441—77.46 (249A) HCBS children’s mental health waiver service providers. HCBS children’s mental health waiver services shall be rendered by provider agencies that meet the general provider standards in subrule 77.46(1) and also meet the standards in subrules 77.46(2) to 77.46(5) that are specific to the waiver services provided. A provider that is approved for the same service under another HCBS Medicaid waiver shall be eligible to enroll for that service under the children’s mental health waiver.
	 77.46(1) General provider standards. All providers of HCBS children’s mental health waiver services shall meet the following standards:
	  a.   	 Fiscal capacity. Providers must demonstrate the fiscal capacity to provide services on an ongoing basis.
	  b.   	 Direct care staff.
	 (1) 	 Direct care staff must be at least 18 years of age.
	 (2) 	 Providers must complete child abuse, dependent adult abuse, and criminal background screenings pursuant to Iowa Code section 249A.29 before employment of a staff member who will provide direct care.
	 (3) 	 Direct care staff may not be the spouse of the consumer or the parent or stepparent of the consumer.
	  c.   	 Outcome-based standards and quality assurance.
	 (1) 	 Providers shall implement the following outcome-based standards for the rights and dignity of children with serious emotional disturbance:
	  1. 	 Consumers are valued.
	  2. 	 Consumers are a part of community life.
	  3. 	 Consumers develop meaningful goals.
	  4. 	 Consumers maintain physical and mental health.
	  5. 	 Consumers are safe.
	  6. 	 Consumers and their families have an impact on the services received.
	 (2) 	 The department’s quality assurance staff shall conduct random quality assurance reviews to assess the degree to which the outcome-based standards have been implemented in service provision. Results of outcome-based quality assurance reviews shall be forwarded to the certifying or accrediting entity.
	 (3) 	 A quality assurance review shall include interviews with the consumer and the consumer’s parents or legal guardian, with informed consent, and interviews with designated targeted case managers.
	 (4) 	 A quality assurance review may include interviews with provider staff, review of case files, review of staff training records, review of compliance with the general provider standards in this subrule, and review of other organizational policies and procedures and documentation.
	 (5) 	 Corrective action shall be required if the quality assurance review demonstrates that service provision or provider policies and procedures do not reflect the outcome-based standards. Technical assistance for corrective action shall be available from the department’s quality assurance staff.
	  d.   	 Incident management and reporting. As a condition of participation in the medical assistance program, HCBS children’s mental health waiver service providers must comply with the requirements of Iowa Code sections 232.69 and 235B.3 regarding the reporting of child abuse and dependent adult abuse and must comply with the following incident management and reporting requirements. Exception: The conditions in this paragraph do not apply to providers of environmental modifications and adaptive devices.
	 (1) 	 Definitions.
“Major incident” means an occurrence involving a consumer during service provision that:
	  1. 	 Results in a physical injury to or by the consumer that requires a physician’s treatment or admission to a hospital;
	  2. 	 Results in the death of any person;
	  3. 	 Requires emergency mental health treatment for the consumer;
	  4. 	 Requires the intervention of law enforcement;
	  5. 	 Requires a report of child abuse pursuant to Iowa Code section 232.69 or a report of dependent adult abuse pursuant to Iowa Code section 235B.3;
	  6. 	 Constitutes a prescription medication error or a pattern of medication errors that leads to the outcome in paragraph “1,” “2,” or “3”; or
	  7. 	 Involves a consumer’s location being unknown by provider staff who are assigned protective oversight.
“Minor incident” means an occurrence involving a consumer during service provision that is not a major incident and that:
	  1. 	 Results in the application of basic first aid;
	  2. 	 Results in bruising;
	  3. 	 Results in seizure activity;
	  4. 	 Results in injury to self, to others, or to property; or
	  5. 	 Constitutes a prescription medication error.
	 (2) 	 Reporting procedure for minor incidents. Minor incidents may be reported in any format designated by the provider. When a minor incident occurs or a staff member becomes aware of a minor incident, the staff member involved shall submit the completed incident report to the staff member’s supervisor within 72 hours of the incident. The completed report shall be maintained in a centralized file with a notation in the consumer’s file.
	 (3) 	 Notification procedure for major incidents. When a major incident occurs or a staff member becomes aware of a major incident, the staff member involved shall notify the following persons of the incident by the end of the next calendar day after the incident:
	  1. 	 The staff member’s supervisor.
	  2. 	 The consumer or the consumer’s legal guardian. EXCEPTION: Notification to the consumer is required only if the incident took place outside of the provider’s service provision. Notification to the guardian, if any, is always required.
	  3. 	 The consumer’s case manager.
	 (4) 	 Reporting procedure for major incidents. By the end of the next calendar day after a major incident, the staff member who observed or first became aware of the incident shall also report as much information as is known about the incident to the department’s bureau of long-term care either:
	  1. 	 By direct data entry into the Iowa Medicaid Provider Access System, or
	  2. 	 By faxing or mailing Form 470-4698, Critical Incident Report, according to the directions on the form.
	 (5) 	 Information to be reported. The following information shall be reported about a major incident:
	  1. 	 The name of the consumer involved.
	  2. 	 The date and time the incident occurred.
	  3. 	 A description of the incident.
	  4. 	 The names of all provider staff and others who were present at the time of the incident or who responded after becoming aware of the incident. The confidentiality of other waiver-eligible or non-waiver-eligible consumers who were present must be maintained by the use of initials or other means.
	  5. 	 The action that the provider staff took to manage the incident.
	  6. 	 The resolution of or follow-up to the incident.
	  7. 	 The date the report is made and the handwritten or electronic signature of the person making the report.
	 (6) 	 Response to report. Submission of the initial report will generate a workflow in the Individualized Services Information System (ISIS) for follow-up by the case manager. When complete information about a major incident is not available at the time of the initial report, the provider must submit follow-up reports until the case manager is satisfied with the incident resolution and follow-up. The completed report shall be maintained in a centralized file with a notation in the consumer’s file.
	 (7) 	 Tracking and analysis. The provider shall track incident data and analyze trends to assess the health and safety of consumers served and determine if changes need to be made for service implementation or if staff training is needed to reduce the number or severity of incidents.
	 77.46(2) Environmental modifications, adaptive devices, and therapeutic resources providers. The following agencies may provide environmental modifications, adaptive devices, and therapeutic resources under the children’s mental health waiver:
	  a.   	 A community business that:
	 (1) 	 Possesses all necessary licenses and permits to operate in conformity with federal, state, and local statutes and regulations, including Iowa Code chapter 490; and
	 (2) 	 Submits verification of current liability and workers’ compensation insurance.
	  b.   	 A retail or wholesale business that otherwise participates as a provider in the Medicaid program.
	  c.   	 A home and vehicle modification provider enrolled under another HCBS Medicaid waiver.
	  d.   	 A provider enrolled under the HCBS mental retardation or brain injury waiver as a supported community living provider.
	  e.   	 A provider enrolled under the HCBS children’s mental health waiver as a family and community support services provider.
	 77.46(3) Family and community support services providers.
	  a.   	 Qualified providers. The following agencies may provide family and community support services under the children’s mental health waiver:
	 (1) 	 Remedial services providers qualified under 441—77.12(249A).
	 (2) 	 Community mental health centers accredited in good standing as providers of outpatient psychotherapy and counseling under 441—Chapter 24.
	  b.   	 Staff training. The agency shall meet the following training requirements as a condition of providing family and community support services under the children’s mental health waiver:
	 (1) 	 Within one month of employment, staff members must receive the following training:
	  1. 	 Orientation regarding the agency’s mission, policies, and procedures; and
	  2. 	 Orientation regarding HCBS philosophy and outcomes for rights and dignity found in 77.36(1)“c” for the children’s mental health waiver.
	 (2) 	 Within four months of employment, staff members must receive training regarding the following:
	  1. 	 Serious emotional disturbance in children and provision of services to children with serious emotional disturbance;
	  2. 	 Confidentiality;
	  3. 	 Provision of medication according to agency policy and procedure;
	  4. 	 Identification and reporting of child abuse;
	  5. 	 Incident reporting;
	  6. 	 Documentation of service provision;
	  7. 	 Appropriate behavioral interventions; and
	  8. 	 Professional ethics.
	 (3) 	 Until a staff member receives the training identified in subparagraphs (1) and (2), the staff member shall not provide any direct service without the presence of experienced staff.
	 (4) 	 Within the first year of employment, staff members must complete 24 hours of training in children’s mental health issues.
	 (5) 	 During each consecutive year of employment, staff members must complete 12 hours of training in children’s mental health issues.
	  c.   	 Support of crisis intervention plan. As a condition of providing services under the children’s mental health waiver, a family and community support provider shall develop and implement policies and procedures for maintaining the integrity of the individualized crisis intervention plan as defined in 441—24.1(225C) that is developed by each consumer’s interdisciplinary team. The policies and procedures shall address:
	 (1) 	 Sharing with the case manager and the interdisciplinary team information pertinent to the development of the consumer’s crisis intervention plan.
	 (2) 	 Training staff before service provision, in cooperation with the consumer’s parents or legal guardian, regarding the consumer’s individual mental health needs and individualized supports as identified in the crisis intervention plan.
	 (3) 	 Ensuring that all staff have access to a written copy of the most current crisis intervention plan during service provision.
	 (4) 	 Ensuring that the plan contains current and accurate information by updating the case manager within 24 hours regarding any circumstance or issue that would have an impact on the consumer’s mental health or change the consumer’s crisis intervention plan.
	  d.   	 Intake, admission, and discharge. As a condition of providing services under the children’s mental health waiver, a family and community support provider shall have written policies and procedures for intake, admission, and discharge.
	 77.46(4) In-home family therapy providers.
	  a.   	 Qualified providers. The following agencies may provide in-home family therapy under the children’s mental health waiver:
	 (1) 	 Community mental health centers accredited in good standing as providers of outpatient psychotherapy and counseling under 441—Chapter 24.
	 (2) 	 Mental health professionals licensed pursuant to 645—Chapter 31, 240, or 280 or possessing an equivalent license in another state.
	  b.   	 Staff training. The agency shall meet the following training requirements as a condition of providing in-home family therapy under the children’s mental health waiver:
	 (1) 	 Within one month of employment, staff members must receive the following training:
	  1. 	 Orientation regarding the agency’s mission, policies, and procedures; and
	  2. 	 Orientation regarding HCBS philosophy and outcomes for rights and dignity found in 77.46(1)“c” for the children’s mental health waiver.
	 (2) 	 Within four months of employment, staff members must receive training regarding the following:
	  1. 	 Serious emotional disturbance in children and service provision to children with serious emotional disturbance;
	  2. 	 Confidentiality;
	  3. 	 Provision of medication according to agency policy and procedure;
	  4. 	 Identification and reporting of child abuse;
	  5. 	 Incident reporting;
	  6. 	 Documentation of service provision;
	  7. 	 Appropriate behavioral interventions; and
	  8. 	 Professional ethics.
	 (3) 	 Until a staff member receives the training identified in subparagraphs (1) and (2), the staff member shall not provide any direct service without the presence of experienced staff.
	 (4) 	 Within the first year of employment, staff members must complete 24 hours of training in children’s mental health issues.
	 (5) 	 During each consecutive year of employment, staff members must complete 12 hours of training in children’s mental health issues.
	  c.   	 Support of crisis intervention plan. As a condition of providing services under the children’s mental health waiver, an in-home family therapy provider shall develop and implement policies and procedures for maintaining the integrity of the individualized crisis intervention plan as defined in 441—24.1(225C) that is developed by each consumer’s interdisciplinary team. The policies and procedures shall address:
	 (1) 	 Sharing with the case manager and the interdisciplinary team information pertinent to the development of the consumer’s crisis intervention plan.
	 (2) 	 Training staff before service provision, in cooperation with the consumer’s parents or legal guardian, regarding the consumer’s individual mental health needs and individualized supports as identified in the crisis intervention plan.
	 (3) 	 Ensuring that all staff have access to a written copy of the most current crisis intervention plan during service provision.
	 (4) 	 Ensuring that the plan contains current and accurate information by updating the case manager within 24 hours regarding any circumstance or issue that would have an impact on the consumer’s mental health or change the consumer’s crisis intervention plan.
	  d.   	 Intake, admission, and discharge. As a condition of providing services under the children’s mental health waiver, an in-home family therapy provider shall have written policies and procedures for intake, admission, and discharge.
	 77.46(5) Respite care providers.
	  a.   	 Qualified providers. The following agencies may provide respite services under the children’s mental health waiver:
	 (1) 	 Providers certified or enrolled as respite providers under another Medicaid HCBS waiver.
	 (2) 	 Group living foster care facilities for children licensed in good standing by the department according to 441—Chapters 112 and 114 to 116.
	 (3) 	 Child care centers licensed in good standing by the department according to 441—Chapter 109 and child development homes registered according to 441—Chapter 110.
	 (4) 	 Camps certified in good standing by the American Camping Association.
	 (5) 	 Home health agencies that are certified in good standing to participate in the Medicare program.
	 (6) 	 Home care agencies that meet the requirements set forth in department of public health rule 641—80.7(135).
	 (7) 	 Adult day care providers that are certified in good standing by the department of inspections and appeals as being in compliance with the standards for adult day services programs adopted by the department of elder affairs at 321—Chapter 24.
	 (8) 	 Assisted living programs certified in good standing by the department of inspections and appeals.
	 (9) 	 Residential care facilities for persons with mental retardation licensed in good standing by the department of inspections and appeals.
	 (10) 	 Nursing facilities, intermediate care facilities for the mentally retarded, and hospitals enrolled as providers in the Iowa Medicaid program.
	  b.   	 Staff training. The agency shall meet the following training requirements as a condition of providing respite care under the children’s mental health waiver:
	 (1) 	 Within one month of employment, staff members must receive the following training:
	  1. 	 Orientation regarding the agency’s mission, policies, and procedures; and
	  2. 	 Orientation regarding HCBS philosophy and outcomes for rights and dignity for the children’s mental health waiver in 77.46(1)“c.”
	 (2) 	 Within four months of employment, staff members must receive training regarding the following:
	  1. 	 Serious emotional disturbance in children and provision of services to children with serious emotional disturbance;
	  2. 	 Confidentiality;
	  3. 	 Provision of medication according to agency policy and procedure;
	  4. 	 Identification and reporting of child abuse;
	  5. 	 Incident reporting;
	  6. 	 Documentation of service provision;
	  7. 	 Appropriate behavioral interventions; and
	  8. 	 Professional ethics.
	 (3) 	 Until a staff member receives the training identified in subparagraphs (1) and (2), the staff member shall not provide any direct service without the oversight of supervisory staff and shall obtain feedback from the family within 24 hours of service provision.
	 (4) 	 Within the first year of employment, staff members must complete 24 hours of training in children’s mental health issues.
	 (5) 	 During each consecutive year of employment, staff members must complete 12 hours of training in children’s mental health issues.
	  c.   	 Consumer-specific information. The following information must be written, current, and accessible to the respite provider during service provision:
	 (1) 	 The consumer’s legal and preferred name, birth date, and age, and the address and telephone number of the consumer’s usual residence.
	 (2) 	 The consumer’s typical schedule.
	 (3) 	 The consumer’s preferences in activities and foods or any other special concerns.
	 (4) 	 The consumer’s crisis intervention plan.
	  d.   	 Written notification of injury. The respite provider shall inform the parent, guardian or usual caregiver that written notification must be given to the respite provider of any recent injuries or illnesses that have occurred before respite provision.
	  e.   	 Medication dispensing. Respite providers shall develop policies and procedures for the dispensing, storage, and recording of all prescription and nonprescription medications administered during respite provision. Home health agencies must follow Medicare regulations regarding medication dispensing.
	  f.   	 Support of crisis intervention plan. As a condition of providing services under the children’s mental health waiver, a respite provider shall develop and implement policies and procedures for maintaining the integrity of the individualized crisis intervention plan as defined in 441—24.1(225C) that is developed by each consumer’s interdisciplinary team. The policies and procedures shall address:
	 (1) 	 Sharing with the case manager and the interdisciplinary team information pertinent to the development of the consumer’s crisis intervention plan.
	 (2) 	 Training staff before service provision, in cooperation with the consumer’s parents or legal guardian, regarding the consumer’s individual mental health needs and individualized supports as identified in the crisis intervention plan.
	 (3) 	 Ensuring that all staff have access to a written copy of the most current crisis intervention plan during service provision.
	 (4) 	 Ensuring that the plan contains current and accurate information by updating the case manager within 24 hours regarding any circumstance or issue that would have an impact on the consumer’s mental health or change the consumer’s crisis intervention plan.
	  g.   	 Service documentation. Documentation of respite care shall be made available to the consumer, parents, guardian, or usual caregiver upon request.
	  h.   	 Capacity. A facility providing respite care under this subrule shall not exceed the facility’s licensed capacity, and services shall be provided in a location and for a duration consistent with the facility’s licensure.
	  i.   	 Service provided outside home or facility. For respite care to be provided in a location other than the consumer’s home or the provider’s facility:
	 (1) 	 The care must be approved by the parent, guardian or usual caregiver;
	 (2) 	 The care must be approved by the interdisciplinary team in the consumer’s service plan;
	 (3) 	 The care must be consistent with the way the location is used by the general public; and
	 (4) 	 Respite care in these locations shall not exceed 72 continuous hours.
This rule is intended to implement Iowa Code section 249A.4 and 2005 Iowa Acts, chapter 167, section 13, and chapter 117, section 3.
[ARC 7741B, IAB 5/6/09, effective 7/1/09; ARC 7936B, IAB 7/1/09, effective 9/1/09]