REQUIRED PROVIDER TRAININGFOR MEDICAID WAIVER SERVICES(5123:2-2-01)COMPLETION TIME: 8 HOURSHouse of New Hope (revised 3/2010)1
Overview This eight-hour course covers all areas required by5123:2-2-01 - Provider Certification. This includes: Understand basic concepts for serving individuals withdevelopmental disabilities Learn the rights of individuals with developmentaldisabilities Understand the basic principles and requirements ofproviding home and community-based waiver services; Requirements for incidents adversely affecting health andsafety; and Universal precautions for infection control, including handwashing and the disposal of bodily waste.2
Objectives include: The foundation for the information that providers of Medicaid waiver services will need tobe knowledgeable about providing services and supports to individuals with disabilities, To gain a basic understanding of current philosophies and best practice for working withindividuals with disabilities, To understand the individual service plan (ISP) and the responsibility of providing servicein accordance with the plan, To have an understanding of MUI’s and the provider’s responsibility for reporting MUI’s, To be aware of what bloodborne infections are, how to prevent illness from bloodbornepathogens and how to handle contaminated matter, and To understand Medicaid waivers, documentation requirements, reporting requirements andwhere to find forms and additional information. This competency-based training requires the applicant/employee to take and passa multiple-choice quiz at the end of the training—100% accuracy is required. Theapplicant/employee will be allowed multiple attempts to take and pass the quiz.The quiz contains questions from all resources provided in the course. The course contains a narrative section and numerous required reading assignmentsincluding articles written by experts in the field.3
What is Developmental Disability (DD)?4 The term ‘developmental disability’ includes a wide array of disabilities thatincludes mental retardation. Examples of other developmental disabilities include:vision impairment, hearing impairment, cerebral palsy, autism and others. Developmental disabilities are defined as “severe chronic disabilities that can becognitive or physical or both. The disabilities appear before the age of 22 and arelikely to be life-long.” “Cognitive” disabilities are those disabilities that are related to thought processesand the ability to comprehend and respond to what a person hears and sees. Thisincludes such disabilities as mental retardation/intellectual disability, learningdisabilities, Asperger’s syndrome, brain injury and others. A person with a cognitivedisability may not be able to process information in the same way or as quickly asa person who does not have a cognitive disability. Because cognitive and physical disabilities can both affect one person, providerswill often work with people who have both types of disabilities. Some developmental disabilities are purely physical, such as congenital deafness orvisual impairment. These are not intellectual disabilities. Other developmentaldisabilities can be caused by cerebral palsy, epilepsy, autism or other disablingconditions. These conditions might or might not include intellectual disabilities.
5 Still other developmental disabilities can result from chromosomal disorders, such asDown Syndrome and fragile X syndrome. These instances could well include intellectual disabilities—but not always. Forexample, according to the Centers for Disease Control, males with fragile Xsyndrome generally have mild to severe intellectual disabilities, whereas femalescan have average intelligence. On the other hand, some causes of intellectual disabilities are not physical. Theseinclude social & environmental factors such as the level of interaction & stimulation achild has during the developmental period and educational factors such as theavailability of family and educational supports that promote mental developmentand greater adaptive skills. Some disabilities are preventable. This includes fetal alcohol syndrome caused bythe mother consuming alcohol during pregnancy. FAS can cause both physical andcognitive disabilities.
Required Reading General Info Fact Sheet Autism Fact Sheet Learning Disability Fact Sheet Intellectual Disability Fact Sheet Severe Disabilities Fact Sheet TBI Fact Sheet Epilepsy Fact Sheet ADHD Fact Sheet Down Syndrome Fact Sheet Cerebral Palsy Fact Sheet Emotional Disturbance Fact Sheet Hearing Loss Fact Sheet Visual Impairment Fact Sheet Speech & Language Fact Sheet ARC Fact Sheet Mental Retardation vs. Mental Illness Fetal Alcohol Syndrome Characteristics6
What is Intellectual Disability?7 The term ‘intellectual disability’ is a fairly new term that has the same meaning asmental retardation. You may see both terms used to mean the same thing. The term “mental retardation” is the term used in law and public policy todetermine eligibility for state and federal programs, including the Individuals withDisabilities Education Act—IDEA (2004), Social Security Disability Insurance, andMedicaid Home and Community Based Waiver. Also, the term ‘mental retardation’ is used for citizenship and legal status, civil and criminaljustice, early care and education, training and employment, income support, health care, andhousing and zoning. While Ohio still uses the term mental retardation in the Ohio Revised Code,administrative rules and other places, in 2009, Governor Strickland signed a billinto law removing the words “Mental Retardation” from the name of the OhioDepartment of Mental Retardation and Developmental Disabilities and from thetitles of other state and county entities, councils, commissions and various funds thatuse the term. As the Ohio Department of Developmental Disabilities, S.B. 79recognized that mental retardation was merely a subset of developmentaldisabilities and had taken on an uncomplimentary connotation.
Definition of Intellectual Disability8 The American Association on Intellectual and Developmental Disabilities (AAIDD)defines ‘intellectual disability, as “a disability characterized by significant limitationsboth in intellectual functioning and in adaptive behavior, which covers manyeveryday social and practical skills. This disability originates before the age of 18’. Intellectual functioning — also called intelligence — refers to general mental capacity, suchas learning, reasoning, problem solving, and so on. Adaptive behavior - Adaptive Behavior includes the age-appropriate behaviors necessaryfor people to live independently and to function safely and appropriately in daily life.Adaptive behaviors include real life skills such as grooming, dressing, safety, safe foodhandling, school rules, ability to work, money management, cleaning, making friends, socialskills, and personal responsibility. One criterion to measure intellectual functioning is an IQ test. Generally, an IQ testscore of around 70 or as high as 75 indicates a limitation in intellectual functioning.
9 Standardized tests can also determine limitations in adaptivebehavior. Adaptive behavior includes three skill types: Conceptual skills—includes skills such as language and literacy; money,time, number concepts and self-direction. Social skills— such as interpersonal skills, social responsibility, self-esteem, gullibility, naïveté (i.e., wariness), social problem solving, and theability to follow rules/obey laws and to avoid being victimized. Practical skills— including activities of daily living (personal care),occupational skills, healthcare, travel/transportation, schedules/routines,safety, use of money, use of the telephone.
10 On the basis of such many-sided evaluations, professionals can determine whetheran individual has an intellectual disability and can tailor a support plan for eachindividual. But in defining and assessing intellectual disability, professionals must takeadditional factors into account, such as the community environment typical of theindividual’s peers and culture. Professionals should also consider language and cultural differences in the waypeople communicate, move, and behave. Finally, assessments must also assume that limitations in individuals often coexist withstrengths, and that a person’s level of life functioning will improve if appropriatepersonalized supports are provided over a sustained period.
What does it Mean to Treat Peoplewith Dignity and Respect?11 It is important to remember that you may be a person with adisability, but you are not a “disabled person.” You are, firstand foremost, a person. Not unlike any other person, you haveyour own set of strengths and weaknesses. Every individual has rights, is capable of learning, working,and being a contributing member of society. People with disabilities should live in a home of their choice,participate in chosen activities, employment and life-style andeach person deserves to be treated with dignity and respect.
12 Providers and others who work and interact with individuals with disabilities mustalways treat the individual with dignity and respect. A few examples include: Speaking to a person directly Speaking to individuals in a respectful manner and tone of voice Listening to the person, however they communicate Getting to know the person as an individual Not discussing a person in front of that person as if they are not present Not discussing an individual’s personal business in public where others can hear Not sharing information about an individual that is private or personal unlessyou have permission of the individual to share specific information Allowing the individual to do those things independently that they are capableof doing Using a person’s name when speaking to them or about them Avoiding derogatory terms when talking about a person – never refer to aperson based on their needs. For example, never call a person a tube feeder, ora pooper.
13 Several important points to remember: Everyone can learn Everyone should have the opportunity to work if they choose Everyone should have choice in where they live Everyone should be treated with dignity and respect People with disabilities can be contributing members of their community People with disabilities can make their own decisions Providers and others are not in control of a person’s life Individuals with disabilities want to have control of their own lives Providers and others need to listen to what a person is telling you and learn howeach person communicates It is important to listen, support and provide what the individual wants andneeds Everyone should have the opportunity to be as independent as possible People with disabilities are not ill Everyone is a citizen with equal rights, whether or not they have a disability
Remember to Think “People First”14 Language is a reflection of how people see each other. Thats why the words we usecan hurt. Its also why responsible communicators are now choosing language thatreflects the dignity of people with disabilities-words that put the person first, ratherthan the disability. Read on for a short course on using language that empowers. Think "people first." Say "a woman who has a developmental disability" rather than "adevelopmentally disabled woman." Avoid words like "unfortunate," "afflicted," and "victim." Try to avoid casting a person witha disability as a superhuman model of courage. People with disabilities are just people,not tragic figures or demigods. A developmental disability is not a disease. Do not mention "symptoms," "patient" or"treatment," unless the person youre writing about has an illness as well as a disability. Use common sense. Avoid terms with obvious negative or judgmental connotations, such as"crippled," "deaf and dumb," "lame" and "defective." If you arent sure how to refer to apersons condition, ask. And if the disability is not relevant to your story or conversation,why mention it at all? Never refer to a person as "confined to a wheelchair." Wheelchairs enable people toescape confinement. A person with mobility impairment "uses" a wheelchair. Try to describe people without disabilities as "typical" rather than "normal."
Current Philosophy and Best Practices15 Some of the key fundamentals in providing services and supports forindividuals with Developmental Disability include: Supporting the individual in having control over his/her own life Supporting the individual in building friendships and relationships Supporting the individual in working and living in their own community Assisting the individual establish & maintain financial control and stability Assuring that each person achieves and maintains an acceptable quality oflife is an important factor in providing services and supports. This section of the course will give a brief overview of several principles that willhelp providers meet this goal. The more familiar you are with each of theseprinciples the better you will be able to support each individual. These principlesinclude self-advocacy, person-centered planning, self-determination, supportedemployment and supported living. The chart below shows some of the keyelements of a quality life.
Self-Advocacy17 Self-advocacy means advocating on ones own behalf. It is the root of all socialactivist movements. The self-advocacy movement was started by and for peoplewith developmental disabilities because they wanted to be their own advocatesrather than having others, such as professionals, parents and other family members,and advocates with or without other disabilities, speak about their needs anddesires. As part of the broader disability rights/independent living movement, theself-advocacy movement is first and foremost a civil rights movement. As with allsocial activist movements, self-advocacy started at the grass-roots level where localleadership was drawn upon to organize groups of people to stand up and speakwith a goal to effect social change. The national self-advocacy organization, Self-Advocates Becoming Empowered (SABE), has defined self-advocacy in 1991 as thefollowing: " [It] is about independent groups of people with disabilities working together for justice byhelping each other take charge of our lives and fight discrimination. It teaches us how tomake decisions and choices that affect our lives so we can be more independent. It alsoteaches us about our rights, but along with learning about our rights we learn responsibilities.The way we learn about advocating for ourselves is by supporting each other and helpingeach other gain confidence in ourselves so we can speak out for what we believe in." TheResearch and Training Center on Community Living (RTC), The University of Minnesota
Person-Centered Planning18 The concept of person-centered planning developed from the work of John O’Brien, BethMount, Marsha Forest, Judith Snow and Jack Pearpoint. They wanted to change the wayfamilies and communities looked at and planned for the futures of persons with disabilities. Upto this point, programs had been created to serve people with disabilities and then peoplewere “plugged into” the program where they best fit. Many of these programs did not helpindividuals succeed in community environments and did not focus on functional skills.Traditionally, services, goals and objectives were determined by and controlled by staff andwere based on remediating a person’s deficits. Through person-centered planning theindividual and those closest to him or her control the development of the plan to help theperson live a life in the community similar to the lives of other community members and theplan focuses on a persons strengths and choices. With person-centered planning, the main concept is to develop a plan to meet personal needs,desires, dreams and choices of individuals, then find or create the services, supports andbudget to make that plan happen. The purpose of the plan is to help the person live the life ofhis or her choosing in the environment of choice. Person-centered planning changed the focusfrom existing services and systems to focus on the individual and each person’s individualchoices, strengths, dreams and needs. Planning focuses on personal strengths, choices anddreams rather than on a person’s weaknesses and deficits.
19 Getting to know someone is a very important part of person-centered planning. The best wayto get to know someone is to spend enough time together doing things, talking, listening, andwatching to figure out how someone chooses to live their life, where someone wants to live, howthey want to spend time each day, who they want to spend time with, and what are theirhopes and dreams for the future. It is also important to figure out the things that get in the wayof those life choices and how to eliminate barriers. There have been a number of formal approaches to person–centered planning includingPersonal Futures Planning, Making Action Plans or MAPS, PATH or Planning AlternativeTomorrows with Hope, Essential Lifestyle Planning and Circle of Friends. “All person centeredplanning approaches share three basic features:1. Everyday events and activities in which the individual participates should be the focusof planning;2. Family and connections within the community are more important than the serviceshistorically available; and3. Planning must be done with the individual with the disability and a group of peoplewho know the person well and are committed to helping the person achieve theirgoals.” (Falvey et al.,1994).
20 Some of the most important features of person-centered planning include: Planning must be based on the individual’s informed choices, preferences, desires, needs,and knowing one’s options Being in control of ones own life Being accepted by other community members as a member of the community Being valued by the community Living, working and enjoying recreational opportunities in the community Having needed supports available Having friends and relationships Having financial resources Having financial stability Holistic planning and support occur Forming interdependent relationships and partnerships with others and the community isimportant Natural supports are identified and used Services and supports are provided in a respectful, image enhancing manner Nonintrusive delivery of services and supports is essential
21 When using the person-centered planning approach, the plan results in thecommitment of many people supporting the person in reaching his or herdesired future, not just the “professionals”. The plan is not based ontraditional assessment or evaluation methods but rather on a processeffective for determining each individual’s choices, preferences and desires.The planning process focuses on building relationships and belonging. Toimplement such a plan, methods and resources for supporting choices,community connections and support, and an agency design that enablessupporting individual’s choices are needed. Ohio has come a long way over the past 20 years since person-centeredplanning first came to the forefront. Individual budgets, service and supportadministration, new funding streams, and choice of providers have allopened the doors to the person-centered approach.
Self-Determination22 Self-determination is a belief that was applied to people,other than those with disabilities, for many years prior tobeing applied to persons with developmental disabilities. This belief had roots in the civil rights movements and wasoften applied to Native Americans. Self-determination is the belief that people can and shouldbe in charge of their own lives to whatever degree thatperson is capable. For a person to be self-determining, they may needsupports, opportunities for decision-making and resources toimplement their choices in all aspects of their lives.
23 The four main principles of self-determination arefreedom, authority, support and responsibility. Thesehave been defined as follows:Freedom: The ability to make life decisions about where and withwhom one lives and what important things one undertakesthat parallels in every important way the decisions thatthose without disabilities make everyday. People have the freedom to determine a meaningful life forthemselves with the assistance of an independent facilitatorand their chosen circle of support.
24Authority: The ability to control a targeted amount of public dollarstogether and any available private money in order to crafta life plan that results in the everyday freedoms that allAmericans desire and the expectations that the lives of thosewith disabilities will mirror, with appropriate assistance whennecessary, the lives of others in this society. People have the authority to develop and control their ownindividual support budget within the constraints of thefunding allocation.
25Support: The organization of these resources in ways that are uniquefor the individual and address the support needed becauseof a disability with a more holistic way of planning andbudgeting that address perennial issues often lost in thesystem of traditional long term care: a place to call home,sustained relationships, community membership and foradults the production of private income through the world ofbusiness and commerce. People set up and control the support they need to have ameaningful life with the assistance of an independentbroker.
26Responsibility: The commitment for the wise use of public dollars and withadded flexibility in public funding seeking a more costeffective way to support individuals with disabilities. From its very inception Self-Determination challenged thehigh cost of “serving” individuals with significant disabilitieswith very few discernable outcomes that would beacceptable to a person without a disability. People take responsibility for managing their individualbudget with the assistance of an independent fiscalintermediary.
27 Ohio has accomplished a number of goals toward the implementation of self-determination including: the Medicaid Buy-In as a start toward allowing people to work without fear of losing theirhealth insurance; service and support administrators are now responsible for completing functionalassessment, developing individual plans, developing individual budgets and overseeingthe plan implementation; Medicaid Waivers have been approved; rules have been changed; new rules have been developed to help change the system in support of person-centeredplanning and self-determination concepts; Home and Community Based Services (HCBS) waiver rules support the development ofindividual budgets; adoption of the Core Indicators; and many other changes as well.
Supported Employment29 Supported employment has opened the door for manyadults with disabilities to leave sheltered work environmentsand become employed in a wide variety of community jobswith the supports needed to remain successfully employed. Community employment programs existed in several countiesin Ohio in the early 1980’s. These eventually evolved intosupported employment programs. Currently, one of thesources of payment for supported employment comes fromone of Ohio’s Home and Community Based Waivers.
30 What is Supported Employment?* Supported employment facilitates competitive work in integrated work settingsfor individuals with the most severe disabilities (i.e. psychiatric, mentalretardation, learning disabilities, traumatic brain injury) for whom competitiveemployment has not traditionally occurred, and who, because of the nature andseverity of their disability, need ongoing support services in order to performtheir job. Supported employment provides assistance such as job coaches,transportation, assistive technology, specialized job training, and individuallytailored supervision. Supported employment is a way to move people from dependence on a servicedelivery system to independence via competitive employment. Recent studiesindicate that the provision of on-going support services for people with severedisabilities significantly increases their rates for employment retention.Supported employment encourages people to work within their communities andencourages work, social interaction, and integration.*Excerpted from: U.S. Department of Labor, Office of Disability Employment Policy
31 Definitions A job coach is a person who is hired by the placement agency toprovide specialized on-site training to assist the employee with adisability in learning and performing the job and adjusting to the workenvironment. Natural supports are support from supervisors and co-workers, such asmentoring, friendships, socializing at breaks and/or after work,providing feedback on job performance, or learning a new skill togetherat the invitation of a supervisor or co-workers. These natural supportsare particularly effective because they enhance the social integrationbetween the employee with a disability and his/her co-workers andsupervisor. In addition, natural supports may be more permanent,consistently and readily available, thereby facilitating long-term job-retention.
32 Basic Components Supported employment services should achieve the following outcomes: opportunity toearn equitable wages and other employment-related benefits, development of new skills,increased community participation, enhanced self-esteem, increased consumerempowerment, and quality of life. The types of supported employment services useddepend on the needs of individual consumers. The following are the basic components of supported employment: Paid Employment -- Wages are a major outcome of supported employment. Workperformed must be compensated with the same benefits and wages as other workers insimilar jobs receive. This includes sick leave, vacation time, health benefits, bonuses,training opportunities, and other benefits. Employment must be for at least 18 hoursper week. Integrated Work Sites -- Integration is one of the essential features of supportedemployment. Individuals with disabilities should have the same opportunities toparticipate in all activities in which other employees participate and to work alongsideother employees who do not have disabilities. Ongoing Support -- A key characteristic which distinguishes supported employmentfrom other employment programs is the provision of ongoing support for individualswith severe disabilities to maintain employment.
33 Supported Employment Models Several supported employment models are being used to provide the benefits of work for people withsevere disabilities. Individual Placement Model -- A person with a disability is placed in a job in a community business which best suitshis/her abilities and preferences. Training is provided on the job site in job skills and work related behaviors,including social skills, by a job coach. As the employee gains skills and confidence, the job coach gradually spendsless time at the worksite. Support is never completely removed. The private or public vocational rehabilitationagency furnishing the job coach is always available to the employer for retraining for new assignments, assisting indealing with challenging behaviors, supplying periodic consultations with co-workers and employer, givingorientation and training for co-workers. Enclave Model -- A small group of people with disabilities (generally 5-8) is trained and supervised amongemployees who are not disabled at the host companys work site. Persons in the enclave work as a team at a singlework site in a community business or industry. Initial training, supervision, and support are provided by a speciallytrained on-site supervisor, who may work for the host company or the placement agency. Another variation of theenclave approach is called the "dispersed enclave." This model is used in service industries (e.g., universities,restaurants, and hotels). Each person works on a separate job, and the group is dispersed throughout the company. Mobile Work Crew -- A small crew of persons with disabilities (up to 6) works as a distinct unit and operates as aself-contained business that generates employment for their crew members by selling a service. The crew works atseveral locations within the community, under the supervision of a job coach. Examples of this type of work mightinclude janitorial or grounds keeping. People with disabilities work with people who do not have disabilities in avariety of settings, such as offices and apartment buildings. Small Business Model -- Within a small business, there may be up to six employees with disabilities, but not more thanthe number of employees without disabilities. The small business operates like any business, generating work andpaying employees from revenues received. The small business is located within the community
34 Benefits to Employers No fee to employer Thoroughly screened applicants Employees abilities matched to job requirements On-site job training by professionals Additional training, as necessary Follow-up services for the duration of employment
Supported Living & Other ResidentialOptions35 Supported LivingSupported Living is a way to assist individuals with mental retardation anddevelopmental disabilities to live as independently as possible in their own homes intheir own communities, with support from public funds. Most often, people insupported living arrangements live with family members, with roommates or bythemselves. They may live in an apartment, condo, duplex, single family home orany other type of housing. Supported living services may be provided in theindividual’s home regardless of the type of home.An individual may share supported living with up to three other individuals withdisabilities in a supported living arrangement. Service providers chosen by theindividuals sharing services may not be the landlord. Services and supports areidentified on an Individual Service Plan (ISP). An individual selects a supportedliving service provider from a list of certified providers.Supported living “includes the provision of housing, food, clothing, habilitation, staffsupport, professional services, and any related support services necessary to ensurethe health, safety, and welfare of the individual receiving the services”.
36 Capital HousingThe Ohio Department of Developmental Disabilities (ODDD) makes available statecapital assistance (bond) funds to assist local County Boards of DD in purchasinghousing for individuals receiving Supported Living services, or Supported Livingservices funded through Home and Community Based waivers. The goal of theprogram is to provide housing options in their own communities that allow peoplewith disabilities to be as fully integrated and independent as possible.The process for accessing Capital Housing dollars is governed through ODDDadministrative rule. Typically, County Boards of DD establish non-profit housingcorporations to receive the funds, and match them with other funding sources.Existing homes in the community are then purchased with these dollars forindividuals with developmental disabilities, often with their active involvement.Capital housing dollars are allocated to counties through an established formulabased on available funds.
37 Licensed FacilitiesThere are many homes throughout Ohio that are licensed residential facilities forperson with mental retardation and developmental disabilities, often called grouphomes. These homes are funded through waivers and ICFMR funds.Ohio law requires the licensure of facilities that provide services to two or moreunrelated individuals with DD, unless the individuals are sharing services in aSupported Living arrangement. In a licensed setting, a specific provider holds thelicense to operate the facility for a specific number of individuals at a specificlocation. Holding the license means that the provider of the housing is the same asthe provider of the services received by the individuals who live there.Currently there are over 1,200 licensed facilities housing over 10,000 individuals.This number of facilities has now been “capped” and will not continue to grow.
38 Intermediate Care Facility Mentally Retarded (ICFMR)ICFMR facilities typically serve persons with the most severe disabilities and, often,multiple disabilities. ICFMR facilities must provide "active treatment" to individualsresiding there. Active treatment is defined as a program of specialized and generictraining, treatment and health services.Intermediate Care Facilities for the Mentally Retarded (ICFMR) are funded throughMedicaid dollars and, in Ohio, are licensed by the ODDD, to be operated by aspecific provider at a specific location. The Department of Health (DOH) certifiesthe licensed facility as meeting the Federal requirements for funding as an ICFMR.The provider is responsible for all aspects of care for the individual, includingfinancial matters, transportation, habilitation, and medical needs.According to the federal regulations, an ICFMR is primarily for the diagnosis,treatment, or rehabilitation for people with mental retardation and provides, in aprotected residential setting, ongoing evaluation, planning, 24-hour supervision,coordination, and integration for health or rehabilitative services to help individualsfunction at their greatest ability.
39Developmental Centers Ohio operates ten developmental centers (as of 2010) that are locatedthroughout the state. Approximately 1,660 individuals reside in these facilities. All developmental centers are licensed as ICFMR facilities. Individuals residing in these facilities typically have severe challenges andreceive comprehensive and intensive services. No resident is ever considered permanently placed at a developmentalcenter. In addition to providing habilitation, centers provide extensive outreachservices to county boards and other providers, including case consultationand staff training.
Required Reading Required Reading: Person-Centered Planning –CMS Definition Person-Centered Planning –Renewed Interest Guiding Principles Circles of Support NCR Fact Sheet on SelfDetermination Supported Living Per the ORC40
Individual Planning41 Individuals with developmental disabilities often receive services from awide variety of service providers. In the past, each provider of servicesdeveloped an individual plan that contained the services and supports thatthey or their agency would provide. Staff from the varying agencies oftenattended each other’s team meetings and attempted to coordinate services,sometimes very successfully and other times, not so successfully. Having morethan one plan often led to duplication of services, services that conflicted,and service needs that were not met at all. With the onset of service and support administration came the requirementfor a single point of contact. This person has the overall responsibility tofocus on the individual, develop one coordinated plan rather than multiple,discordant plans, and assure the plan is carried out in accordance with allapplicable rules and best practices. Service and support administration alsoassures that quality assurance reviews are carried out and the results ofthose reviews are incorporated into the individual’s plan and services.
42 One person now has the responsibility for overseeing and coordinating services, supports andneeds of an individual. This person also has the responsibility for developing one plan therebyassuring comprehensive, coordinated planning and service delivery for and with eachindividual. That responsible person is the service and support administrator. The service andsupport administrator can have any assigned job title. Some examples are case manager,case coordinator, service coordinator, service & support specialist and many other titles.County boards are required to provide service and support administration to any individual,regardless of age, who is applying for or enrolled in an HCBS waiver; any individual threeyears of age or older who is eligible for county board services, and requests, or a person onthe individual’s behalf requests service and support administration; and any individualresiding in an ICF/MR is eligible for service and support administration related to moving theindividual from the ICF/MR to a non-ICF/MR community setting. County boards may provideservice and support administration to any other individuals who are eligible for county boardservices. Individuals with a sole diagnosis of mental illness are not eligible for county boardservices.Each individual who receives services and support administration must have a service andsupport administrator who is the single point of accountability. This means that an SSA isidentified who is responsible to an individual for the development, effective implementationand coordination of his or her ISP process.
Individual Plan DevelopmentRequirements43 Service and support administrators are responsible for developing and revising theindividual’s individual service plan (ISP). The ISP is the basis for all service deliveryand should focus on the individual’s strengths, interests, talents, choices, preferencesand dreams as well as skill development, increasing independence, and assuringhealth and safety. The ISP defines the goals and objectives established by theindividual and the services needed to assist the individual in meeting his/her goals.It also defines the type, frequency and duration of each service selected by theindividual and serves as the authorizing document for all services. For individuals onwaivers, the payment authorization form must be completed prior to commencementof services.SSAs must assure that the individual to be served and other persons selected by theindividual, and, when applicable, the provider(s) selected by the individual, are allactive participants in the development of the ISP. SSAs are also responsible forintegrating all sources of supports available to meet the needs and desiredoutcomes of the individual including alternative services.
44 When assisting individuals with plan development, the focus should be onsuch areas as helping the individual engage in meaningful, productiveactivities and develop community connections; selecting the provider;identifying the frequency of services and supports; and identifying thefunding source for each service and activity. The plan needs to specifywhich services will be coordinated among which providers and across allappropriate settings for the individual. If an ISP includes HCBS waiverservices, the plan must be in compliance with all applicable rules.The ISP also serves as a key document to ensure that services are providedin accordance with the plan, no matter who the service provider is, andensure that the health and welfare needs of the individual are met asoutlined in the plan. The ISP is also key to monitoring that the number ofBoard authorized units of service are delivered.SSAs do not “own” the plan but are the “recorders” of the plan whodocument the process for the individual to achieve desired outcomes.
Critical Issues of Planning45 The ISP is the document that is the basis for not only what services and supports the individualis to receive and what the health and welfare needs are of the individual, but the ISP is alsothe means that allows for the monitoring of service providers. The plan must be sufficientlyspecific to be able to document that the intent of the plan was met. It also needs to be writtento allow for adequate flexibility to meet the needs of the individual…sometimes a fine line towalk.Individual plans must be written in a manner that is easily understood by all concerned personsincluding the individual, family members and those who will be implementing various serviceand supports outlined in the plan. Plans need to contain sufficient detail to clearly define theservices to be delivered and must clearly identify health and safety concerns of the individual.The plan must indicate how those involved in plan implementation will address those concerns.Within the ISP, there must also be a balance between choices of the individual and the risksincurred by those choices that may impact health and safety.The planning process is an ongoing process. This means that the ISP will be changed andupdated as needed. This may be in response to changing desires of the individual, change inproviders, changes due to results of monitoring, changes in the individuals health orcircumstances or many other issues/occurrences.
Why is the ISP important?46 Individual service plans are important for a multitude of reasons. Some ofthe most important reasons include: Individuals are relying on this plan to help them achieve their goals andidentified choices, preferences, desires, dreams and needs. Individuals are relying on this plan to develop more independence and acquiremore community connections. Individuals are relying on this plan to maintain their health and safety. Individuals are relying on this plan to develop new skills and improve existingskills. Individuals are relying on this plan to develop community connections. Individuals are relying on providers to deliver services based on this plan. Providers are responsible for delivering services as outlined in the plan. Providers are held accountable for the proper delivery of services as outlined inthe plan. This is a legal document that provides a roadmap of the person’s life plan. Over time the ISP provides an historical view of the person’s life.
47 SSAs need to be work collaboratively with the individual and his orher family and circle of support, be responsive to the needs anddesires of the individual and family, and be respectful, in allinteractions with the individual and family.The individual service plan (ISP) is what provides the content anddirection for what services and support are to be provided to theindividual. The best practices discussed above are some of the manytools, principles and philosophies that should be used in the planningand delivery of the services and supports to assure that thoseservices and supports result in meeting the intent of the plan, theexpected outcomes of the plan and provide the quality of lifechosen by the individual and his/her circle of support.
Preparation and Quality Assurancefor the ISP48 Planning is a critical process that drives services andsupports and involves many people and numerous steps andprocesses. These typically include: evaluating/determining choices, preferences needs and desiresof the individual; meeting to develop a plan, developing a budget based onavailable resources, implementing the plan; evaluating the outcomes of the plan through quality assurancereviews, revising or redeveloping the plan as needed.Each of these are briefly discussed below. These steps may differbased on the chosen planning process and other variables.
49 Evaluation and data gathering provide the basis for the plan.The SSA oversees the process of working with the individual and others togather and review information that is already available about theindividual including strengths, choices, preferences, desires and needs. TheSSA in conjunction with the team then decides if the group needs moreinformation to develop a plan to support the individual. If so, additionalinformation can be gathered using best practices. Collecting needed information.The designated person gains permission to gather the needed information.If there are guardians they must give informed, written permission.Information can be gathered through a variety of means including formaland informal assessments, functional assessments, circles of support, person-centered planning, and other chosen best practices. Communication with theindividual and those who know the person best is critical to determiningwhat should be included in the person’s plan.
50 Developing the individual’s plan based on gathered data.The content of the individual plan drives the services and supports theindividual will receive. This plan must be clearly and well written. It is key toachieving the desired outcomes and assuring the health and safety of theindividual. Team meetings are commonly held to develop the plan. Meetingsare usually composed of people that the individual invites. They are personcentered and typically include many of the people that provide servicesand support to the individual. During the team meeting discussions andplanning occur to help the individual achieve their desired goals in life. Determining how the services and supports will be funded and developing anindividual budget.How are services and supports to be funded? Is the individual eligible forDD and related services? What other sources of funds are available? Theteam/circle of support works with the individual to identify, secure andbudget available resources.
51 Choosing a provider.The individual has free choice of provider. The individual, with assistance asneeded, will choose the provider(s) to carry out the plan. This may includeresidential providers, county boards, and a host of private providers. Implementation and Quality Assurance ReviewsImplementing the plan is the next essential step in providing services and supports toassist the individual attain his or her desired outcomes. Quality assurance reviewsare periodically conducted to assure the plan is carried out in accordance with theindividual’s wishes as written in the plan and the expected outcomes are achieved. Revision & Redevelopment of the PlanWhen it is determined that the plan needs to be revised or redeveloped the processbegins again. The plan may need to be revised, reviewed or redeveloped forvarious reasons, some of which include rule requirements, changes desired by theindividual, as a result of the quality assurance review, due to a change in thepersons circumstances, or many other reason.
52 Examples of team members that may help the individualwith planning and supports: Guardians, family members, friends and advocates Providers and agencies Sheltered workshop personnel The individual’s employer Speech/Physical/Occupational therapists Service and Support Administrators Social Workers Local Transportation Agencies Supported Employment Staff (BVR or local employment agencies)
Individual Rights: An Ohio Focus54 Throughout history, individuals with disabilities have often beendenied their rights that most Americans take for granted. Ohio has reinforced the rights of individuals with developmentaldisability through statute. Section 5123.62 of the ORC Rights ofPersons with Mental Retardation or a Developmental Disabilities isthe statute that addresses these rights. Other Ohio statute andFederal law address other aspects of rights of individuals as well. When interacting with individuals, including when providing servicesand supports, it is imperative that you be aware of and honor eachindividual’s rights. Following is information that will help yourecognize and honor those individual rights.
55 What is the Revised Code?The Ohio Revised Code (ORC) is the law in the state of Ohio. Whena bill is passed by the state legislature and signed by the Governor,it becomes a part of the Ohio Revised Code. It is the law.ORC 5123.62The Ohio legislature passed a bill that identifies the “rights forpersons with mental retardation or a developmental disability” in1986. It remains the law in Ohio today.Federal LawRights for persons with DD are also in federal law. In addition, allU.S. citizens have the rights guaranteed them in the U.S. Constitution.There are the basic civil rights for everyone with or withoutdisabilities.
56 What are ‘Rights’?‘Rights’ are the rules that help to make everyone equal. As aperson, you have some rights when you are born. These are called‘human rights’. In addition, you have ‘legal rights’ that are a part ofthe law in this country and in this state (Ohio). It is important to knowyour rights so that if people try to take them away, you can stopthem or get help to stop them. Differences in Adult and Children RightsLegal rights are held by parents for their children because parentsare legal guardians unless a court has intervened. Every child hasbasic human rights protected by state and federal law. A person is“emancipated” at the age of 18 and assumes his/her legal rights.This is true for people with or without disabilities.
57 GuardianshipIndividuals with DD are their own guardian at the age of 18 unless acourt has appointed a legal guardian. Guardianship may be full orlimited to specific areas. An individual who has a court appointedguardian maintains all rights unless a specific right has beenrestricted by the court or the guardian. What are ‘Responsibilities’?‘Responsibilities’ are the things that other people expect us todo. Responsible people know what their rights are and respect therights of other people. Being responsible means that you care aboutthe rights of other people.
58 Additional Support NeededIndividuals with DD often need additional education in learning theirrights and responsibilities. Special classes and teaching materialshelp people with DD learn more about their rights and how to speakup and advocate for themselves. The Bill of RightsOhio’s law has specified ‘rights’ for individuals with mentalretardation and/or other developmental disabilities. It is the responsibility of all staff to assure that these rights aregranted and that each person with a developmental disability isaware of and understands his or her rights.
ORC 5123.62 The rights of personswith a developmentaldisability include, butare not limited to, thefollowing: ORC 5123.62…59
60 Courtesy and Respect… Individuals have the right to be treated at all times with courtesyand respect and with full recognition of their dignity andindividuality. In simple terms… To always be treated nicely and as a person nomatter the circumstances. A Safe Place To Live… The right to an appropriate, safe, and sanitary living environmentthat complies with local, state, and federal standards andrecognizes the persons’ need for privacy and independence. In simple terms… Have a clean safe place to live in and a placeto be alone
61 Good Nutrition… The right to food adequate to meet acceptedstandards of nutrition. In simple terms… to have food that is good for you. Freedom of Religion… The right to practice the religion of their choice or toabstain from the practice of religion. In simple terms… to be able to go, if you want, to anychurch, temple, mosque
62 Medical Care… The right of timely access to appropriate medical or dentaltreatment. In simple terms…to be able to go to a doctor or dentist when youare sick or need a check-up. Ancillary Services… The right of access to necessary ancillary services, including, butnot limited to, occupational therapy, physical therapy, speechtherapy, behavior modification and other psychological services. In simple terms…To be able to have people help you with theway you walk, talk, do things with your hands, act or feel, if youneed it.
63 Medical Treatment… The right to receive appropriate care and treatment in theleast intrusive manner. In simple terms…To be treated kindly and gently when youreceive the care you need and want. Privacy… The right to privacy, including both periods of privacy andplaces of privacy. In simple terms…To be able to have time and a place to goto be by yourself.
64 Communication… The right to communicate freely with persons of their choicein any reasonable manner they choose. In simple terms… To be able to call, write letters or talk toanyone you want about anything you want Personal Property… The right to ownership and use of personal possessions so asto maintain individuality and personal dignity. In simple terms… To be able to have your own things and tobe able to use them.
65 Friendships… The right to social interaction with members of either sex. In simple terms… To be able to have men and women asfriends. Be All That You Can Be… The right of access to opportunities that enable individualsto develop their full human potential. In simple terms… To be able to join in activities, havefriends, participate in community activities and do thingsthat will help you grow to be the best person you can be.
66 Contribute to Your Own Support… The right to pursue vocational opportunities that will promote andenhance economic independence. In simple terms…To be able to work at a job of one’s choosingand make money. Americans with Disabilities Act … Assures employers shall not discriminate against a qualifiedindividual with a disability. Legislation passed by the United States Congress in 1990 toprohibit discrimination against people with disabilities andto guarantee them equal access to employment, publicservices, public accommodations, and telecommunications.
67 Equality… The right to be treated equally as citizens under thelaw. In simple terms…To be treated just like everyone else. Free From Harm… The right to be free from emotional, psychological orphysical abuse. In simple terms…To not be hit, yelled at, cursed at orcalled names that hurt you.
68 Learning, Growing, Playing… The right to participate in appropriate programs ineducation, training, social development, and habilitation andin programs of reasonable recreation. In simple terms…To be able to learn new things, makefriends, have activities to do, and go out in your community Freedom To Choose… The right to participate in decisions that affect their lives. In simple terms…To be able to tell people what you wantand be part of making plans or decisions about your life
69 Advocacy or Representation… The right to select a parent or advocate to act on theirbehalf. In simple terms…To be able to ask someone you want tohelp you, let others know how you feel or what you want. It’s My Money… The right to manage their personal financial affairs, basedon individual ability to do so. In simple terms…To be able to use your money to pay forthings you need and want.
70 Privacy… The right to confidential treatment of all information in theirpersonal; and medical records, except to the extent thatdisclosure or release of records is permitted under sections5123.89 and 5126.044 of the Revised Code. In simple terms…To be able to say yes or no before peopletalk about what you do at work or home or look at your file. ORC 5123.89 Confidentiality of records; disclosure. ORC 5126.044 Disclosure of identity of individual or release of record or report.
71 Freedom of Speech… The right to voice grievances and recommend changes in policiesand services without restraint, interference, coercion,discrimination, or reprisal. In simple terms…To be able to complain or ask for changes if youdo not like something without being afraid of getting in trouble. Freedom… The right to be free from unnecessary chemical or physicalrestraints. In simple terms… Not be given medicine that you dont need orwant, nor be held down if you are not hurting yourself or others.
72 The Right to Vote… The right to participate in the political process. In simple terms…To vote, learn about laws and yourcommunity. The Right To Say “NO”… The right to refuse to participate in medical,psychological, or other research experiments. In simple terms…To say “yes” or “no” to being a partof a study or experiment.
ORC 5123.62 Client Rights73 Every state agency, county board of mental retardation and developmental disabilities, orpolitical subdivision that provides services, either directly or through a contract, to persons witha developmental disability shall give each provider a copy of the list of rights contained insection 5123.62 of the Revised Code. Each public and private provider of services shall carryout the requirements of this section in addition to any other posting or notification requirementsimposed by local, state, or federal law or rules. The provider shall make copies of the list of rights and shall be responsible for an initialdistribution of the list to each individual receiving services from the provider. If the individual isunable to read the list, the provider shall communicate the contents of the list to the individualto the extent practicable in a manner that the individual understands. The individual receivingservices or the parent, guardian, or advocate of the individual shall sign an acknowledgementof receipt of a copy of the list of rights, and a copy of the signed acknowledgement shall beplaced in the individual’s file. The provider shall also be responsible for answering anyquestions and giving any explanations necessary to assist the individual to understand therights enumerated. Instruction in these rights shall be documented. Each provider shall make available to all persons receiving services and all employees andvisitors a copy of the list of rights and the addresses and telephone numbers of the legalrights service, the department of mental retardation and developmental disabilities, and thecounty board of mental retardation and developmental disabilities of the county in which theprovider provides services.
75 5123.64 Enforcement duties of providers; procedure upon violation Every provider of services to persons a developmental disability shall establish policiesand programs to ensure that all staff members are familiar with the rights enumerated insection 5123.62 of the Revised Code and observe those rights in their contacts withpersons receiving services. Any policy, procedure, or rule of the provider that conflicts with any of the rightsenumerated shall be null and void. Every provider shall establish written procedures forresolving complaints of violations of those rights. A copy of the procedures shall beprovided to any person receiving services or to any parent, guardian, or advocate of aperson receiving services. Any person with mental retardation or a developmental disability who believes that theperson’s rights as enumerated in section 5123.62 of the Revised Code have been violatedmay: Bring the violation to the attention of the provider for resolution; Report the violation to the department of mental retardation and developmentaldisabilities, the ombudsperson section of the legal rights service, or the appropriatecounty board of mental retardation and developmental disabilities; Take any other appropriate action to ensure compliance with sections 5123.60 to5123.64 of the Revised Code, including the filing of a legal action to enforce rights orto recover damages for violation of rights.
76 5123.65 Self-administration of medication. In addition to the rights specified in section 5123.62 ofthe Revised Code, individuals with developmentaldisabilities who can safely self-administer medicationor receive assistance with self-administration ofmedication have the right to self-administer medicationor receive assistance with the self-administration ofmedication. The department of mental retardation anddevelopmental disabilities shall adopt rules as itconsiders necessary to implement and enforce thissection. The rules shall be adopted in accordance withChapter 119. of the Revised Code.
77 Remember….it is the responsibility of everyone whoworks with, supports or otherwise interacts with personswith disabilities to assure they are aware of, understandand are afforded their rights. When Rights Violations Becomes an MUISome rights violations must be reported as a MajorUnusual Incident. A rights violation that results inphysical or emotional harm must be reported as anMUI.
78 Restricting Rights Rights must never be restricted without the approval of the individual and/or hisor her guardian. Rights are often violated through the use of behavior plans,through the mode of “not enough money” and through medication“restraint.” Everyone who supports an individual with DD must be on guard toguarantee and protect rights. Reporting Rights Violations… Any person with DD who believes their rights have been violated may: Tell their provider so it may be resolved; Report it to the Department of DD or the Ohio Legal Rights Service; Tell their Service and Support Administrator; or, File a legal action. Annual Review of Rights Individuals who receive services from a county board of DD must have theirrights reviewed each year and sign a statement that it was done.
Rights: An International Focus79 The United Nations Department of Economic and Social Affairs based in New Yorkand the Office of the High Commissioner for Human Rights in Geneva have multipleresponsibilities including: to support the full and effective participation of persons with disabilities in social life anddevelopment; to advance the rights and protect the dignity of persons with disabilities and; to promote equal access to employment, education, information, goods and services. One of the mandates of the Secretariat for the Convention on the Rights of Personswith Disabilities was to develop the Convention on the Rights of Persons withDisabilities which was adopted in 2006. The Convention on the Rights of Persons with Disabilities and Optional Protocolentered into force on May 3, 2008. This marked ‘a major milestone in the effort topromote, protect and ensure the full and equal enjoyment of all human rights andfundamental freedoms of persons with disabilities and to promote respect for theirinherent dignity’.
80 Over 130 nations have now signed the Convention agreeing to abide by its principles. Thereare eight guiding principles that underlie the Convention and each one of its specific articles.These are: Respect for inherent dignity, individual autonomy including the freedon to make one’s own choices, andindependence of person’s Non-discrimination Full and effective participation and inclusion in society Respect for difference and acceptance of persons with disabilities as part of human diversity andhumanity Equality of opportunity Accessibility Equality between men and women Respect for the evolving capacities of children with disabilities and respect for the right of children withdisabilities to preserve their identitiesMonitoring occurs to assure implementation through a committee on the rights of persons withdisabilities. For more information on the Convention, visit www. un.org/disabilities.
Required Reading Required Reading We Have HumanRights: A Handbook forPeople withDevelopmentalDisabilities81
MUI: Major Unusual Incidents82 ORC 5123:2-17-02Incidents Adversely Affecting Health and Safety What does Major Unusual Incident (MUI) mean?Major unusual incident means the alleged, suspected, oractual occurrence of an incident when there is reason tobelieve the health or safety of an individual may beadversely affected or an individual may be placed ata reasonable risk of harm, if the individual is receivingservices through the DD service delivery system or willbe receiving such services as a result of the incident.
83 Why are MUI’s reported? MUIs are reported to protect individuals with developmentaldisabilities -- to ensure their health and safety. By reporting eachand every MUI, the cause, factors or trends leading to an MUIcan more easily be identified and plans and safeguards can beestablished or revised to prevent future incidents. Who must report an MUI? All providers who are contracted, certified or licensed to servepersons with developmental disabilities are required to reportMUIs to the appropriate county board. All county board and ODDD staff are required to reports MUIs. Anyone providing Medicaid waiver services must report MUIs.
84 When must an MUI be reported?All incidents of possible abuse, neglect, misappropriation or deathmust be reported to local law enforcement and the county board orto the public children’s service agency, when applicable, no matterwhere the incident occurred.Other categories of MUIs must be reported according to 5123:2-17-02 when the incident occurred in a program operated by acounty board or contractor or the county board or when theindividual is being served by a licensed or certified provider.Reporting/notification should occur as soon as possible but no laterthan 4 hours after the incident occurred. Written reports are to besubmitted no later than 3 p.m. the day following the incident.
What is an MUI?85 An MUI includes, but is not limited to, the following:Abuse Physical - Physical force that can reasonably beexpected to result in harm or serious physical harm.Examples of physical abuse include hitting, slapping,pushing, throwing objects at a person and others. Sexual - Unlawful sexual conduct or sexual contact asdefined in 2907.01 of the ORC. Verbal - Using wordsor gestures to threaten, coerce, intimidate, harass orhumiliate an individual.
86 Physical Abuse Example Peter is on a homecare waiver. A staff member observed himbeing hit by his care worker. If the staff person hitting causedharm, the county board and law enforcement needs to benotified immediately. Sexual Abuse Example Steve is well known by staff in the workshop to be a sexualpredator and is to have “eyes-on supervision.” Two staffintervened in a behavioral episode with other clients, which gaveSteve the opportunity to slip into the bathroom and fondle Larry. This would be an MUI if it was unwanted, not consensual sexualcontact. Staff was failing to provide supervision. (How manyMUI’s? Two. Two victims - two primary people involved)
87 Verbal Abuse Example The consumer wet the bed. Staff yelled, “I’m tiredof this-this better not happen again.” The consumerreported that her feelings were hurt. This would be an MUI if the consumer feltthreatened, humiliated or intimidated.
88 Attempted Suicide – Actual physical attempt –regardless of whether harm resulted. Attempted Suicide Examples An individual attempts to commit suicide by taking abottle of pills. The pills turn out to be placebos and theindividual suffers no physical harm. An individual attempts to commit suicide by cutting theirarm. Seven stitches are required to treat the wound.
89 Death – Any cause. Exploitation – Unlawful or improper acts using an individual or anindividual’s resources for monetary or personal benefit, profit orgain. Failure to Report – A person, who is required to report pursuant tosection 5123.61 of the Revised Code, has reason to believe that anindividual has suffered or faces a substantial risk of suffering anywound, injury, disability, or condition of such a nature as toreasonably indicate abuse or neglect of that individual, and suchperson does not immediately report such information to a lawenforcement agency, a county board, or, in the case of an individualliving in a developmental center, either to law enforcement or thedepartment.
90 Known Injury – Injury from a known cause that is not consideredabuse or neglect and that requires immobilization, casting, five ormore sutures or the equivalent, second or third degree burns, dentalinjuries, or any injury that provides the individual from participatingin routine daily tasks for more than two consecutive days. Law Enforcement – An incident that results in an arrest, filing ofcharges or incarceration. Law Enforcement Example The county board should be notified immediately for abuse/neglect, theft,accidental or suspicious death, missing person or serious injury. Medical Emergency – Emergency medical intervention is required tosave an individual’s life. Medical Emergency Example Heimlich maneuver, CPR, intravenous fluids given due to dehydration
91 Misappropriation – Depriving, defrauding, or obtaining byany other means the real or personal property of anindividual by means prohibited by the ORC. Missing Person – The individual cannot be located for aperiod of time longer than specified in the individual serviceplan and the individual cannot be located after actionsspecified in the individual service plan are taken and theindividual cannot be located in a search of the immediatesurrounding area; or circumstances indicate that theindividual may be in immediate jeopardy; or lawenforcement has been called to assist in the search for theindividual.
92 Neglect – When there is a duty to do so, failing to providean individual with any treatment, care, goods, supervision orservices necessary to maintain health and safety. Neglect Example A child at a swimming pool jumped into the deep end bymistake. The lifeguard rescues the child. This would be an MUI if there was a failure to supervise and/or if amedical emergency occurred. Peer-to-Peer Acts – Acts committed by one individualagainst another when there is physical, verbal or sexualabuse; any exploitation; or intentional misappropriation ofproperty of significant value.
93 Prohibited Sexual Relations – An employee engaging inconsensual sexual conduct/contact with an individual theyare employed to provide care at the time of the incidentand includes persons in the employees supervisory chain ofcommand. Rights Violation – Any violation of rights that creates areasonable risk of harm to the person’s health or safety. Didthe act negatively create risk to the individual’s healthand/or safety? Rights Violation Examples: The individual sustains food poisoning after staff inadvertently servesthe individual moldy bologna. Staff padlocks the refrigerator. The individual sustains lacerationtrying to break the lock.
94 Unapproved Behavior Support – The use of any aversive behaviorstrategy or intervention implemented without appropriate approvalsor without informed consent. Unknown Injury – Any injury of an unknown or suspicious origin thatrequires treatment by a physician, physician assistant, or nursepractitioner or any injury of a known or non-suspicious origin thathas a significant impact on their physical health. Unscheduled Hospital Admission – Any unplanned or unscheduledhospital admission (not expected as a part of a person’s medicalcondition. Not included in ISP under specific criteria as to whenperson would be admitted).
Notification and Reporting Requirementsfor MUIs95 All incidents of possible abuse must be reported tolocal law enforcement and to the county board or to thepublic children’s service agency, when applicable, nomatter where the incident occurred. The county boardhas the responsibility of reporting incidents on theODDD on-line incident tracking system (ITS). All MUIs involving abuse, neglect, exploitation,misappropriation or death must be reported/filed nomatter where the incident occurred.
96 Other categories of MUIs must be reported according to5123:2-17-02 when the incident occurred in a programoperated by a county board or when the individual is beingserved by a licensed or certified provider. The providermust notify the County Board of DD. Whenever an MUI occurs, first and foremost, measures toensure the health and safety of the individual must be taken.This may include: Medical care Removal of an employee from direct contact with an at-riskindividual when the employee is alleged to have been involved inthe abuse or neglect Any other appropriate measures to protect the health and safetyof the individual
MUIs must be reported to the ODDDunder any circumstances listed below97 5123:2-17-02 (I) Department-directed Investigations (1) The department shall conduct the administrative investigation when the MUI includes an allegation against: (a) The superintendent of a county board or developmental center. (b) The executive director or equivalent of a regional council of governments. (c) A management employee who reports directly to the superintendent of the county board, the superintendent of a developmentalcenter, or executive director or equivalent of a regional council of governments. (d) An investigative agent. (e) A service and support administrator. (f) An MUI contact employed by a county board. (g) A current member of a county board. (h) A person having any known relationship with any of the persons specified in paragraph (I)(1)(a) to (I)(1)(g) of this rule when suchrelationship may present a conflict of interest or the appearance of a conflict of interest. (i) An employee of a county board when it is alleged that the employee is responsible for an individual’s death, has committedsexual abuse, engaged in prohibited sexual activity, or committed physical abuse or neglect resulting in emergency room treatmentor hospitalization. (2) A department-directed investigation or investigation review may be conducted following the receipt of a requestfrom a county board, developmental center, provider, individual, or guardian if the department determines thatthere is a reasonable basis for the request. (3) The department may conduct a review or investigation of any MUI or may request that a review or investigationbe conducted by another county board, a regional council of governments, or any other governmental entityauthorized to conduct an investigation.
98If the provider has receivedinquiries from the mediaregarding an MUI, theprovider must immediately,but no later than four hoursafter discovery of theincident, notify the countyboard by means identifiedby the county board.
Investigation Requirements All MUI’s require an investigation that meet therequirements outlined in Appendix A or Appendix Bof 5123:2-17-02. Each county board is required toemploy at least one investigative agent or contractwith a person or governmental entity for theservices of an investigative agent. This person mustbe appropriately certified by ODDD.99
Investigation Closure Written Summaries Must be submitted five calendar days after recommendation made that the reportbe closed. This must include: Allegations Facts & findings Whether or not the case was substantiated Preventive measures required, if applicable The summary is to be provided to: The individual or his or her legal guardian or an advocate selected by the individual The licensed or certified provider The service and support administrator or other person chosen by the individual to coordinateservices101
In the case of death, the written summary is to be given to the family, upon request The summary is NOT to be given to the PPI, the PPI’s spouse, or the PPI’s significantother. The PPI is to be notified as to whether the MUI was substantiated, unsubstantiateddue to insufficient information or unsubstantiated due to being unfounded If no SSA is assigned to the individual, a county board designee is to beassigned responsibility for ensuring any preventive measures in the summaryare implemented unless the individual resides in an ICF/MR. Any findings in the report may be disputed by following the guidelinesfound in 5123:2-17-02.102
Review of MUIs County boards and agency providers must have a written procedure inplace for internal review of all MUIs and for reasonable steps to preventMUIs. An individual’s team is required to collaborate to develop preventivemeasures for future MUIs. The ODDD has the responsibility to review and close reports submitted bythe county board or developmental center for such incidents as abuse,death, neglect and others as required by rule 5123:2-17-02. The county board has the responsibility to review and close reports forincidents such as attempted suicide, medical emergencies and others asrequired by rule 5123:2-17-02.103
The department and the county board both use the following criteria whendetermining whether or not to close a case: Have sufficient reasonable measures have been taken to ensure the health and safety of any at-riskindividual Has a thorough investigation has been conducted consistent with the standards for protocol and non-protocol investigations Has the team, including the county board and provider, collaborated on developing preventivemeasures to address the causes and contributing factors Has the county board ensured that the preventive measures have been implemented to preventreoccurrence Is the incident part of a pattern or trend or does it require some additional action Have all requirements in statute or rule been satisfied. No later than five days after a case is closed, the county board is to notify theprovider that the case was closed.104
Patterns and Trends County boards are required to conduct quarterly and annual reviews ofMUIs to look for trends and patterns, analyze the data and developpreventive measures to address any identified trends or patterns to preventreoccurrence. This analysis is submitted to the ODDD twice a year, per rule. Any trends orpatterns related to any individual must also be addressed in that person’sindividual plan. Each county board must have a committee that reviews trends and patternsand to identify areas for improving the quality of life of individualssupported in the county.105
Unusual IncidentsWhat does Unusual Incident (UI) mean? An unusual incident is an event or occurrence involving an individual that isnot consistent with routine operations, policies and procedures, or the careor individual service plan of the individual, but is not an MUI. Unusualincidents include, but are not limited to: Medication errors Falls Peer-to-peer incidents that are not MUIs Overnight relocation of an individual due to fire, natural disaster, or mechanicalfailure Any injury to an individual that is not an MUI106
Each agency provider and county board must develop and implement apolicy and procedure that: Identifies what is to be reported as a UI including those defined by rule Requires anyone who becomes aware of a UI to report it to the person designatedby the provider who can initiate proper action Requires the report to be made no later than twenty-four hours after the occurrenceof the incident Requires appropriate actions be taken to protect the health and safety of any at-riskindividuals Staff are to be trained and knowledgeable regarding the policy andprocedure. Notification procedures and timelines are to be followed bystaff.107
UIs are to be reviewed as necessary, but no less than monthly, to ensureappropriate preventive measures have been implemented and trends andpatterns identified and addressed as appropriate. A log of all UIs must bemaintained and must include, but not be limited to, the name of theindividual, a brief description of the incident, any injuries, time, date,location, and preventive measures. These logs are to be reviewed at leastmonthly by the appropriate agency per rule 5123:20-17-02 guidelines. UI reports, documentation of identified trends and patterns, and correctiveaction must be available to the county board and ODDD upon request. The ODDD conducts reviews of county boards and providers as necessaryto ensure the health and safety of individuals and compliance with therequirements of this 5123:2-17-02.108
Training Regarding MUIs and UIs All staff of agency providers and county boards are to be trained regarding theidentification and reporting of MUIs and UIs and other requirements of 5123:2-17-02, inaccordance with all provisions of 5123:2-17-02, prior to unsupervised contact with anyindividual and in all cases, no later than thirty calendar days after employment. Thereafter, allemployees are to receive training during each calendar year which includes a review ofhealth and safety alerts released since the previous calendar year’s training. All agency providers and county boards are to ensure that all staff responsible foradministrative compliance with this rule receive training on all applicable requirements of thisrule at the time of employment or no later than ninety calendar days from the time ofemployment and each calendar year thereafter. The county board is to ensure that staff responsible for conducting investigations receive initialand annual department-approved training. The department provides technical assistance andtraining to providers and county boards as necessary. The department will periodicallymonitor compliance with the provisions of this rule.109
MUI/UI Summary MUIs and UIs are reported to protect individuals with developmentaldisabilities -- to ensure their health and safety. By reporting each andevery MUI and UI, the cause, factors or trends leading to an incident canmore easily be identified. Plans and safeguards can then be established orrevised to prevent future incidents. It is the responsibility of all staff who work with persons with mentalretardation and developmental disabilities to be able to recognize andidentify MUIs and UIs and to know what actions they are required to followto report such incidents. When in doubt that an incident is a UI or MUIdocument the incident as if it is a UI or MUI. Review your agencies policies and procedures on MUIs and UIs and becomefamiliar with reporting procedures and forms.110
Required Reading Required Reading 5123:2-17-02 Incidentsadversely affectinghealth and safety.111
Overview of Individual Optionsand Level One Waivers What is a Waiver?A waiver is a part of a state’s Medicaid State Plan. It is an exception to the Medicaidlegislation that is granted to a state by the federal Centers for Medicare and MedicaidServices allowing the state to waive some of the requirements of Medicaid. To gain approval,waivers must be cost effective, efficient, and consistent with the objectives of the Medicaidprogram. Waivers serve people who are elderly, who have mental retardation and/ordevelopmental disabilities and/or who have physical disabilities. The purpose of waivers is tokeep people living in their own homes rather than moving to more expensive options such asnursing homes or intermediate care facilities.Waivers are one of the optional benefits that states may choose to offer through the MedicaidState Plan as an alternative to institutional care. Through this option, Ohio’s State Plan offersHome and Community-Based Services Waivers (HCBS). These waiver programs providealternatives to living in facility-based care settings such as a nursing home or intermediatecare facility for the mentally retarded (ICFMR). Because this type of care can be costly, OhiosMedicaid program can help Medicaid-eligible Ohioans pay for their long-term care.112
Waiver programs were first authorized in 1981 under section 1915c of the SocialSecurity Act. The first time these waivers became available in Ohio was July 1991.This first waiver was called the Individual Options waiver and is one of the twowaivers available today in Ohio. The second waiver to become available is theLevel One waiver that began in 2003. Waivers are available on a limited basis,based on available funds and meeting eligibility requirements. Since waivers are a part of Medicaid, they are administered by the same agenciesas the overall Medicaid program. At the Federal level, Medicaid is administered bythe U.S. Department of Health and Human Services, Centers for Medicare andMedicaid Administration (CMS). In Ohio, the Medicaid program is administered bythe Department of Jobs and Family Services (ODJFS). Other agencies administerspecific Medicaid programs through interagency operating agreements with ODJFS.ODJFS applies for all HCBS waivers and sets parameters for waiver programs.113
The ODDD Eligibility Unit, Division of Medicaid Administration anddevelopment processes all waiver applications and determines level of carefor HCBS waivers. County Boards of DD administer HCBS waivers asdefined in ORC Section 5126.055. There is an annual renewal process forcontinued waiver services and individuals enrolled on waivers must meetMedicaid eligibility requirements every month. Before waiver services can be provided an authorization for waiverservices must be secured. This process authorizes the ISP and associatedpayment. Why is authorization of waiver services important? The resultspecifies how much of what services an individual will receive, when, andaccording to what parameters. The process associated with theauthorization of waiver services includes allocation of state and localresources for the reimbursement of services provided.114
Individuals who have been approved to receive waiver services will choose their serviceprovider through the Free Choice of Provider Process. It is the responsibility of the service andsupport administrator to assist individuals in the selection of service providers. Serviceproviders must be certified through the ODDD. Per 5123:2-9-11 of the Ohio AdministrativeCode, which has details about the Free Choice of Provider Process, “An individual shall beresponsible for making all decisions regarding free choice of providers unless the individualhas a guardian, in which case the guardian shall be responsible for making such decisions.Individuals, including those with guardians, have the right to participate in decisions regardingthe free choice of providers. An individual who does not have a guardian or an individualsguardian may designate another person, including a member of the individuals family, toparticipate in the process of making decisions regarding free choice of providers…” Other details available in this rule include such areas as the requirement for ODDD tomaintain a current provider list and details on the requirement that SSAs must utilize this list toassist individuals when selecting providers.115
Individual Options Waiver(IO Waiver) Waiver services provide certain Ohio citizens the training and support that they need inaddition to the Medicaid State Plan services that they can receive. Medicaid State Planservices are often called ‘Medicaid Card’ services and include prescription medication,hospital care, physician visits and other healthcare services. Waiver services allow a limited number of people who meet certain conditions to stay in theirown homes and receive services there and in the community instead of living in anIntermediate Care Facility for the Mentally Retarded (ICF/MR). To receive IO waiver services,an individual must be eligible for Medicaid and have an ICF/MR Level of Care approved bythe Department of Job and Family Services. As of 2008, all 88 counties have individuals enrolled on the IO waiver with approximately12,000 individuals enrolled across the state. The average cost in 2008 of Individual Options waiver services per person is approximately$47,000 while theaverage cost of ICF/MR services per person is approximately $90,000. Not only does anindividual benefit from staying in their own home, but a significant cost savings can be gained.116
Service and Support Administrators (SSAs) who work in each county board ofmental retardation and developmental disabilities will assist individuals to apply forMedicaid and complete their Level of Care paperwork. Through the individualplanning process, with help from the SSA and input from professionals and serviceproviders, each individual, his/her family and advocates will determine whichservices are needed, how often they are needed, where they will be provided andwho will provide them. The funding ranges and payment amounts that will be available to an individual forthe IO waiver funded portion of these services are based on the needs of eachindividual as measured by the Ohio Developmental Disabilities Profile (ODDP). TheAcuity Assessment (AAI) is also used to determine a waiver budget amount if anadult needs out of home day services through the waiver.117
The IO waiver provides thefollowing services: Adult Day ServicesThese services are available to individuals who are not eligible to receiveeducational services. Adult Day Services include: Adult Day SupportThese services are provided separate from any home or facility in which an individualresides, focus on non-work activities, and include five components: Assessment -- may be formal or informal, for the purpose of developing an Individual Service Plan(ISP) Personal care -- includes personal hygiene, eating, communication, mobility, toileting, and dressing Skill reinforcement -- includes implementing behavioral intervention plans, and help with the use ofcommunication and mobility devices Training in self-determination -- includes developing self-advocacy skills and acquiring skills thatenable an individual to become more independent Recreation and leisure -- includes supports identified in the ISP that are therapeutic, and help todevelop and maintain social relationships and family contacts118
Vocational HabilitationThese services teach and reinforce concepts related to worksuch as: * Responsibility * Attendance * Task completion * Problem Solving * Social Interaction * Motor skill development * Safety119
Supported employment Supported Employment – Community This service provides job coaches, supervision and training to help individualsfind and keep paying community jobs at places where persons withoutdisabilities are employed and to work side-by-side with them. Supported Employment – Enclave This service provides job coaches, supervision and training to help individualswho work as a team to find and keep paying jobs at one or more work sitesof the ‘host’ community business. Non-Medical TransportationThis service pays for transportation needed by an individual to get to and fromplaces where he/she receives Supported-Employment – Community, SupportedEmployment – Enclave, Adult Day Services and/or Vocational Habilitationwaiver services.120
Environmental Accessibility Adaptations This service includes changes to the individual’s home that help him/her to be moreindependent. The modifications may include widening doorways, building ramps intothe home, changing bathrooms for individuals who use wheelchairs or other aids towalk, and installing special electric or plumbing changes needed to operate medicalequipment. Home Delivered Meals Preparation and delivery of up to two meals each day, seven days per week isprovided for individuals who are unable to make their own meals or get healthymeals for themselves in some other way.121
Homemaker/Personal CareServices are provided to increase the independence of the individual within his/her home orthe community and may include: Basic personal care and grooming such as bathing, hair care and help dressing; Assisting the individual going to and/or using the bathroom; Help with household chores for the individual, such as changing bed linens and doing thelaundry, so the individual remains in good health and is comfortable; Helping the individual take his/her medication or perform health-related tasks that havebeen delegated by the individual’s physician and a licensed nurse; Helping the individual to prepare shopping lists, to make meals, to shop in the communityfor food and clothing; Assisting the individual to go to medical appointments, to use community services, to takewalks and participate in recreational activities inside and outside the home; Cooking meals with the individual or for the individual; Assisting the individual to get to and from work and other vocational activities; Running errands on behalf of the individual, such as picking up medication from the drugstore.122
Interpreter ServicesPeople who provide this service help the individual to communicate his/hermessages and feelings and understand the messages of others. Nutrition ServiceA nutritionist provides direction to individuals who are at risk because they a noteating the right kinds of foods to stay healthy. The service can be used to preparea plan for healthy eating and can also be used to teach the individual, family orothers who help with meals. Respite CareServices are provided to individuals for a short period of time in an ICF/MR and/orother home licensed by the Department of DD in order to give persons who care forthem a break. Respite services are also available when caregivers are unable toprovide care because of their illness or absence123