Division of Intellectual Disabilities Services
James R. Finch, Ed.D.,Deputy Commissioner

How do providers, service recipients and family members access DIDS mediation services as discussed in Section 2.11.a. of the Provider Manual?

Mediation services may be requested by contacting Brenda Clark at the DIDS Central Office by telephone at 615-253-6811 or via email at brenda.clark@tn.gov.

Who can request external mediation services as discussed in Section 2.11.a. of the Provider Manual?

Any of the parties involved in a dispute may request external mediation. DIDS staff may suggest external mediation when two or more parties involved in service provision or when a provider and the service recipient/family cannot resolve a particular issue. All involved parties must agree to participate in external mediation for conflict resolution to be successful.

Section 2.11.b. of the Provider Manual discusses requests for deputy commissioner intervention as an option for conflict resolution. When intervention is requested, what is the time frame for response

In most cases, conflict resolution is expected to occur within 30 days. However, resolution may occur sooner and in some cases may take longer. The time frame involved will depend on the complexity and number of issues involved, the number of parties involved and the mechanism chosen to achieve resolution.
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In Section 2.12. of the Provider Manual, why are there differences in the appeals process depending on whether services are state-funded or federally-funded?

Medicaid–funded services are an entitlement for those who are eligible for such services. Medicaid–eligible service recipients are guaranteed certain protections by federal law and regulation. State-funded services are not an entitlement. Medicaid protections do not apply to state-funded services.

Who is responsible for providing notice within 10 days to avoid interruption in services?

The entity denying the service is responsible for providing notice. If the service is denied by DIDS, DIDS must provide appropriate notice.

Does the Individual Support Plan (ISP) contain information that would cause a provider to be non-compliant with the Health Insurance Portability and Accountability Act (HIPAA) if shared with direct support professionals?

The primary limitation that HIPAA places on disclosing Protected Health Information (PHI) is that it must be information that the person reviewing it "needs to know". “Needs to know” is not clearly defined in Federal law or regulation; therefore, the need to know is a case-by-case determination. The information in an ISP is germane to direct care staff duties, and thus should be accessible to them. The only consistent exception would be for PHI that relates to sexually transmitted diseases. This information should be kept separate or segregated from other medical records and disclosed only to those in the health related professions for whom such details are necessary to provide appropriate medical treatment and care to the service recipient.
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In Illustration 3.3 in the Provider Manual, there is a statement that reads: “Informal social activities are planned that are not related to the planning of paid services, during which Circle of Support members act as natural supports for the service recipient.” Does this statement mean that the person has to call a Circle of Support meeting every time the service recipient plans an informal social activity?

No. This statement does not mean that the C ircle of Support must meet prior to every social occasion. It means simply that Circle of Support members may participate in social activities with the service recipient that are not related to planning services and supports.

What are “natural supports”?

“Natural supports” is defined in the Provider Manual Glossary as: “People, places and support mechanisms that already exist or can be created to provide supports to service recipients”. Natural supports are also sometimes referred to as “generic supports”.

Is there a form for a Simplified Support Plan?

There is no standardized format for the Simplified Support Plan. Requirements for a Simplified Support Plan were provided rather than a standardized form. Simplified Support Plan requirements specified in Section 3.15.b. of the Provider Manual are consistent with planning requirements specified in the Department of Mental Health and Developmental Disabilities’ licensure rules.

How is it determined that state-funded service recipients require a Simplified Support Plan rather than an Individual Support Plan?

The Provider Manual, Chapter 3, Section 3.19. states that service recipients who receive ongoing DIDS state-funded services with an annual cost of less than $20,000 require a Simplified Support Plan rather than a Individual Support Plan. Determination of annual cost will be based on the prior year’s authorizations. If the prior year’s authorizations are less than $20,000, a Simplified Support Plan would be required instead of an Individual Support Plan.
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Who is responsible for Individual Support Plans for state-funded service recipients with annual service cost of $20,000 or more?

For the time being, the provider agency case manager will continue to be responsible. It is anticipated that the majority of these service recipients will be enrolled in waiver services. For those that are not, a decision will be made at a later date regarding responsibility for developing and updating the Individual Support Plans on an ongoing basis.

What are “staff instructions”?

Staff instructions are defined in the Provider Manual Glossary as: “Written strategies, including step-by-step approaches or guidelines for those tasks or actions that must be implemented by direct support staff employed by the day, residential or personal assistance provider.”

Are providers required to develop staff instructions?

Staff instructions are to be developed and implemented at the provider’s discretion. DIDS will hold providers accountable for implementing the Individual Support Plan. Development/implementation of staff instructions is suggested as a method that providers may employee to ensure that direct support professionals have thorough understanding of their responsibilities in implementing the Individual Support Plan.

What is the procedure for providers to address problems with support coordinators/case managers or other providers regarding lack of cooperation or job performance issues?

A provider complaint resolution process will be developed with information included in a new final chapter of the manual. In the interim, providers may report issues to DIDS Regional Office Directors or their designees.
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Why are state employees able to handle more individuals on their caseloads than support coordinators?

Case loads for case managers include individuals in services, those entering services and those who continue to wait for services. Not everyone on the case manager’s case load will be in services, require support planning or service monitoring. DIDS will monitor case load assignments over the next year and make adjustments as necessary.

Why is a higher frequency of face-to-face visits required for cla ss members than for other service recipients?

Visitation requirements for class members are set forth by Federal courts and cannot be changed by DIDS.

Section 6.3.f. of the Provider Manual states that the provider must "directly communicate" when verifying previous employment and obtaining personal references. Does this mean that the provider must make these calls themselves and can no longer use an external entity to conduct background and reference checks?

A provider may employ a subcontractor to conduct background and reference checks. Please refer to Section 6.9. of the Provider Manual, which describes requirements for provider subcontracts. If a provider agency chooses to use an external entity to perform background/reference checks, there must be a written subcontract that passes on any requirements related to performing background/reference checks to the subcontractor. When a subcontract is established, the provider is still responsible for the work the subcontractor does, including ensuring compliance with DIDS requirements.

The language "directly communicate" was inserted to ensure that the references and employment verifications are actually checked and not just attempted. The person performing employment verifications and reference checks, whether employed by the provider or a subcontractor, is expected to actually speak to a person able to respond in providing the necessary information and not just record that an attempt was made. If a potential employee gives references that are not available, they are expected to provide additional references or provide additional information regarding how to reach the previously identified individuals.
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Will the state reimburse for background checks for volunteers, natural supports and subcontractors?

Background checks are not required for natural supports. Background checks are required for employees, volunteers and subcontractor employees who have direct contact with or direct responsibility for service recipients. Reimbursement for the cost of background checks is available only when requirements specified in Section 6.3.e. of the Provider Manual are met.

How does a Provider Management Plan differ from a well written Agency Policy and Procedures Manual? Are both necessary? If a provider’s Policy and Procedures Manual covers the requirements of a Management Plan, why is it necessary to produce a Provider Management Plan?

The management plan is a formal, written plan that describes how the provider conducts business to ensure successful operation and compliance with applicable requirements. In particular, it specifies the provider’s processes for protecting the health, safety and welfare of service recipients. It is intended to be a dynamic document that changes as the provider determines that changes are needed to improve services. For example, the prevention plan that is required is seen as something that can evolve over time, given the changing needs of service recipients. DIDS has not specified the actual format of the management plan, only basic components and additional components required only for certain services.

Is every newly appointed provider agency board chair required to attend new provider orientation or is this just for new providers?

All new board chairs are required to attend whether the provider agency is new or established. It is essential that board chairs understand their responsibilities in ensuring effective management of a provider agency. DIDS recognizes the difficulty in recruiting willing and able board members. Consequently, the intent is to develop a videotape of the provider orientation that can be distributed to providers for new board chairs to view.
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The Provider Manual, Section 6.8. states that: “The service recipient’s support coordinator or case manager must be notified with as much advance notice as possible any time that a provider anticipates that expected/scheduled services may not be delivered." As long as providers are fulfilling the contract agreement of 243 days, are they expected to notify support coordinators if closing for an in-service day or weather related event?

The intent is for the support coordinator/case manager to be able to plan services, even when atypical events occur, to ensure that service recipient needs are met. If prior arrangements have been made and the service recipient’s needs are met, the support coordinator/case manager can be notified within a very short timeframe.

Section 6.10. of the Provider Manual requires providers to make a “reasonable effort” to identify a representative payee who is a family member or friend of the service recipient. What is a reasonable effort?

A reasonable effort involves providing unbiased and objective information about what is required to be a representative payee to relatives who are involved in the service recipient’s life and inquiring as to willingness and ability to perform required functions. At a minimum, parents, grandparents, spouses and siblings who are mentally and physically capable/competent to perform representative payee functions should be approached. For relatives who have not been involved in the service recipient’s life or relatives who are more distant, it is not necessary to approach them about becoming the service recipient’s representative unless the service recipient chooses to solicit their involvement.

Are providers allowed to charge a management fee for acting as a service recipient’s representative payee as allowed by Social Security representative payee guidelines?

Charging fees is not prohibited by the Social Security Administration. However, the intent here is to prohibit charging fees for serving as the service recipient’s representative payee. This prohibition is specified in TennCare policy and must be adhered to by DIDS and DIDS contracted providers.
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Is there a requirement for provider staff to have skin tests to screen for tuberculosis (TB)?

Please refer to the Provider Manual, chapter 6, Section 6.3.a. #7 and the current Department of Health policy for TB skin testing provided in Appendix I of the Provider Manual. High risk staff should be tested in accordance with DOH policy.

Are providers required to complete drug screening on employed staff?

Yes. Please refer to the Provider Manual, Chapter 6, Section 6.3.a. #8. Any entity accepting federal funding must maintain compliance with federal drug-free workplace requirements.

Who is required to take medication training?

Medication Administration Training is required only for staff who are to administer medications to service recipients.

Has the division developed the Pre Service training titled “Introduction to MR/MD”? Is there a test for this training curriculum? Does this training replace “orientation” addressed on the Quality Assurance checklist?

The Introduction to MR/DD curriculum has been developed and has a test. The Quality Assurance checklists will be revised to reflect the training requirements in the provider manual.

Section 7.5. of the Provider Manual stipulates that CPR training must be done in an American Heart Association or Red Cross course. There are private companies that are accredited/certified/licensed by the American Heart Association to provide such training. Are such courses acceptable?

As long as the course content includes the American Heart or American Red Cross protocol, it is acceptable.

How long are records kept for persons who have been residing at an agency for periods of 15 to 20 years or more?

Providers licensed by Department of Mental Health and Developmental Disabilities (DMHDD) should keep records for a period of ten years in accordance with DMHDD licensure standards. Providers who do not require licensure from DMHDD should follow state law for their specific provider type. For instance, home care organizations are licensed by the Department of Health (DOH). DOH regulations specify requirements for retaining records. For providers who have no existing records requirements for licensure, Bureau of TennCare Rules requires maintenance of records for a period of five years.
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The Provider Manual requires that the primary provider be able to retrieve information from other providers within a two hour time frame? What does this mean?

The primary provider is responsible for the comprehensive record and is required to maintain the original documents relating to the services for which the primary provider is responsible. The primary provider is also responsible for maintaining copies of the documentation obtained from other providers that are essential to the provision of services for which the primary provider has responsibility. If there are components of the comprehensive record that other providers are responsible for maintaining, the primary provider has to have information as to the whereabouts of that information and how to get it within a two-hour time period. The primary provider is not required to maintain copies of all documents contained in the comprehensive record.

Primary providers may still maintain the comprehensive record in its entirety if determined beneficial, but this is no longer a requirement. If providers elect to have a cooperative arrangement for sharing comprehensive record contents, it is necessary that the details of how records will be made available to auditors/surveyors within a two-hour time frame should be determined in advance.

Why is time in/time out for therapy service providers to be recorded on staff notes?

There must be a mechanism for recording the amount of time that is spent in delivering a service. For therapy services, Chapter 13 or the Provider Manual, Section 13.14.a., states that therapists are required to sign in and out to document the time period during which services were provided. For service recipients receiving therapy services in a residential or day setting, such notations are to be made in the staff notes section of the residential or day record. For individuals living in a family home who do not receive residential or day services, therapy contact notes must be recorded at the service site to document time in and out. Contact notes containing time in and time out must include the signature of the service recipient (if able to sign verifying the correct times) or a caregiver or family member present within the home who is able to verify the time period during which therapy services were provided. A separate entry is required for the time services began and ended. Contact notes must be signed by the licensed therapist providing or supervising services. If time in and out is not appropriately documented, recouping may occur due to inability to verify service units provided. DIDS realizes that there are certain issues related to relying on this method for documenting therapy services. Consequently other options are currently being considered. Revisions will be made to the provider manual as needed.
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If person receives only personal assistance services, what are the record requirements? Is it the PA only info contained in the grid or is it everything contained in a comprehensive record?

For service recipients receiving personal assistance in absence of residential or day services, the personal assistance provider is designated as the primary provider, responsible for maintaining the comprehensive record. Records requirements in Section 8.11.of the Provider Manual is considered essential to the provision and documentation of personal assistance services, whether or not the personal assistance provider is responsible for maintaining the comprehensive record. When designated as the primary provider, the personal assistance provider must also meet records requirements specified in Section 8.6. of the Provider Manual. For portions of the comprehensive record that the personal assistance provider is not required to maintain to provide and document personal assistance services, the personal assistance provider must maintain current information regarding where other pieces of the record are kept and how to obtain them within a two-hour time frame for audit/survey purposes.

How is data "gathering" captured when performing assessment activities for billing purposes?

A review of the necessary records in the home when the service recipient and staff are present for input is billable. However, records not required to be included in the home record may not be transported from other locations to the service recipient’s home for the purpose of increasing reimbursement. Time spent reviewing records at other locations, such as provider agency offices, are not billable.

In addition, documenting specific clinical data gathered via hands-on techniques or through observation of the service recipient during the assessment is also billable. Contact notes to indicate what assessment components were completed with the time-in and time-out documented are necessary for reimbursement to be provided.

What constitutes an acceptable record for emergency type respite versus on-going respite?

The requirements in Section 8.12. of the Provider Manual are intended for agencies that provide ongoing respite services as defined in Section 16.2. of the Provider Manual. In the event that an established residential provider provides respite for emergency, one-time only cases, then the provider should maintain the information necessary to safely provide the service. For example, the Individual Support Plan, the health care oversight form; medication administration records for the time periods when respite is provided; a physician-ordered treatment log for treatments provided during the respite service; physician’s orders; the health passport; insurance cards; emergency crisis plan; and staff notes should be kept as applicable to the service recipient.
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Who keeps administrative records for providers who go out of business or terminate their contract to provide services in the DIDS system?

Generally, licensure rules would make the provider responsible for keeping records for a defined period following cessation of operations. For DIDS purposes, a terminating provider will be required to either designate a location where records will be accessible to DIDS or forward copies of records to be maintained in the appropriate DIDS Regional Office.

When a person changes support coordination agencies, Is the transferring support coordination provider required to send support notes with the record?

Section 8.16.d. of the Provider Manual states that the transferring support coordination provider must ensure that a transfer summary and a copy of the support coordination record for at least the previous one (1) year time period be made available for transfer to the receiving support coordination provider. The service recipient can request additional records as needed to provide adequate historical information.

Section 8.8.of the provider manual does not list support notes as being a part of the support coordination record. Support coordination monthly reviews that are required should contain adequate documentation of all funded services that were provided by the transferring support coordination provider.

Is the use of electronic signatures acceptable?

No. Please refer to the Provider Manual, Chapter 6 and Section 6.13.b.

Data Sheets are being summarized in reports. Is it necessary to keep all information used to compile reports?

The provider whose staff documented information on the data sheets is the only entity required to keep the original documentation. Other providers who maintain copies for the purpose of compiling a report may appropriately discard this documentation when no longer needed in accordance with confidentiality requirements; however, such providers are required to maintain copies of the compilation reports generated based on the data.

Information on Outcomes and Action Steps is written within the content of the staff communication notes. Is this required documentation?

Section 8.7.a. of the Provider Manual states that staff communication notes are to include information relevant to the implementation of staff instructions, the completion of ISP actions steps and/or the progress made toward achieving ISP outcomes.
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Are direct support professionals required to document the presence of clinicians in the staff notes?

Yes. Please see the Provider Manual, Chapter 8, Section 8.7.a. #7.

Are clinician contact notes a part of the Comprehensive Record?

All documentation of the provision of services is a part of the Comprehensive Record. However, the designated primary provider does not have to maintain copies of clinical service contact notes. The primary provider’s responsibility would be in knowing how to obtain any part of the Comprehensive Record needed for audit/survey purposes within a two-hour time frame.

What is the appropriate place to document that therapy or behavior services were provided?

Chapter 8 of the Provider Manual provides a description of records requirements for different provider types. Sections 8.2., 8.3., 8.4., 8.9., 8.14., 8.15., 8.16 a., 8.16.b., 8.16.e., 8.16.f. and 8.16.g. are applicable to clinical service providers such as therapists and behavior analysts/specialists. Section 8.7.a. #7 requires that direct support professionals document clinician presence in the staff notes section of the residential record. Chapter 13 of the Provider Manual, Section 13.14.a. indicates when therapists provide services at day and residential service sites, they should document time in and out in separate entries in the staff notes section of the residential record. When clinical services are provided in a home owned by the service recipient’s family, sign in and out should be done in the clinical contact notes and the service recipient or a family member who can verify the times during which services were provided should co-sign the contact note.

Will there be different requirements for the comprehensive record depending on the type of provider that is designated the “primary provider”?

No.

Are providers required to keep documentation of clinical license, as well as, transcripts and diplomas to document professional status of clinical providers?

Providers must follow their own policies for credentialing staff and must maintain any documentation attached to the employment application in each individuals personnel file. For clinical staff required to obtain and maintain a license or certification to practice, licensure/certification is dependent on the submission of transcripts to the licensing or certification entity. Consequently, licensure/certification will be accepted by DIDS as proof that educational requirements have been met and should be kept on file.

Behavior Analysts and Specialists are not required to obtain licensure in Tennessee; however, credentials/qualifications are verified during the provider approval process. For such behavior providers, the DIDS letter of approval to participate as a DIDS-approved provider must be kept on file as proof that educational requirements have been met.
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How long is a provider required to save information obtained from other providers?

If the information obtained from the other provider is a required part of the record as indicated in Chapter 8, maintenance requirements stated in Section 8.2.b. are applicable.

What happened to daily notes?

The term “daily notes” has been replaced by the term “staff communication notes”. Staff communication notes are discussed in the Provider Manual in Chapter 8, Section 8.7.a.

How are late entries to be documented in records?

Late entries are not discussed in the Provider Manual. If there is need for a late entry to be recorded, the entry should be clearly documented as a late entry. The actual time and date the entry was made should be included, as well as, the date the event described actually occurred. Providers should have their own documentation policies that include procedures for documenting late entries.

Section 9.2.c states that providers can charge "80% of the maximum Supplemental Security (SSI) benefit for the current calendar year" for room and board expenses for a service recipient residing in a residential habilitation home. However, Section 9.10.b states that earned income obtained from supported employment or day habilitation workshops cannot be used for room and board. The amount of SSI a service recipient receives decreases as earned income increases. If the provider is not allowed to use earned income, room and board expenses will remain constant, but the provider will not be able to charge as much for such expenses. Does this not provide a disincentive for providers to assist people in finding jobs?

The intent is for providers to be able to charge 80% of the maximum SS rate for the current calendar year. If the amount of SSI received is less than 80% of the maximum, other income may be used. However, Section 9.10.b. was included in the manual based on an old Medicaid policy that prohibited use of income earned in sheltered workshops for paying room and board expenses. DIDS is currently attempting to clarify whether such policy still exists and is considered to be in effect. If not, revisions will be made to the provider manual.
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Does everyone really need a prevocational assessment every three years to determine their employment desires?

The vocational assessment is needed every three years, not only to reevaluate employment opportunities, but also to promote meaningful activities. The assessment identifies what a service recipient can do, as well as, what individuals like to do and the supports needed to achieve positive outcomes. Routine periodic reassessment ensures that service recipients know they can choose to work and provides information to the service recipient regarding the benefits of working.

Why is a 1:3 staff to service recipient ratio required for community-based day services?

The 1:3 staff/service recipient ratio helps to ensure that adequate supervision is available to provide for participation in meaningful activities for each service recipient . In addition, maintaining this ratio promotes increased opportunity for integration as large groups can be stigmatizing and viewed as abnormal in the community.

Who may complete a Physical Status Review (PSR)—licensed or unlicensed staff?

Any person who has received the training , licensed or unlicensed, may complete a PSR.

May nursing service units be billed and reimbursed for the purpose of completing the Health Passport?

Use of nursing services solely for completion of the Health Passport would not be reimbursable in accordance with the current waiver nursing service definition.
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Where and how is a medication error to be documented in the service recipient’ s record?

Medication error forms or incident reports are not to be kept in the service recipient’s record. The medication given or omitted should be recorded on the medication administration record. Any consequences that result from the medication error should be noted in the staff communication notes, as well as, resulting staff interventions or actions. Staff communication notes should be brief and factual without omission of guilt or error. Staff communication notes should not reference that a medication error or incident report was completed.

There needs to be a way to address safety issues identified during therapy evaluations that put the service recipient at risk. Can emergency units be requested and approved immediately in such cases?

In situations where an identified risk issue is identified during the assessment, the therapeutic service provider will need to work with the service recipient’s support coordinator/case manager to integrate the recommended services into the Individual Support Plan and submit it for expedited review so that services can be initiated as soon as is possible.

If the service recipient needs more service hours authorized than the waiver service definitions allow, is there an appeal process?

Service hours in excess of the limits specified in the approved waiver document are considered non-covered. Federal matching funds would not be available to pay for services in excess of the limits specified. The service appeals process described in Chapter 2 of the Provider Manual applies anytime a service is requested and denied. Generally, non-covered services are not authorized via the appeals process.
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Why are assess and treat orders not acceptable?

Assess and treat orders are not allowed in accordance with current waiver service definitions. Such prohibition was included to ensure that physicians ordering therapy services remained cognizant of therapy services being provided and to ensure that physician’s orders are descriptive of the therapy services rendered.

Why are therapy students and clinical fellows prohibited from providing services to waiver service recipients?

The Centers for Medicaid and Medicare Services (CMS) has advised that federal funding is not available for services provided by practitioners who have not yet obtained a license.

What are billable nursing services?

Examples of physician-ordered skilled nursing services include:
Foley catheter care and insertion of an intermittent or indwelling catheter;
Respiratory nebulizer treatments, including nursing assessment before and after administration of the medication or treatment;
Administration of Oxygen, including equipment and nursing assessment of the service recipient’s respiratory status;
Deep suction, involving insertion of a suction catheter 6" or more below the voice box via tracheotomy, oral or nasal routes;
Sterile dressings, wound care or treatment of decubitus ulcers (bed sores); and/or
Medication therapy requiring hemaport irrigation.

What is “staff misconduct”?

Reportable Staff Misconduct is an event involving a staff person and a service recipient where the staff person acted inappropriately without causing the service recipient harm, pain, mental anguish or significant risk of harm. Examples include staff arguing in the service recipient’s home, but not in the presence of the service recipient, or staff sleeping on duty while the service recipient’s needs were met by other staff. Staff misconduct will address many of the former “21” issues.

Are provider staff who are accused of wrong-doing or substantiated in an investigation afforded an opportunity to appeal?

There is no process for appealing the results of an investigation. However, there is a process for requesting an investigation review. A provider may request such a review on behalf of a staff member. Staff who are substantiated for abuse, neglect or mistreatment and are referred for placement on the abuse registry have due process and appeal rights.

 

Providers have 15 days to request review of an investigation. When does the 15 day time period start?

The 15 day time period begins when the provider receives the final investigation report. The date of receipt is either the email date, the fax date or 5 days from the mailing date of the report.

Why is there a separate definition of an independent provider and home health agency in the glossary since all providers offering nursing or therapy must be licensed as Professional Support Service Agencies?

There are other types of independent providers besides those who provide nursing and therapy services. Examples are behavior analysts/specialists and nutritionists/dietitians.
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