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Adult Day Training

Provider Requirements and Service Limitations

From The July 2007 Florida Medicaid Provider Handbook

Adult Day Training - Requirements To Receive

Description

Day training programs for adults are training services intended to support the
participation of recipients in daily, meaningful, valued routines of the community,
which for adults may include work-like settings that do not meet the definition of
supported employment.
Adult day training (ADT) services stress training in the activities of daily living,
self-advocacy, adaptive and social skills and are age and culturally appropriate.
The service expectation is to achieve the outcomes (goals) defined by each
recipient; and to attain and support participation in less restrictive settings. The
training, activities and routine established by the adult day training program
shall be meaningful to the recipient and provide an appropriate level of variation
and interest. This training is provided in accordance with a formal
implementation plan, developed under the direction of the recipient, reflecting
goal(s) from the current support plan.
Services are typically facility-based and are usually furnished at a minimum of
six hours per day on a regularly scheduled basis, for one or more days per
week. Four of the six hours must be spent in training and program activities.
Services may also be provided in the community if the activity is reflected in the
individual’s support plan and included in the implementation plan. Adult day
training services may be provided as an adjunct to other services included on a
recipient’s support and cost plan. For example: a recipient may receive
supported employment or other services for part of a day or week and adult day
training services at a different time of the day or week. Adult day training
services will only be billable for the prorated share of the day or week that the
recipient actually attended that service.
Mobile crews, enclaves and entrepreneurial models that do not meet the
standards for supported employment and that are provided in groups of four or
more recipients are included as ADT off site services.
Any recipient receiving adult day training or ADT-off site services who is
performing productive work that benefits the organization or that would have to
be performed by someone else if not performed by the recipient must be paid.
Recipients who are working must be paid commensurate with members of the
general work force doing similar work per wage and hour regulations of the U.S.
Department of Labor.
At least annually, providers will conduct an orientation informing recipients of
supported employment and other competitive employment opportunities in the
community.
ADT-off site models include the following services that teach specific job skills
and other services directed at meeting specific employment objectives:
1. Enclave - A group approach to training where recipients with disabilities
work either as a group or are dispersed individually throughout an
integrated work setting with supervision by the provider.
2. Mobile Crew - A group approach to training where a crew (lawn
maintenance, janitorial) of recipients with disabilities are in a variety of
community businesses or other community settings with supervision by the
provider.
3. Entrepreneurial - A group approach to training where recipients with
disabilities work in a small business created specifically by or for the
recipient’s.

Limitations

Adult day training services are usually provided five days a week, for up to six
structured hours per day of operation, and up to 240 days a year. The stepped
rate published for ADT and ADT off-site services is based on seven hours of
staff time to accommodate the variance in recipient schedules for attendance.
The provider shall render services at a time mutually agreed to by the recipient
and the provider. This will allow a recipient the flexibility to determine when to
attend the ADT program for limited hours or only on certain days. Billing will be
by the quarter hour for the number of quarter hours attended each day the
recipient is present.
Recipients attending full time, six hours, will be billed at the quarter hour rate for
each full day the recipient is present. This service generally begins at the age
of 22 when a recipient is out of the public school system or when they have
graduated from the public school system, receiving a standard diploma.
However, a recipient can begin at the age of 16 without a standard diploma if
the public school system is willing to provide funding for this service throughout
the recipient’s legal age of eligibility. Recipients over the age of 22 who have
not graduated shall also be eligible.
Adult day training services are limited to the amount, duration, and scope of the
service described on the recipient’s support plan and current approved cost
plan. The staffing ratio shall not exceed ten recipients per direct care staff. This
service cannot be provided concurrently with personal care assistance or
companion services.
A recipient may not receive a combination of ADT, companion, or supported
employment services that exceeds 30 hours per week. A recipient may not
receive more than a total of 30 hours a week of a paid support or a combination
of paid supports designed to be used as a meaningful day activity.

Reimbursement* and monitoring documentation to be maintained by the
provider:
1. *Copy of claim(s) submitted for payment;
2. *Daily attendance log indicating attendance on the dates billed for the
service;
3. *Recipient’s implementation plan and supporting data; and
4. Staffing documentation such as staffing schedules, payroll records
indicating identified support staff and hours worked, and any other
supplemental support staffing schedules that document required staffing
ratios.
In addition to the minimum required components of the individual
implementation plan described in the definitions section of this handbook, the
individual implementation plan for adult day training service must contain the
following: a description of methods that the provider will use to ensure the
recipient makes an informed choice concerning types of work and meaningful
day activities (type of activities). This information is to be discussed with
recipients and documented at least annually.
1. *Monthly summaries for the period being reviewed;
2. An annual report;
3. Results of the annual satisfaction survey; and
4. Performance data on the selected service outcomes for this service; and
Documentation to be submitted to the waiver support coordinator by the
provider:
1. Copy of service log, monthly;
2. Copy of recipient’s implementation plan at the time of first claim submission,
and at least annually thereafter at the time of the support plan update and,
any time updates and changes are made before they are implemented; and
3. Annual report prior to the annual support plan update.
*Indicates reimbursement documentation.
Note: Refer to the definitions section for additional information regarding
specific documents required.

Place of Service Adult day training services must be provided in a designated adult day training
center or other training sites in the community as agreed to by the recipient and
provider.
Special Considerations
Adult day training providers are paid separately for transportation services only
when they are enrolled as a transportation provider and transportation is
provided between a recipient’s place of residence and the training site.
Transportation between day training sites, if the activities provided are a part of
day training services, will be included as a component part of the adult day
training services and included in the rate paid to the provider of the adult day
training service.
ADT staff is responsible for assisting recipients into and out of facilities when
they have been transported in vehicles not owned or operated by the ADT.
Drivers of such vehicles are responsible for ensuring the recipient’s safe entry of
and exit from the vehicle.
When the supervisor of a mobile crew or enclave does not meet the
qualifications for a supported employment coach, even when the recipient meets
the criteria for supported employment, the support must be billed as adult day
training-off site.
Adult day training services and ADT off-site services will be billed based on the
stepped rate for the services that are listed on the Provider Rate Table, at the 1
staff to 10 recipient ratio rate level. Exceptions to this rate level shall be made
only when it has been determined through use of the APD-approved assessment
and the support planning process that a recipient requires a different support
staffing ratio. The rate and staffing ratio shall be identified in the recipient’s
support plan and cost plan and on the authorization for service submitted to the
provider by the recipient’s support coordinator. The rate ratio is determined by
what is the usual and customary service delivery pattern and does not fluctuate
with incidental absences of one or more recipients included in the rate ratio.

Adult day training services shall be billed at the standard rate level for the service
based on the Provider Rate Table The standard rate is paid when a recipient
requires minimal assistance, through instructional prompts, cues, and supervision to
properly complete the basic personal care areas of eating, bathing, toileting,
grooming and personal hygiene. A rate other than the standard rate level for this
service shall only be authorized when it has been determined through use of the
APD-approved assessment and the support planning process that a recipient requires
an enhanced level of supports.
Indicators of a one staff to five recipient staffing rate ratio level include:
Recipients who have a moderate level of support for personal care services on
the APD-approved assessment may receive the rate level identified as moderate
for the service. The moderate rate is paid when a recipient routinely requires
prompts, supervision and physical assistance to complete the basic personal care
areas of eating, bathing, toileting, grooming, and personal hygiene; or
A recipient who is on a behavioral services plan that is implemented by the adult
day training provider, and who requires visual supervision during all waking hours
and occasional intervention as determined by a Certified Behavioral Analyst. The
recipient does not have to live in a licensed residential facility.
Indicators of a one staff to three recipient staffing rate ratio level include:
An intense level of personal care support services as indicated on an APD
approved assessment;
Recipients who have an intense level of support identified in the current abilities
section of the APD-approved assessment may receive the rate level identified as
intense for the service. The intensive rate is paid when a recipient requires total
physical assistance, to include lifting and transferring, in at least three of the basic
personal care areas of eating, bathing, toileting, grooming, and personal hygiene,
due to physical, cognitive or behavioral limitations; and
A recipient who is on a behavioral services plan that is implemented by the adult
day training provider and who exhibits the characteristics required for behavioral
residential habilitation services as determined by a Certified Behavioral Analyst.
The recipient does not have to live in a licensed residential facility. The
behavioral services plan and its effects on the behavior must be reviewed by the
Local Review Committee (LRC) on a regular schedule as determined appropriate
by the LRC.

Indicators of a one staff to one recipient staffing rate ratio level include:
A recipient who is on a behavioral services plan that is implemented by the
adult day training provider, and that exhibits the characteristics required for
behavioral residential habilitation or intensive behavioral residential
habilitation services as determined by a Certified Behavior Analyst. The need
for this level of supervision must be verified in writing by the APD Area Office
Review Committee Chair. The recipient does not have to live in a licensed
residential facility. The behavioral services plan and its effects on the
behavior must be reviewed by the Local Review Committee (LRC) on a
regular schedule as determined appropriate by the LRC.
The ADT provider must maintain documentation of the LRC review schedule,
the LRC review dates and recommendations made, and the changes made
related to these recommendations.
If the support is provided to groups larger than eight recipients, regardless of the
wage, the service will be billed as adult day training-off site. If the support is
provided in groups of eight or less and the recipients are paid less than minimum
wage, the service shall be billed as adult day training-off site.
Payment shall not be made for any time period the recipient is absent from the
service.
Providers shall combine each day’s service in a month and bill at the end of the
month, using the last day of the month as the date of service. If services
terminate before the end of the month, providers shall combine each day’s service
for the service period and bill at the end of the service period, using the last day of
the service period as the date of service.

Adult Day Training Provider Requirements


Provider Qualifications:
Providers of adult day training services shall be designated by the APD Area Office as adult day training centers. Unless waived in writing by the Area
Office, the provider shall meet the following minimum qualifications for staff
and staffing ratio:
The manager or director will not have full-time responsibility for
providing direct services.
The program director will possess at a minimum a bachelor’s degree
from an accredited college or university and two years related
experience.
Instructors (supervisors) will possess at least an associate’s degree and
two years experience in a related field.
Related experience will substitute on a year-for-year basis for the
required college education.
Direct service staff will work under appropriate supervision.
The staffing ratio will not exceed 10 recipients per direct service staff for
adult day training facility-based programs. Administrative staff and
those not providing direct service to the recipient are not considered
direct service staff.
Direct service staff must be at least 18 years of age and possess at
least a high school diploma or equivalent. When determining the
equivalency of high school degrees, providers may accept official
transcripts, affidavits from educational institutions, and other formal or
legal documents that can be reasonably used to determine educational
background. Employees who have been hired using the best judgment
of the hiring agency, prior to this amendment, will not be affected by this
change.
Training Requirements Proof of training in the areas of Cardiopulmonary Resuscitation (CPR),
HIV/AIDS and infection control is required for all staff within 90 days of
initially providing adult day training services. Proof of annual or required
updated training shall be maintained on file for review. At all times when
recipients are present, a minimum of a least one staff member or 50 percent
of all staff at the facility (whichever is greater), must be trained in CPR,
infection control techniques, zero tolerance (of sexual abuse), core
competencies, and the use of approved restraints and seclusion approved
by the Agencies.
The provider is responsible for all training requirements outlined in the Core
Assurances. Staff is required to attend eight hours of annual in-service
training related to implementation of individually tailored services.
Note: Refer to the Core Assurances in Appendix A for the provider training
requirements.

Projected Service Outcomes:
Projected services outcomes are goals used to determine through
monitoring and review the accomplishments of providers and the
effectiveness of service provision, which include:
Recipients receiving services demonstrate an increase in abilities,
consistent with their support plan.
Recipients served who have a stated support plan goal to be employed
in the community, have been provided with specific information,
opportunities for exploration, and the necessary support to make
progress toward this goal on supported employment or other
competitive employment opportunities.
Recipients served who have a stated support plan goal to be involved in
the community in another type of arrangement such as volunteer work
have been provided with specific information, opportunities for
exploration, and necessary support to make progress towards the goal.
All recipients served who have responded to the annual satisfaction
survey are satisfied with the services based on the results or that the
provider has addressed any concerns raised during the survey.
Recipients achieve goals on their support plan throughout the year.
Recipients demonstrate freedom of choice, including being informed
about rights and service options (e.g., more inclusive programs,
supported employment).