Provider Requirements and Service Limitations
From The May 2010 Florida Medicaid Provider Handbook
Information highlighted in yellow indicates a change since the July 2007 version of this handbook.
Adult Day Training - Requirements To Receive
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, selfadvocacy, 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 inaccordance 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:
- 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.
- 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.
- Entrepreneurial - A group approach to training where recipients with disabilities work in a small business created specifically by or for the recipient’s.
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:
- *Copy of claim(s) submitted for payment;
- *Recipient’s implementation plan and supporting data; and
- 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 concerningtypes of work and meaningful day activities (type of activities). This information is to be discussed with recipients and documented at least annually.
Quarterly summaries are completed as follows:
1. A quarterly summary for each quarter of the support plan year;
2. A quarterly summary for the third quarter of the support plan year also serves as the annual report and must include:
- a summary of the fourth quarter of the previous support plan year, and
- a summary of the first three quarters of the current support plan year.
Documentation to be submitted to the waiver support coordinator by the provider:
1. Copy of service log, monthly;
2. Copy of the recipient’s implementation plan developed at a minimum within 30 days of the initiation of a new service, or within 30 days of the support plan effective date for continuation of services and annually thereafter. A copy of the implementation plan, approved by the individual/guardian shall be furnished to the individual/guardian and to the waiver support coordinator; and
3. Quarterly summaries as follows:
- A quarterly summary for each quarter of the support plan year;
- A quarterly summary for the third quarter of the support plan year also serves as the annual report and must include:
- a summary of the fourth quarter of the previous support plan year, and
- a summary of the first three quarters of the current support plan year.
*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 theend 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 onfile 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.