Amended Statewide Transition Plan    

Pursuant to 42 C.F.R. § 441.301, the Oklahoma Health Care Authority (OHCA) is required to give public notice and receive public input on any significant proposed changes to the 1915(c) Home and Community-Based Services (HCBS) waivers. 

Oklahoma Transition Plan for Home and Community-Based Services (HCBS) Settings

The purpose of this Transition Plan is to ensure the individuals receiving Home and Community-Based Services (HCBS) are integrated in and have access to supports in the community, including opportunities to seek employment, work in competitive integrated settings, engage in community life, and control personal resources.  The State has prepared a revised transition plan in order to comply with federal regulations for community-based settings. Overall, the Transition Plan provides assurance that the individuals receiving HCBS have the same degree of access as individuals not receiving Medicaid HCBS. This updated Transition Plan outlines the proposed process that Oklahoma will be utilizing to ensure implementation of the new HCBS requirements. 

All HCBS settings have to be in compliance by March 2019. The State must continue to submit Statewide Transition Plans to CMS until both an initial and final approval of the plan is received. The following is an outline of the CMS Statewide Transition Plan submission and approval process:

  1. Initial Proposed Plan
  2. Clarifications and/or Modifications required for Initial Approval (CMIA): The communication CMS sends to the state notifying the state that public comment, input and summary requirements are met, but CMS has identified issues that must be resolved in the STP prior to initial approval.
  3. Initial Approval with Milestones and a Resubmission Date: The communication CMS sends to the state notifying the state that public comment, input and summary requirements are met, the STP is sufficient, but systemic and/or site-specific assessments are not yet completed.  The response to the state will vary dependent on whether the state has or has not identified settings that are presumed to have institutional characteristics and any information the state may wish CMS to consider under the heightened scrutiny process.  
  4. Final Approval: The communication CMS sends to the state notifying the state that public comment, input and summary requirements are met, the STP has provided all necessary information including but not limited to; systemic assessment, site specific assessment, settings presumed to have institutional characteristics, information regarding heightened scrutiny or the state’s decision to let the presumption stand, and clear remedial steps with milestones are delineated.  
  5. Approved Plan:  The CMS approved STP.

Please view the Amended Statewide Transition Plan in its entirety here: Amended Statewide Transition Plan. The plan will be posted for public comments from December 22, 2016 - January 22, 2017. The Amended Statewide Transition Plan was submitted to CMS on December 22, 2016. 

For more information regarding the Statewide Transition Plan, please see the training webinar video

Previous Submissions and CMS Feedback, concerning the Statewide Transition Plan, can be viewed here:

Please submit your comments via the comment box below. Written comments will also be accepted and can be sent to the Oklahoma Health Care Authority, 4345 N. Lincoln Blvd. Oklahoma City, Oklahoma 73105. Attention: Health Policy 1915(c) Waivers. A non-electronic version of this Statewide Transition Plan can be requested by writing to the address above or calling 1-888-287-2443.




Comments

Order:

Anonymous
If you're trying to integrate everyone into community jobs, sadly you will have alot of people who will be both sad and along e because they can't for whatever reason work in the public, but they still need a workshop to go to and earn money and have friends. To say that all of the people we serve are capable of being in a public setting and work is classifying them as all the same and they are as individual as you or I are.
OHCA Staff Reply
Thank you for your feedback. OHCA considers all input seriously and will take your comments under advisement.
10/13/2016

Jeanne Thompson
Not everyone is capable of working independently in the community and the state does not want to pay for the continuous support. Natural supports are great, but are not always readily available in the real world. Believe it or not, there are individuals that DO NOT want to work in the community. They've tried it, several times, and don't like it. They want to work with their friends and staff they trust, not people that change every day or two, not people that talk to them like they are children or don't talk to them at all or treat them like they don't even exist and yes, that does happen to the population we work with more often than anyone cares to admit.
OHCA Staff Reply
Thank you for your feedback. OHCA considers all input seriously and will take your comments under advisement.
10/17/2016

jennifer j johnson
low fuctioning non verbal autism needs are not met with a meanful day out in her community this ppulation needs to be looked into
OHCA Staff Reply
Thank you for your feedback. OHCA considers all input seriously and will take your comments under advisement."
10/27/2016

Holly Howard
Concerns remain regarding the Oklahoma Amended Transition Plan for the HCBS Final Rule and the current service system delivery structure and methodology. Oklahomans that receive the waiver do currently live in segregated disability specific circumstances and live a life of “choice” determined by funding, provider resources and/or policies and beliefs, and the policies of Oklahoma Developmental Disability Services. Their ability to determine and then experience the life they want to live is hampered by the very policies used in this transition plan for justification of compliance to the Final Rule.
The stated intention of the Final Rule includes:
• HCBS Settings are integrated in and supports access to the greater community
• Provides opportunities to seek employment and work in competitive integrated settings, engage in community life, and control personal resources
• Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
Home and Community-Based Setting Requirements:
• Is selected by the individual from among setting options, including non-disability specific settings and an option for a private unit in a residential setting – Person-centered service plans document the options based on the individual’s needs, preferences; and for residential settings, the individual’s resources
• Ensures an individual’s rights of privacy, dignity, respect, and freedom from coercion and restraint
• Optimizes individual initiative, autonomy, and independence in making life choices
• Facilitates individual choice regarding services and supports, and who provides them
Home and Community-Based Setting Requirements for Provider-Owned or Controlled Residential Settings:
• Each individual has privacy in their sleeping or living unit
• Units have lockable entrance doors, with the individual and appropriate staff having keys to doors as needed
• Individuals sharing units have a choice of roommates
• Individuals have the freedom to furnish and decorate their sleeping or living units within the lease or other agreement
• Individuals have freedom and support to control their schedules and activities and have access to food any time
• Individuals may have visitors at any time
• Setting is physically accessible to the individual
Concerns have been raised previously regarding the methodology and assessment process used to determine and enforce compliance i.e. National Core Indicators and OK-Aim Surveys. There is no mention of these tools in the latest version of the transition plan and by all accounts it now appears that the only assessment method will be through the Developmental Disability Services Quality Assurance Staff effectively expecting the organization that oversees the services to monitor itself and those they have contracted with to deliver those services presenting an enormous conflict of interest. OKDHS and individual providers benefit from appearing 100% compliant with CMS standards. There is no mention of any outside quality assurance, assessment, or compliance determination method and with the rate cuts that providers experienced the previous fiscal year and the loss of appropriations to DHS resulting in large scale reduction in force (including Case Managers, administrative, oversight and protection positions), what transparent reporting and assessment can we expect?
In the Appendixes, the States Justification of Compliance Determination continues to only record policy as the determining factor justifying compliance. I would point out that written policy does not make something a reality. We have countless laws, rules and mandates to ensure equal opportunity and protection of human rights and yet we continue to have individuals with disabilities experiencing institutional, segregated, isolated lives controlled by systems and others hence the recognition by CMS for the need of the HCBS Final Rule. Following are observations of concern:
Group Home Settings and DLS Homes:
• Residents have diminished opportunities to travel into the community and participate in the community at their discretion because of transportation limitations. A GH may have only one van for 6 to 12 residents; Staff ratio of 1:6 to 12; DLS may have a staff ratio of 1:3 (during some hours 2:3) and the staff dependent on their personal vehicle for resident’s transportation – staff that on average make $8-$9 an hour and may not have reliable transportation themselves.
• Group Homes often require shared rooms and when an individual moves to a group home they get the empty bed with no choice regarding with whom they share a room. In DLS homes, residents have no say in who their housemates will be. Generally, if an individual has been approved for DLS the Case Manager determines what “open slot” would “work best” and that is the home offered. It is a difficult and cumbersome ordeal for an advocate, guardian, individual or family member to find the open placements and arrange to visit those places to determine compatibility and make an informed choice. Residents requests to move to a more preferable setting find this an arduous, delayed and even ignored request and most requests are denied especially if the individual wants to live in a setting different than the one they currently live.
• Residents have varying level of support needs and due to the lack of staffing and overall inherent training philosophy of a model of care the entire home will be leveled down to the individual with the highest support needs which impacts the choice, community involvement, and overall life quality of the others in the home.
• Group Homes are not always in neighborhood settings and consistently are set apart from the community. Many Group Homes are actually on large campuses connected to more institutional type settings.
• DLS homes may be regular homes in a neighborhood but they are set apart and undeniably defined by the neighbors as different. With the coming and going of staff, therapists, case managers, etc. they are recognized as different. The staff are not trained to interact and engage nor assist the residents to interact and engage with neighbors and their community.
• Often, both Group Homes and DLS homes are located in areas that are inherently rural in nature lacking public transportation access, community activities, opportunities for inclusive employment and recreational activities.
• Individuals are not regularly given keys to their homes and often the doors are unlocked 24 hours a day. Group Homes and DLS homes do not have established guidelines for individuals to choose who visits their home and when. It appears more like an open-door policy mostly relating to the staff and/or their families, therapists, and DDS staff.
• Relating to the assessment by the state of full compliance regarding individuals being in control of their own finances, what percentage of individuals being supported have Representative Payee’s and what is the percentage of those individual’s money/finances being controlled by their provider agency? Is there a process to determine if an individual has any unpressured choice or role in decision making regarding control of their finances?
Person Centered Planning:
Person Centered Planning must begin with Person Centered Thinking. Person-Centered thinking is a set of skills and tools based on the values of independence, rights, choice and control, working together and inclusive communities. The presence of Person Centered thinking is a necessary condition for delivering Person Centered support and outcomes. It is always driven by the person at the center of the process with THEIR chosen allies helping. If the current service delivery structure does not understand or hold within their core philosophy Person Centered Thinking, then there is no way to deliver supports in a Person-Centered Process.
• A multi-page interview form authorized and completed by the staff, provider agency and/or case manager does not meet the core of Person Centered Thinking or Planning
• Information filled into the forms prior to a Person-Centered Planning meeting does not constitute choice, independence and control
• A format that considers supporting the family over supporting the individual first many times hinders an individual’s right to choose the life they want
• Beyond the forms provided by DDS or provider agency most support staff and case managers have limited knowledge of any other Person Centered Tools and the forms provided are viewed as a requirement to meet statutory obligations rather than as tools to facilitate the development of a Person-Centered Plan for a person to experience the life they choose
• There is a greater emphasis on the assurance of including the provider agency and behavioral support providers in a “team meeting” than on the inclusion of allies, advocates, friends (not paid staff), guardians and families that the person has chosen or would choose to attend
• Often times guardians, advocates and families are not included in the “team meetings”
• How often are individuals not in attendance to their own meeting?
• How often are individuals “talked about” at their meetings rather than included in the actual discussion regarding what they want their life to look like and how best to support them?
• When an individual only experiences what they experience they do not often know what other opportunities are available and just because they are told about another opportunity does not necessarily give them the information they need in the manner they need it to make an informed choice. What standards of measure are used to ensure that individuals have true choice and opportunities to try out different experiences?
• A Provider may have a contractual relationship or operate a “day program/sheltered workshop” and that gives them inherent motivation to encourage an individual to make that selection or an automatic assumption that is what an individual will do for their day activity (for ease of transportation, staffing, and additional funding allocations). What accountability standards are in place to prevent undue influence?
• An individual with a more significant disability or a person that has nontraditional expressive language has the ability to participate in their planning process but generally there are no tools to facilitate their participation including limitations to assistive technology, time constraints and an inherent belief that they are unable to contribute. What methods of assurance are used to guarantee that all individuals are equally equipped and encouraged to participate?
• Guardianship has been utilized as a technique to infringe on the rights of individuals to make decisions rather than as it was intended to assist with decision making ONLY when a person lacks the capacity to make informed decisions on their own.
• The options for living, employment, recreation and/or transportation that are considered all fall within the context of the service delivery system and the contracted providers. Options for non-disability specific settings are not included. Beyond just saying that those options were offered and the individual declined, what evidence and accountability will be documented reflecting true choices were considered, explored and experienced?
• Once a plan is written and approved, what is the process to make modifications, report issues or file grievances? This is not transparent.
• A Person-Centered Plan is a living document and should be treated as such. All the professionals in an individual’s life should be familiar with the most recent plan, outcomes, actions, and choices; however, there is not a process for this to occur and there is no mechanism to ensure that what is in a plan is actually taking place throughout the year.
• Considering the frequency of staff turnover and now with the continuous changes within the Developmental Disability Services division itself, a plan in Oklahoma is filed paperwork for statutory requirement. What is the guarantee that anyone in an individual’s life at the moment is even familiar with their plan?
Quality Assurance:
• Historical lack of punitive consequences to a provider that does not appropriately support and/or protect the individuals they serve. If a provider agency is at full capacity, “vendor hold” does not constitute any real concern and is generally a temporary consequence at best. Rigorous Quality Assurance occurs only when there are sufficient monitors outside of the system of influence so as to insure no conflict of interest.
• The process for an individual to express fear of or actions of abuse, neglect or exploitation is not transparent. How would an individual report abuse without having to fear retribution? How is that reporting tracked?
Sheltered Workshops:
• How many individuals in Oklahoma Disability Services are still experiencing “employment” in a sheltered workshop setting? What are the specific Person Centered tools used to determine choice regarding employment, volunteering or combination of both? What measurements are utilized to determine when training is completed?
• Changing the language from Sheltered Workshops to Center Based Services does not change the inherent nature of segregation, isolation and disability specific settings. Oklahoma’s long history of supporting sheltered workshop (training) programs has rarely resulted in meaningful self-sufficient employment opportunities in the greater community. How long is long enough for an individual to be in a training program?
Day Programs:
The long history of day programs (adult day care) does not reflect personal choice of activities or recreation. The option to choose from a given set of activities is not actually choice. Day programs are most often settings that are away from the greater community and when a community activity is planned it is with a group not individually so a person does not have the opportunity to experience inclusion. An additional concern is the disparity in age of the participants.
Managed Care:
As noted, the State of Oklahoma, pursuant to House Bill 1566 which passed the Oklahoma Legislature and was signed by Governor Mary Fallin in April 2015, is in the process of issuing a Request for Proposal (RFP) for a care coordination model for the Aged, Blind, and Disabled populations (ABD).
Advocates, stakeholders, families and self-advocates have consistently expressed concern that a managed care model will have a great and detrimental impact on the quality of services/supports and quality of life for individuals receiving waivered services.
• There is evidence that organizations have limited understanding of the support needs for individuals with disabilities and how to facilitate a life in the greater community no different than the one others experience. Statements in printed material that reflect supports would be options like a refrigerator to hold an individual’s insulin are alarming to say the least.
• When a solicitation is awarded under managed care the organization will know what they will be paid and the only way for them to increase their profit margin is to reduce the services, supports or options for individuals they are supporting. Considering that the organizations that will be bidding are FOR PROFIT large corporations, that leaves one to wonder what impact that would have on an individual’s life?
• It has been stated that the organizations would have Case Managers (care coordinators) at a ratio of 1:70 and up to 100. How is a care coordinator supposed to facilitate the supports and person centered planning process for 70 to 100 cases?
• Often times the case manager is the only true oversight, the person that has the ability to recognize and identify if there is a cause for concern. There has been an indication that under the managed care model there may be an Ombudsman that would be employed by the organization. What assurance of non-biased determinations exist within that context?
• The stakeholders, advocates, self-advocates, providers, and the public at large will have almost no direct knowledge of the contents of the RFP until it is released for solicitation limiting our ability to address specific concerns or problems.
• With the Care Coordination set to begin for the waivered recipients at the same time compliance for the Final Rule is expected, what are the assurances, measurements and oversight processes to ensure that the organizations that are awarded the contracts will follow the expectations of the Final Rule?
There is acknowledgement that the state is operating under extremely difficult circumstances and funding shortages have significantly impacted the service delivery system and providers. It is also important to note that the state has progressed in closing all the state funded large congregant institutional settings; however, it is our obligation as advocates to identify and reveal concerns regarding the Oklahoma Transition Plan. Intent, even of the truest kind; mission statements; and policies do not constitute nor guarantee that the state is in compliance with the expectations outlined in the HCBS Final Rule. The fundamental outcome of the Final Rule is to ensure the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services. The intent is that individuals receiving Medicaid-funded HCBS have the opportunity to receive these services in a manner that protects individual choice and promotes community integration so that they can live their best life.
OHCA Staff Reply
Thank you for your feedback. OHCA considers all input seriously and will take your comments under advisement.
11/6/2016

Anonymous
Member shall have access to food any time.
Medicaid services do not reimburse for food in assisted living, however have opted to dictate and place limits on room and board rates. Room and board rates include rent, gas, water, sewage, electric, and food. Room and board rates can’t exceed $631.00 a month. If expectations are that Assisted Living provide more services and goods to Medicaid Resident than is required under Assisted Living Licensure or OSDH rules and regulation or what is offered to Private Pay residents than the Statewide Transition Plan needs to revisit the room and board restriction placed on the Assisted Living’s Room and Board rates. Again Medicaid does not currently reimburse for the food but does determine how much we can bill for food and under the Transition Plan my imply changes in the quantity of food on hand and services in order to have food available any time.
If it is the intent under the Transition Plan is that Medicaid resident have access to keep their own food in their own refrigerators and pantry stoke outside of what the Assisted Living Community offers for meal service than the verbiage for such needs to be clearly spelled out in the Plan.
OHCA Staff Reply
Thank you for your feedback. OHCA considers all input seriously and will take your comments under advisement.
1/13

Mary Brinkley
There are still some concerns that exist with the HCBS Transition Waiver that are of real concern to providers including:
Opportunities to seek employment - for the elderly population in Adult Day, this is not realistic. They need assistance with activities of daily living and the average age is 83. I'm not sure why they would need to assess employment opportunities.
Most Adult Day centers don't have transportation. With limited funding for transportation and staff to accompany the participants, this is not feasible. To coordinate transportation for community outings, additional staff is needed to ensure the safety of the residents which is yet another financial barrier. Coming to an adult day center is a way to get older adults out of their homes for social interaction. Adult day centers bring the community into the adult day center with arts, activities, social events, educational events, intergenerational events and other organized activities to enhance the lives of the participants. Some have to ride up to 30 minutes each way to the center. Why put them back on a bus for an outing with this can be brought in for all participants? Keep in mind, many would not be able to travel. Many currently plan outings but weekly outings would be a challenge for all participants and providers.
Most all adult day centers have secure outdoor areas for the participants to enjoy. We have concerns with the safety of the residents who would be allowed to exit the center at will. Very few would be competent to travel freely outside the center.
We have worked with providers for years to offer a truly person-centered environment and this process has helped work toward that goal with such requirements as the open dining.
There real barriers to some of the requirements and with the very limited funding, some of the requirements are not realistic given the current reimbursement structure, i.e. the weekly outings that would require coordination, staff accompaniment, and the cost of transportation or trying to find a way to provide it.
Adult day providers are struggling to survive. It would be unfortunate if these requirements would result in the loss of providers.
OHCA Staff Reply
Thank you for your feedback. OHCA considers all input seriously and will take your comments under advisement.
1/21

Anonymous
We have many clients that need assistance that Medicaid does not provide. Limiting this assistance forces out clients to live and function the same as they were doing prior to gaining the help and assistance of mental health employees. Changing benefits for clients that OHCA serves would be detrimental to not only the service providers, but also for the clients themselves. We help provide them with clothing closet, food banks, food stamps, etc., that you feel is not necessary....well it is. And anyone working within the mental health field will tell you that this will not be helpful in anyway.
OHCA Staff Reply
Thank you for your feedback. OHCA considers all input seriously and will take your comments under advisement.
6/29


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