Waiver Review Project Report CROW WING COUNTY

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					Waiver Review Project Report

June 2007

                               Prepared with the assistance of
Department of Human Services                                                   Waiver Review Project
                                                                                 CROW WING COUNTY
                                                                                           June 2007

This report was prepared by the Minnesota Department of Human Services with assistance
from the Improve Group. The findings presented in this report are based on a comprehensive
review process made possible through the help and assistance of Crow Wing County.


                          The Minnesota Department of Human Services helps people meet their
basic needs by providing or administering health care coverage, economic assistance and a
variety of services for children, people with disabilities and older Minnesotans. The Minnesota
Department of Human Services touches the lives of one in four Minnesotans with a variety of
services intended to help people live as independently as possible. DHS is the state's largest
agency, with an annual budget of approximately $8 billion and 6,600 employees located
throughout Minnesota.

                                   ABOUT THE IMPROVE GROUP
                                   The Improve Group is an independent evaluation and
planning firm with the mission to help organizations deliver effective services. The research
design, data collection, analysis and reporting expertise of the Improve Group particularly
emphasizes building the capacity of local organizations to make information meaningful and
Executive Summary
In April 2007, the Minnesota Department of Human Services conducted a review of Crow Wing
County’s Home and Community Based Services (HCBS) programs. Crow Wing County is a
growing but predominantly rural county located in north central Minnesota. Its county seat is
located in Brainerd, Minnesota and the County has another 17 cities and 28 townships. Crow
Wing County’s 2005 population was 59,917 and in 2005, it served 779 people through the HCBS
programs. Crow Wing County Social Services manages the HCBS programs which serve older
persons, persons with disabilities and persons with developmental disabilities. Cases are
managed by a case manager who gets support from the mental health unit when a participant
has a mental illness. The initial assessment is conducted in collaboration with a public health
nurse, but intermediate visits are managed by the social services agency. The long term care
cases (EW, AC, CAC, CADI and TBI) are managed by case managers with mixed case loads and
when mental health is an issue for a CADI client a mental health case manager is assigned to
the case. The case managers who have MRRC clients typically do not work with other
programs except, occasionally, CADI.

Introduction and Methods
The primary goal of the Waiver Review Project is to support the assurances that the
Minnesota Department of Human Services (DHS) makes to the Centers for Medicare &
Medicaid Services (CMS) about Home and Community Based Services. The HCBS programs,
including five waivers (EW, CAC, CADI, TBI, MRRC) and the Alternative Care program, are
overseen by the Minnesota Department of Human Services. When developing the Waiver
Review Project, DHS intended to both monitor compliance with state and federal regulations
and identify successful practices that improve the quality of service to HCBS participants.

The Waiver Review Process employed seven methods for collecting data to substantiate the
State’s assurances: (1) participant case files; (2) contracts held by Crow Wing County for
services; (3) policies developed by Crow Wing County to guide it in administering the HCBS
programs; (4) a survey instrument completed by County staff; (5) interviews with
administrative and supervisory staff; (6) a focus group of staff working across the six HCBS
programs; and (7) county operational indicators developed using state data. Sixty-three (63)
case files and fifteen (15) provider contracts were examined during the Crow Wing County
visit. The systematic way the data was collected during this review will be used in other lead
agency waiver reviews over the next five years. Much of the data was collected on-site
                                                                               Executive Summary - i
Department of Human Services                                                       Waiver Review Project
                                                                                     CROW WING COUNTY
                                                                                               June 2007

through a three-day site visit process during which participant records and contracts were
reviewed and staff participated in interviews and the focus group.

The HCBS quality framework developed by the Centers for Medicare & Medicaid Services1 was
used as a guiding force for this review and includes the following seven framework areas: (1)
Participant Access; (2) Person-Centered Planning and Delivery; (3) Provider Capacity and
Capabilities; (4) Participant Safeguards; (5) Participant Rights and Responsibilities; (6)
Participant Outcomes and Satisfaction; and (7) System Performance.

Waiver Review Findings- County Strengths and Promising Practices
The following findings around Crow Wing County’s promising practices and strengths are
drawn from reports by County staff, reviews of participant case files and provider service
contracts and observations made during the site visit.

•      Crow Wing case managers are strong advocates for their clients, connected to their
       community resources and networks, and are creative and resourceful with providers. They
       are familiar with resources in the community and can solve problems informally, including
       encouraging providers to offer new or additional services in order to maintain continuity
       and stability for participants. Case managers have the opportunity to telecommute which
       keeps them close to participants in the community and cases for these workers are
       assigned geographically.

•      Crow Wing County has developed formal and informal networks with hospitals, nursing
       homes and other community organizations which allows for early identification and
       referral of participants in need of Long Term Care Consultations. The intake workers have
       also helped the system of early detection by ensuring providers know who to contact if
       they are serving a person in need of services.

•      Case managers in Crow Wing do a good job of being in the community to meet with
       participants. The vast majority (94%) of case files included documentation of a visit to the
       participant within the past six months. In addition, over a third (41%) of case files
       documented visits to participants on a quarterly or more frequent basis.


                                                                                   Executive Summary - ii
Department of Human Services                                                   Waiver Review Project
                                                                                 CROW WING COUNTY
                                                                                           June 2007

•   This County has strong provider capacity, which allows Crow Wing to ensure services for
    people with higher needs and allow participants to age in place as their emerging needs
    are supported through residential services. Participants have a variety of provides and
    services to choose from. Homemaker and companion services are well-developed in Crow
    Wing, and the County is able to “stretch” providers and seek new services as needed, this
    is demonstrated by a low percent of participants admitted to institutional settings (less
    than 3% in the AC and EW programs and just 2% in the CAC, CADI and TBI programs).

•   The care plan format used in the MRRC waiver is very good and is used consistently by
    staff. Most cases showed evidence that the goals were customized to the individual
    participant, and that the services selected to meet the goals are actually being used by
    participants, with over three-quarters of the authorized dollars being used for services in
    the MRRC (90%), CCT (84%) and elderly (76%) programs.

•   Based on allocations reports, Crow Wing County waiver budgets are well managed. The
    rate setting tools used in the County are very practical and work well. In 2005, Crow Wing
    County spent 97% of their allowed MRRC waiver budget. For CCT, the County authorized at
    a rate of 7% less than their allowed budget for these programs in SFY 2006.

•   The format of the assisted living and MRRC contracts is strong, and the MRRC contract
    includes language tying provider performance to the goals stated in individual care plans
    (ISPs), which allows stronger monitoring of expected outcomes.

Waiver Review Findings- County Barriers and Areas for Improvement
The following findings around Crow Wing County’s barriers and areas for improvement are
drawn from reports by the County’s staff, reviews of participant case files and provider
service contracts and observations made during the site visit.

•   The quality of case file documentation varied among case managers, with some not
    containing all of the required elements. Although all case managers reported a strong
    commitment to participant care and service, a few expressed frustration with the
    required level of documentation. Some of the documentation missing from case files
    included an annual review of ICF/MR level of care requirements, back up plans and
    emergency contact information. Additionally, while all CADI, AC and EW files included
    OBRA Level One documents, some of these documents were missing from CAC and TBI

                                                                               Executive Summary - iii
Department of Human Services                                                   Waiver Review Project
                                                                                 CROW WING COUNTY
                                                                                           June 2007

    files. There was also inconsistency noted across documents (screening, assessment, care
    plan and service agreements) in some case files.

•   Contract formats do not include all of the required elements that will allow Crow Wing to
    monitor provider performance and quality, including provisions for ensuring provider
    accountability, program-specific elements, and tying contracts to plans of care in each

•   Many care plans are not being completed within ten days for the waiver programs that
    serve people with disabilities (CAC, CADI and TBI). One (of two) CAC cases, two (of five)
    TBI cases and 31% of (4 of 13) CADI cases did not have care plans developed within 10 days
    of an assessment.

•   In some cases, the same staff person served as both a case manager and a public

Recommendations and Corrective Action Requirements
The following are recommendations and required corrective actions developed by the Waiver
Review Team. The recommendations are intended to be ideas and suggestions that could help
Crow Wing County work toward reaching their goals around HCBS program administration.
Corrective action requirements are areas where Crow Wing County was found to be
inconsistent in meeting state and federal requirements and will require a response by Crow
Wing County.


The following recommendations would benefit Crow Wing County and its HCBS participants.

•   Consider expanding and strengthening the available service networks for serving
    participants’ in their homes, such as care giver supports, home modifications and use of
    PCA services. Because the culture within the County supports aging in place, expanding
    the network of providers who ensure this is worthwhile.

•   Considerable variation in the quality of case file documentation was noted. Developing a
    more formal process for auditing documentation in case files, such as a checklist or peer
    review system, can ensure that all case managers understand expectations for
    documentation and are held accountable for maintaining their case files.

                                                                               Executive Summary - iv
Department of Human Services                                                                       Waiver Review Project
                                                                                                     CROW WING COUNTY
                                                                                                               June 2007

•   Some of the programs have strong processes for obtaining and documenting participant
    consent, but these are not consistent across programs. Using the consent page for all
    programs will ensure that choice and consent is documented for each participant.

•   Approximately a third of contracts did not list the services to be provided, define the
    services to be provided, establish a rate for services or present the basis on which the
    rate was established. The contracting process in Crow Wing could be improved by
    developing a strong umbrella contract that is in effect for multiple years and including
    rates as attachments that can be updated when appropriate. This would streamline the
    contracting process and ensure that all contract elements are always current.

•   The practice of frequent visits to participants could be expanded to include an assessment
    of provider quality and participant satisfaction. By adding a few questions to the quarterly
    visit tool, case managers could monitor these issues and use the information in care plans.

Corrective Action Requirements

The following are areas in which Crow Wing County will be required to take corrective action.

•   Complete ICF/MR level of care documentation for participants in the MRRC program that
    do not have this documentation in the next 30 days.2 Maintain a copy of the findings in the
    participant’s case file. It is required that ICF/MR level of care criteria are reviewed
    annually for MRRC participants and that the findings are documented in the case file. 86%
    of MRRC cases had no ICF/MR level of care documentation.

•   Complete an OBRA Level One form for all participants of CAC and TBI that do not have
    one, in the next 30 days.3 Maintain a copy of this completed form in the participant’s
    case file. One (of two) CAC cases and two (of five) TBI cases did not contain this form.
    While it is a requirement that this form be in the case file, it is considered a promising
    practice to update this form yearly.

  The ICF/MR Level of Care form can satisfy this documentation requirement. The form can be accessed at:

  The OBRA Level One form can be accessed at:

                                                                                                    Executive Summary - v
Department of Human Services                                                    Waiver Review Project
                                                                                  CROW WING COUNTY
                                                                                            June 2007

•   Complete new screening documents for participants when significant changes occur in the
    areas of needs or services and input the data from screening documents into MMIS at each
    assessment and reassessment. Significant change is defined by a change that results in an
    addition of new services, or a significant change in need that results in a significant
    service or service limit change. This ensures continuity across the different documents
    that are used to manage cases (screening, assessment, care planning and service
    authorization); in Crow Wing County, it was noted that 14% of cases showed a lack of
    continuity across these documents, including five CADI cases, two EW cases, one TBI case
    and one MRRC case.

•   Beginning immediately, speed up LTC screenings so that at least 80% occur within 10 days
    of referral. State legislation requires that LTC screenings should be conducted within 14
    calendar days (10 business days) of a request for screening. Currently, 70% of LTC
    screenings for AC and EW participants and 62% of LTC screenings for CCT participants
    occur within this time frame. If a screening cannot take place in required time period,
    document the reason for the delay in the client record.

•   Update contract formats and add explicit provisions to check accountability. Include
    discrete rates and all other required attachments for all programs. There are
    requirements specific to the AC and MRRC programs that were not found in several
    contracts. No MRRC contract (0%) showed evidence of (1) compliance agreement for parts
    9525.1800-9525.1930, (2) description of ongoing training and (3) Provision A. No AC
    contract (0%) showed complete evidence of quality assurance measures.

•   Include a back up plan and emergency contact information in the care plan of all CAC,
    CADI and TBI (CCT) participants. All care plans must be updated with this information
    within six months. This is required for all CCT programs to ensure health and safety needs
    are being met in the community. In Crow Wing County, 90% of CCT cases did not include a
    back up plan and 85% of CCT cases did not show evidence of emergency contact

•   Beginning immediately, all future care plan development must be completed within ten
    (10) days of the assessment or reassessment date for all waiver programs serving persons
    with disabilities (CAC, CADI, TBI). This is required for all CCT programs. Overall, only 65%
    of waiver programs serving persons with disabilities administered by Crow Wing County
    met this standard.

                                                                                Executive Summary - vi
Department of Human Services                                                   Waiver Review Project
                                                                                 CROW WING COUNTY
                                                                                           June 2007

•   For all HCBS participants with public guardianship designate separate case management
    and guardianship roles for participants by the time of the next screening or care plan
    update. For HCBS participants with public guardianship, it is required that one staff
    maintains the role of case manager and a separate staff member maintains the role of
    guardian. In the case files reviewed of participants with public guardianship, both roles
    were being held by one case manager. When one person is holding both roles, they are
    unable to provide informed consent or true choice on behalf of the participant and ensure
    that both signatures appear on required documents. Some MRRC cases were found to have
    the same person serving as both the case manager and public guardian.

                                                                              Executive Summary - vii
Department of Human Services                                                   Waiver Review Project
                                                                                 CROW WING COUNTY
                                                                                           June 2007

Appendix F: Glossary of Terms
AC is the Alternative Care program

CDCS refers to Consumer-Directed Community Services

CAC is the Community Alternative Care Waiver

CADI is Community Alternatives for Disabled Individuals Waiver

Care Plan is the service plan developed by the HCBS participant’s case manager (also
referred to as Community Support Plan, Individual Support Plan and Individual Service Plan)

CCT refers to the CAC, CADI and TBI programs, which serve people with disabilities

CMS is the federal Centers for Medicare & Medicaid Services

Disability waiver programs refers to the CAC, CADI and TBI Waiver programs

EW is the Elderly Waiver

DHS is the Minnesota Department of Human Services

HCBS are home and community-based services for persons with disabilities and the elderly:
For the purpose of this report, HCBS include the Alternative Care program, CAC, CADI,
Elderly, MRRC and TBI Waivers

Home care services refers to extended home care services, including personal care attendant

Care Plan is the service plan developed by the HCBS participant’s case manager (also
referred to as Community Support Plan, Individual Support Plan and Individual Service Plan)

MRRC is Mental Retardation and Related Conditions and refers to the program serving persons
with developmental disabilities

Local Lead Agency (LLA) is the local organization that administers the HCBS programs: LLA
may be a county department, health plan or tribal community

                                                                     Appendix A: Glossary of Terms - 1
Department of Human Services                                                    Waiver Review Project
                                                                                  CROW WING COUNTY
                                                                                            June 2007

Participant case files were examined for much of the evidence cited in this report. They
included the written participant records and information of case management activity from
electronic tracking systems

Operational process- refers the actual methods and activities used by a LLA to accomplish
business objectives

Promising practice: An operational process used by the LLA that consistently produces a
desired result beyond minimum expectations

Participants are individuals enrolled and receiving services in a HCBS program

Policies are written procedures used by LLA’s to guide their operations

Provider contracts are agreements for goods and services for HCBS participants, executed by
the LLA with local vendors

Site visits were conducted to collect most of the data used in this report

TBI is the Traumatic Brain Injury Waiver

                                                                      Appendix A: Glossary of Terms - 2

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