catcher;
(iv) A specialized swing set;
(v) Toothettes or an electric toothbrush;
(vi) A seat lift;
(vii) Weight loss programs or gym memberships when:
(I) There is an identified weight loss or increased physical activity need;
(II) Justified by outcomes related to weight loss, increased physical activity or stamina; and
(III) In subsequent POC year requests, documentation is provided that supports the member's progress toward weight loss, increased physical activity, or stamina; or
(viii) Swimming lessons.
(E) SD-GS is not used for:
(i) Medical services co-payments;
(ii) Over-the-counter medications;
(iii) Items or treatments not approved by the Food and Drug Administration;
(iv) Homeopathic services;
(v) Services available through any other funding source, such as SoonerCare, Medicare, private insurance, the public school system, rehabilitation services, or natural supports;
(vi) Room and board including deposits, rent, and mortgage payments;
(vii) Personal items and services not directly related to the member's disability;
(viii) Vacation expenses;
(x) Vehicle maintenance or other transportation related expense;
(xi) Costs related to internet access;
(xiii) Tickets and related costs to attend recreational events;
(xiv) Services, goods, or supports provided to the member or benefiting persons other than the member;
(xv) Experimental goods or services;
(xvi) Personal trainers;
(xvii) Spa treatments; or
(xviii) Goods or services with costs that significantly exceed community norms for the same or similar goods or services.
(F) SD-GS are reviewed and approved by the DDS director or designee.
(e) Member Responsibilities. When the member chooses the SDS option, the member or member's representative is the employer of record and:
(1) Within forty-five (45) calendar days of enrolling in SDS training, the member or member's representatives completes the DDS-sanctioned self-direction training course. Exceptions to this timeframe may be approved by the DDS director or his/her designee. The training is completed prior to implementing SD. The training covers:
(A) Staff recruitment;
(B) Hiring of staff as an employer of record;
(C) Staff orientation and instruction;
(D) Staff supervision including scheduling and service provisions;
(E) Staff evaluation;
(F) Staff discharge;
(G) SD philosophy
(H) OHCA SD policy;
(I) Individual budgeting;
(J) SD support plan development;
(K) Cultural diversity; and
(L) Rights, risks, and responsibilities, and
(2) Signs an agreement with DDS;
(3) Agrees to utilize the FMS subagent services;
(4) Agrees to pay administrative costs for background checks, FMS subagent fees, and workers' compensation insurance from his or her SDS budget;
(5) Complies with federal and state employment laws and ensures no employee works more than forty (40) hours per week in an SD-HTS capacity;
(6) Ensures that each employee is qualified to provide the services for which he or she is employed to do and that all billed services are actually provided;
(7) Ensures that each employee complies with all DDS training requirements per OAC 340:100-3-38 et seq.;
(8) Recruits, hires, supervises, and discharges all employees providing SDS, when necessary;
(9) Verifies employee qualifications;
(10) Obtains background screenings on all employees providing SD-HTS services per OAC 340:100-3-39;
(11) Sends progress reports per OAC 340:100-5-52.
(12) Participates in the Plan and SDS budget process;
(13) Notifies the DDS case manager of any emergencies or changes in circumstances that may require modification of the type or amount of services provided for in the member's Plan or SDS budget;
(14) Waits for budget modification approval before implementing changes;
(15) Complies with DDS and OHCA administrative rules;
(16) Cooperates with DDS monitoring requirements per OAC 340:100-3-27;
(17) Cooperates with FMS subagent requirements to ensure accurate records and prompt payroll processing including:
(A) Reviewing and signing employee time cards;
(B) Verifying the accuracy of hours worked; and
(C) Ensuring the appropriate fund expenditures; and
(18) Completes all required documents within established timeframes;
(19) Pays for services incurred in excess of the budget amount;
(20) Pays for services not identified and approved in the member's SDS budget;
(21) Pays for services provided by an unqualified provider;
(22) Determines staff duties and qualifications and specifies service delivery practices consistent with SD-HTS Waiver service specifications;
(23) Orients and instructs staff in duties;
(24) Evaluates staff performance;
(25) Identifies and trains back-up staff, when required;
(26) Determines amount paid for services within plan limits;
(27) Schedules staff and the services provisions;
(28) Ensures SD-HTS do not implement prohibited procedures per OAC 340:100-5-58; and
(29) Signs an agreement with the SD-HTS.
(f) FMS. The FMS subagent is an entity that DDS designates as an agent to act on a member's behalf who has employer and budget authority. The FMS subagent's purpose is to manage payroll tasks for the member's employee(s) and SD-GS payments as authorized in the member's plan. FMS subagent duties include, but are not limited to:
(1) Compliance with all DDS and OHCA administrative rules and contract requirements;
(2) Compliance with DDS or OHCA random and targeted audits;
(3) Tracking individual expenditures and monitoring SDS budgets;
(4) Processing the member's employee payroll, withholding, filing and paying of applicable federal, state, and local employment-related taxes and insurance;
(5) Employee time sheets collection and processing and making payment to member's employees;
(6) SD-GS invoice collection and processing as authorized in the member's SDS budget;
(7) Providing each member with information that assists with the SDS budget management;
(8) Providing reports members and member representatives, as well as providing monthly reports to DDS and to OHCA upon request;
(9) Providing DDS and OHCA authorities access to individual member's accounts through a web-based program;
(10) Assisting members in verifying employee citizenship status;
(11) Maintaining separate accounts for each member's SDS budget;
(12) Tracking and reporting member funds, balances, and disbursements;
(13) Receiving and disbursing funds for SDS payment per OHCA agreement; and
(14) Executing and maintaining a contractual agreement between DDS and the SD-HTS (employee).
(g) DDS case management responsibilities in support of SDS.
(1) The DDS case manager develops the member's plan per OAC 340:100-5-50 through 340:100-5-58.
(2) The DDS case manager meets with the member or, when applicable, the member's representative or legal guardian to discuss the Waiver service delivery options in (A) and (B) of this paragraph:
(A) Traditional Waiver services; and
(B) SDS including information regarding scope of choices, options, rights, risks, and responsibilities associated with SDS.
(3) When the member chooses SDS, the DDS case manager:
(A) Discusses the available amount in the budget with the member or the member's representative;
(B) Assists the member or representative in developing and modifying the SDS budget;
(C) Submits request for SD-GS to the DDS director or designee for review and approval;
(D) Assists the member or representative developing or revising an emergency back-up plan;
(E) Monitors plan implementation per OAC 340:100-3-27;
(F) Ensures services are initiated within required time frames;
(G) Conducts ongoing monitoring of plan implementation and of the member's health and welfare; and
(H) Ensures the SD-HTS does not implement prohibited procedures, per OAC 340:100-5-58. If the Team determines restrictive or intrusive procedures are necessary to address behavioral challenges, requirements must be met, per OAC 340:100-5-57.
(h) Government fiscal/employer agent model. DDS serves as the Organized Health Care Delivery System (OHCDS) and FMS provider in a Centers for Medicare and Medicaid Services approved government fiscal/employer agent model. DDS has an interagency agreement with OHCA.
(i) Voluntary termination of self-directed services. Members may discontinue SDS without disruption at any time, provided traditional Waiver services are in place. Members or representatives may not choose the SDS option again until the next annual planning meeting, with services resuming no earlier than the beginning of the next POC. A member desiring to file a complaint must follow procedures per OAC 340:2-5-61.
(j) SDS involuntary termination.
(1) Members may be involuntarily terminated from SDS and offered traditional Waiver services when the DDS director or designee has determined that any of the criteria in (A) through (F) of this paragraph exist:
(A) Immediate health and safety risks associated with self-direction, such as, imminent risk of death or irreversible or serious bodily injury related to Waiver services;
(B) Intentional misuse of funds following notification, assistance and support from DDS;
(C) Failure to follow and implement policies of self-direction after receiving DDS technical assistance and guidance;
(D) Suspected fraud or abuse of funds;
(E) A member no longer receives a minimum of one (1) SDS Waiver service per month and DDS is unable to monitor the member; or
(F) Reliable information shows the employer of record or SD-HTS engaged in illegal activity.
(2) When action is taken to involuntarily terminate the member from SDS, the case manager assists the member in assessing needed and appropriate services through the traditional Waiver services option. The case manager ensures that no lapse in necessary services occurs for which the member is eligible.
(3) The Fair Hearing process, per OAC 340:100-3-13 applies.
(k) Reporting requirements. While operating as an OHCDS, DDS provides OHCA reports detailing provider activity in the format and at times OHCA requires.