DIVISION OF DEVELOPMENTAL DISABILITIES
Olympia, Washington

TITLE: ICF/MR ADMISSIONS PROTOCOL POLICY 3.04

Authority: 42 CFR 440 Services: General Provisions

42 CFR 483 Requirements for States and Long Term Care

Facilities

Chapter 71 A RCW Developmental Disabilities

Chapter 388-825 WAC Developmental Disabilities Services Rules

Chapter 3 88-835 WAC ICF/MR Program and Reimbursement

SCOPE

A. This protocol applies to persons requesting placement at an Intermediate Care Facility for

the Mentally Retarded (ICF/MR). This includes the following:

1. ICF/MRs located at a Residential Habilitation Center (RHC) operated by the Division of Developmental Disabilities (DDD). This includes Fircrest School, Frances Haddon Morgan Center, Lakeland Village, and Rainier School; and

2. Private ICF/MR facilities located in the community.

B. Clients requesting ICF/MR placement directly from a state psychiatric hospital must also follow the procedures and process described in this policy.

C. This protocol does not apply to persons on short-term admission to an ICF/MR for respite care. However, for short term stays lasting longer than ninety (90) days, see Procedures, Section C of this policy.

POLICY

A. A statewide team of professional staff known as the Admissions Review Team (ART)

will review all requests for admission to ICF/MRs and provide advice and recommendations to the Division Director. The Director will designate the team chair.

CHAPTER 3
DDD POLICY MANUAL 1 OF 7 ISSUED 4/08

TITLE: ICF/MR ADMISSIONS PROTOCOL POLICY 3.04

The ART will consist of the following members appointed by the Director:

1. The Central Office RHC Program Manager;

2. The Central Office Community Residential Services Program Manager;

3. The Clinical Director or a Licensed Psychologist;

4. A Registered Nurse;

5. A Field Services representative; and

6. An RHC staff representative (e.g., QMRP, Habilitation Plan Administrator).

B. Persons age thirteen (13) and older requesting admission must be eligible for Medicaid

services and also meet specific eligibility criteria for ICF/MR as follows:

1. Meet the ICF/MR eligibility determination in the DDD Assessment; and

2. Need active treatment per 42 CFR 483.440(b) (1) requiring:

a. 24-hour awake supervision for the protection of self and others (42 CFR 483 .430c (2)); and

b. Supervision or substantial training in the following activities of daily living:

1) Toileting;

2) Personal hygiene;

3) Feeding self;

4) Bathing;

5) Dressing;

6) Grooming;

7) Communication; and

8) Self-medication.

C. DDD shall determine the actual placement location. Children and youth under 21 may only be admitted to Fircrest School, Frances Haddon Morgan Center, and Yakima Valley School (nursing facility only).

D. Children age eight (8) through twelve (12) may be admitted to an RHC ICF/MR only by an Exception to Policy approved by the Division Director. When such requests are considered, the ETP must be accompanied by a current DDD Assessment that includes all three modules: the Support Assessment, the Service Level Assessment and the Individual

CHAPTER 3
DDD POLICY MANUAL 2 OF 7 ISSUED 4/08

TITLE: ICF/MR ADMISSIONS PROTOCOL POLICY 3.04

Support Plan (ISP). No children under the age of eight (8) years will be admitted to an RHC ICF/MR, except for children who are on an HCBS waiver and in the Medically Intensive Program.

E. If admission is approved, the client will be admitted to a facility as determined by the

Division Director.

1. Clients must be admitted to the facility no later than ninety (90) days from approval for admission. If not admitted within ninety (90) days, based on the choice of the client and her/his legal representative, it will be necessary to reapply for admission if future ICF/MR placement is desired.

2. Clients who are admitted to an RHC and are subsequently discharged at their own or their legal representative’s request will need to re-apply for admission should they want future placement at an RHC. If admission is approved, the Division Director will determine the placement facility.

3. If a client’s legal representative or family member demonstrates by a pattern of behavior (e.g., interfering with programming, staff, etc.) that there is likelihood the placement will be disrupted and cause harm to the client, DDD will make a report to Adult Protective Services (APS), Child Protective Services (CPS) or the Complaint Resolution Unit (CRU), as appropriate.

PROCEDURES

A. Requests for ICF/MR Admission

1. If the client, his/her legal representative, and/or family requests ICF/MR

placement, the Case Resource Manager (CRM) will talk with the person to ascertain his/her willingness to reside at a DDD RHC or a private ICF/MR facility.

a. If the client appears to be certain that he/she wants to reside at an ICF/MR, the CRM shall have the client sign the Request for ICF/MR Admission form (Attachment A) and document the request in the person’s Individual Support Plan (ISP). If the client has a legal representative with full guardianship powers, the legal representative must also sign the request.

b. Regardless of the preference of the client’s legal representative or family, if the client communicates or otherwise exhibits an unwillingness to reside at an ICF/MR, the CRM will document this in the client record and DDD will take no further action.

CHAPTER 3
DDD POLICY MANUAL 3 OF 7 ISSUED 4/08

TITLE: ICF/MR ADMISSIONS PROTOCOL POLICY 3.04

2. The CRM will discuss community residential placement options/services with the client, his/her legal representative and family, and assist them in visiting an RHC, a community ICF/MR, and other community options. This should be done prior to or within thirty (30) days of the signed request for ICF/MR admission. However, if the client has been denied access to a Home and Community Based Services (HCBS) waiver and no other community funding options are available, the CRM will proceed to Step 3 below.

3. The CRM will:

a. Complete a new DDD Assessment (all three modules) if circumstances warrant. DDD Assessments completed within the past year are acceptable, provided that there have been no significant changes in the client’s status or functioning. Contact the ART Chairperson if you are unsure.

b. Compile a packet for the ART that includes the following:

1) A cover letter from the Regional Administrator with the signed

ICF/MR Admissions Request form.

2) A written case summary that addresses:

(a) The client’s current status and a brief description;

(b) The reason/circumstances for the request;

(c) The urgency of the request;

(d) Where the client is currently residing and prior placements;

(e) Any extraordinary or unstable medical conditions;

(f) Any challenging behaviors the client exhibits and the severity of the behaviors;

(g) Special staffing or supports required at home or school;

(h) Alternatives to RHC placement that have been explored;

(i) Whether the client or his/her legal representative will accept community placement if offered;

(j) Placement goals; and

(k) Plan for discharge.

3) A copy of the client’s most recent DDD Assessment Details

Report.

4) Any other relevant information (e.g., psychiatric report or

evaluation, positive behavior support plan, etc.) that you want the ART to consider.

CHAPTER 3
DDD POLICY MANUAL 4 OF 7 ISSUED 4/08

TITLE: ICF/MR ADMISSIONS PROTOCOL POLICY 3.04

5) CRM and/or regional staff name and contact information.

6) A completed DSHS 13-830, ICF/MR Admissions Review Team Checklist. Note: Also email the checklist to the ART chairperson.

c. Forward the complete packet to the Regional Administrator for review and

approval.

4. If the Regional Administrator approves, forward the complete packet to the ART Chairperson in DDD Central Office.

B. RHC Short Term Stays (STS) Lasting Beyond 90 Days

1. The originating Region will initiate an admissions request and an Exception to

Rule (ETR) request when a client has been on STS for longer than ninety (90) days and:

a. There is no active or identified provider interested in serving the person; and

b. No resources have been identified to support the person in the community.

Proposed admission must meet both tests (“a” and “b” above). To be considered an “active or identified provider” the provider must, at a minimum, have met and visited the client.

2. Regions are expected to be actively working on returning the client to his or her

community. The originating Region will initiate an Exception to Rule (ETR) request to the Division Director using the Comprehensive Assessment and Reporting Evaluation (CARE) system. The ETR must indicate the providers you are working with and an estimated placement date.

C. ART Process

1. At each meeting, the ART will review the current RHC population data.

2. The ART will review the client information packet and confirm eligibility for ICF/MR services. During the ART meetings, the CRM and/or a regional staff who knows the client well must be available by telephone in the event the ART needs additional information, clarification, or has questions.

3. After review and discussion, the ART will make recommendations regarding admission, placement location, and possible diversion.

CHAPTER 3
DDD POLICY MANUAL 5 OF 7 ISSUED 4/08

TITLE: ICF/MR ADMISSIONS PROTOCOL POLICY 3.04

4. The ART chairperson will meet with the Director to discuss each request and will notify the Region of the Director’s decision. The Region is responsible to notify the client and his or her legal representative. Client notification for all decisions must follow the notice procedures in DDD Policy 5.02, Necessary Supplemental Accommodation.

5. If admission is approved, a Pre-admission Planning Conference must be scheduled immediately with the client, his or her legal representative/family, regional staff and RHC staff. The conference must address what supports are needed at the RHC to enable the client to return to his or her home community.

D. Washington State Considerations for ICF/MR

1. The DDD Assessment will be used to assist in determining if the client’s support

needs require ICF/MR level of care as follows:

a. The Support Assessment Acuity Scales ratings;

b. Evidence of behaviors requiring intervention to prevent injury to self, others, or property (documented in the DDD Assessment);

c. If the client scores low on the acuity scales referred to in “a” above, the ART may consider the following documented habilitation needs, which meet ICF/MR criteria, but are not adequately reflected in the above assessments:

(i) Severity of challenging behaviors;

(ii) Safety of the client, family, caregiver, and community; and/or

(iii) Unstable health conditions.

2. The following two (2) conditions must also be present:

a. The client must exhibit a willingness to reside at an ICF/MR and participate in active treatment discharge planning; and

b. The client’s critical safety and/or health needs are currently not being met (i.e., shelter, food, medical, personal care, and supervision).

3. The ART must also consider the safety of the other RHC or Community ICF/MR

residents.

CHAPTER 3
DDD POLICY MANUAL 6 OF 7 ISSUED 4/08

TITLE: ICF/MR ADMISSIONS PROTOCOL POLICY 3.04

E. Review Period

1. Reviews of ICF/MR admission requests will be completed within ninety (90) days of the date of receipt of the signed request, unless the time period is extended by mutual agreement of the requestor and DDD.

2. If admission is approved, the RHC will review the person’s continued need for ICF/MR level of care annually [42 CFR 483.440(f) (2)].

F. Notice and Appeal Rights

1. The client must be notified of the decision in accordance with the requirements of DDD Policy 5.02, Necessary Supplemental Accommodation.

2. If an ICF/MR placement request is denied, information about appeal rights and a form for requesting a Fair Hearing will be enclosed with the notice.

3. The person and his or her legal representative have ninety (90) days to appeal the denial or termination of ICF/MR services.

EXCEPTIONS

Any exceptions to this policy must have the prior written approval of the Division Director. SUPERSESSION

DDD Policy 3.04 Issued June 1, 2007

DDD Policy 3.04 Issued April 24, 2006

DDD Policy 3.04 Issued January 9, 2006

DDD Policy 3.04 Issued March 9, 2004

Approved: /s/ Linda Rolfe Date: April 1, 2008

Director, Division of Developmental Disabilities

CHAPTER 3
DDD POLICY MANUAL 7 OF 7 ISSUED 4/08

You have requested to receive services in an Intermediate Care Facility for the Mentally Retarded (ICF/MR) at a Residential Habilitation Center (RHC) operated by the Division of Developmental Disabilities (DDD) or at a private ICF/MR in the community. Please read and sign this request form.

What happens now?

A team of professionals appointed by the Division Director will review your request, including current assessment information, and determine if you meet federal criteria for ICF/MR admission.

· After review, the team provides its recommendation to the Director.

· The Director makes the final decision regarding admission and determines the actual placement location.

· You will receive written notification of the decision within 90 days of the date of receipt of this signed request.

What are the eligibility criteria for admission to an ICF/MR?

You must be eligible to receive Medicaid services and also meet the following criteria:

5 Federal regulations state that “clients admitted to the facility must be in need of and receiving active treatment services” [42 CFR 483.440(b) (1)] and “Admission decisions must be based on a preliminary evaluation of the client that is conducted or updated by the facility or by outside sources” [42 CFR 483 .440(b) (2)].

5 What is active treatment?

Active treatment is continuous and “includes aggressive, consistent implementation of a

program of specialized and generic training, treatment, health services and related services. Active treatment does not include services to maintain generally independent clients who are able to function with little supervision or in the absence of a continuous treatment program” [42 CFR 483 .440(a].

Is my admission to the ICF/MR permanent?

CFR ICF/MR Interpretive Guideline W199 states: “No admission should be regarded as permanent.”

Can I be discharged from the ICF/MR?

CFR ICF/MR Interpretive Guideline W201 states: “Transfer or discharge occurs only if one of the following reasons exists:

· The facility cannot meet the individual’s needs;

· The individual no longer requires active treatment program in an ICF/MR setting;

· The individual chooses to reside elsewhere; or

CHAPTER 3
DDD Policy 3.04 Attachment A Page 1 of 2 Issued 4/08

• When a determination is made that another level of service or living would be more beneficial and in the best interest of the client.”

Who decides what services I will receive in the ICF/MR?

You, your legal representative and/or family will be involved in developing your habilitation plan. These services are called “habilitative services” and may include personal care assistance and training, employment/day programs, counseling, nursing, and other therapies.

What are my legal rights as a resident of the ICF/MR?

Your admission to the ICF/MR is voluntary and you retain all of the legal rights you had in the community, including the right to appeal any action of the department that denies, reduces, or terminates your service. If you wish to leave the facility after admission, the facility staff will assist you to leave the facility and identify available services in the community.

What happens next if I am approved for ICF/MR placement?

If you are determined eligible for admission, your Case Resource Manager will notify you and assist you in compiling information needed for admission.

What are my appeal rights if I am denied ICF/MR placement?

You have 90 days from receipt of the Planned Action Notice to file a request for a Fair Hearing to appeal this decision. You will receive a Right to Appeal form with the notice.

I understand this information and choose to receive services in an RHC ICF/MR instead of in the community.

Signature of adult client Date

This signature is required even if there is a legal representative or other decision maker.

Signature of other decision maker Date

Legal relationship of other decision maker Date

CHAPTER 3
DDD Policy 3.04 Attachment A 2 OF 2 ISSUED 4/08