Provider Requirements and Service Limitations
From The May 2010 Florida Medicaid Provider Handbook
Residential Habilitation- Requirements To Receive
Residential habilitation provides supervision and specific training activities that assist the recipient to acquire, maintain or improve skills related to activities of daily living. The service focuses on personal hygiene skills such as bathing and oral hygiene; homemaking skills such as food preparation, vacuuming and laundry; and on social and adaptive skills that enable the recipient to reside in the community. This training is provided in accordance with a formal implementation plan, developed with direction from the recipient, and reflects the recipient’s goal(s) from their current support plan.
Recipients with challenging behavioral disorders may require more intense levels of residential habilitation services described as behavior focus residential habilitation or intensive behavioral residential habilitation. The necessity for these services is determined by specific recipient behavioral characteristics that impact the immediate safety, health, progress and quality of life for the recipient, and the determination that less intensive services have not been sufficient to alter these behaviors. The need for more intense levels of residential habilitation, behavior focus residential or intensive behavioral residential habilitation must be verified by APD.
This service is not available to individuals enrolled on the DD Waiver – Tier Four.
Note: Refer to special considerations under behavioral analysis and behavioral assistant services for additional requirements.
Residential habilitation services (quarter hour) are provided to children living in their family home or adults 18 years of age or older living in their own home. Residential habilitation services (daily, monthly, or live-in) are provided to children and adults living in a licensed facility.
A child or an adult may receive residential habilitation services as follows:
- Residential habilitation services (quarter hour) may be provided in the family home for children ages 16-18 with a focus on developing independent living skills.
- Residential habilitation services (daily, monthly, or live-in) may be provided for children or adults with an emphasis on acquisition, generalization and skill maintenance. Children or adults with severe behavioral issues may also receive services in a licensed facility.
- Children living in their family home, or adults living in their own home, whose primary problem is behavioral in nature should receive services through behavior assistant services. When behavior assistant services are not available, residential habilitation services (quarter hour) may be provided to children or adults with severe behavioral issues under the supervision of a certified behavior analyst. Residential habilitation quarter hour services cannot be approved with behavior assistant services. The child or adult must have a written behavior analysis services plan that is written and monitored by a certified behavior analyst. The focus of the service for children is to assist the parents in training and implementing the behavior analysis services plan. The focus of the service for adults is to assist the recipient to develop new skills and to reduce socially inappropriate behaviors.
Recipients may not receive residential habilitation services and supported living coaching services at the same time, except when the recipient lives in a licensed residential facility and has a personal goal or outcome for supported living on their support plan. In this case, the recipient may receive both services for a maximum of ninety days prior to their move to the supported living setting.
Recipients may not receive any combination of residential habilitation services and inhome support services.
A recipient who receives residential habilitation services that are billed by the quarter hour is limited to no more than four hours, or 16-quarter hour units, of the service in a calendar day. When this service is provided in a recipient’s own home or family home, the service must be directly related to a training goal(s) on the recipient’s support plan and cannot be used for the supervision of the recipient. If a recipient is receiving residential habilitation services and has a goal on the support plan to move to their own home, supported living coaching services may also be provided for up to 90 days prior to moving to his own home.
The APD Area Office may approve the use of residential habilitation, live-in services at the appropriate live-in rate for the service for recipients who are in need of support and who reside in a licensed foster or group home, limited to no more than three recipients living in the home. Residential habilitation live-in services may be billed up to 365 days a year when the recipient is present. A provider or employees of a provider do not have to “live-in” the licensed home for the live-in rate to be applied for the service. The live-in daily rate provides from 8 to 24 hours of supports.
Reimbursement* and monitoring documentation to be maintained by the provider:
- *Copy of claim(s) submitted for payment;
- *Daily attendance log;
- *Copy of the individual implementation plan to be 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;
- *Quarterly summary: the third quarterly summary shall include a summary of the first three quarters of the support plan year and will be considered the annual report;
- LRC review an approval dates and recommendations made specific to the plan and review schedules for the plan as indicated in rules 65G-4.009 and 65G- 4.010, F.A.C. for individuals residing in licensed behavior focus or intensive behavior homes; and
- Staffing documentation such as direct care staffing schedules, payroll records indicating identified direct care support staff and hours worked, and any other supplemental support staffing schedules which document staffing ratios and direct contact hours worked.
Documentation to be submitted to the waiver support coordinator by the provider:
- Copy of daily attendance log, monthly;
- Copy of individual implementation plan;
- Quarterly summary: the third quarterly summary shall include a summary of the first three quarters of the support plan year and will be the considered the annual report;
- LRC review dates and recommendations made specific to the plan and review schedules for the plan as indicated in rules 65G-4.009 and 65G-4.010, F.A.C., for individuals residing in licensed behavior focus and intensive behavior homes; and
- If the provider plans to transport recipients in his private vehicle, at the time of enrollment, the provider must be able to show proof of valid: 1) driver’s license; 2) car registration, and 3) insurance. Subsequent to enrollment, the provider is responsible for keeping this documentation up-to-date.
*Indicates reimbursement documentation.
Place of Service:
This service shall be provided primarily at the recipient’s place of residence, which must be the recipient’s own home, family home, a licensed foster home or a licensed residential facility. However, some activities associated with daily living that generally take place in the community, such as grocery shopping, banking or working on social and adaptive skills are included in the scope of this service.
Residential habilitation providers are paid separately for transportation services if they are currently enrolled as a DD waiver transportation provider, only when transportation is provided between a recipient’s place of residence and another waiver service training site. Incidental transportation or transportation provided as a component of residential habilitation services is included in the rate paid to the provider.
Residential habilitation training services shall not take the place of a job or another meaningful day service, but must be scheduled around such events. For example, if a recipient works a Monday through Friday, 9 a.m. - 4 p.m. schedule, residential habilitation training services must be scheduled in the evening hours and on weekends.
Employees of licensed residential facilities that provide residential habilitation are usually direct care staff; however, in certain situations it may be appropriate to include other staff as residential habilitation direct care providers.
Providers of residential habilitation services provided in a recipient’s own home or family home must bill for services by the quarter-hour based on the rate for the service listed on the Provider Rate Table. Up to three recipients may receive this service during the same time period, if approved by the APD Area Office. If more than one recipient receives the service during the same time period, the service will be billed at the stepped rate ratio for the service.
When residential habilitation is provided in a recipient’s own home, the provider shall not be the recipient’s landlord or have any interest in the ownership of the housing unit, as provided in rule 65G-5.004, F.A.C. If renting, the name of the recipient receiving residential habilitation services must appear on the lease either singularly, with a roommate or a guarantor. Provider is defined as an independent provider or a corporation including all board members and any paid employees and staff of the provider agency, its subsidiaries or subcontractors.
Providers of residential habilitation and behavior focus residential habilitation in a licensed facility shall bill for services only when the recipient is present, up to 350 days a year, using the monthly or daily rate authorized based on the published rate for the service.
Minimum Staffing Requirements for Standard and Behavior Focus Residential Habilitation Services Provided in a Licensed Facility:
Providers of standard and behavior focus residential habilitation services shall provide a minimum level of staffing consistent with the minimum Direct Care Staff Hours per Person per 24 Hour Day identified in the table below. Staffing ratios shall be established by the provider using the available total minimum Direct Care Staff Hours per Person per 24 Hour Day consistent with the support and training needs of recipients receiving residential habilitation services for functional, behavioral or physical needs. The provider will meet the minimum staffing levels on a per day basis for each home, or shall provide the required staffing over a seven day period for each home to accommodate for absences from the home and to establish optimal coverage on weekends. Providers of residential habilitation services and their employees shall provide sufficient staffing and staff ratios while delivering these services to meet individual needs and provide appropriate levels of training and supervision for recipients of the service.
Direct Care Staff Hours per Person per 24 Hour Day:
Level of Disability Level of Staffing
Hours per Day Hours per Week
Basic Level 2 14 Minimal Level 4 28 Moderate Level 6 42 Extensive 1 Level 8 56 Extensive 2 Level 11 77
Hours counted must be provided by direct care staff or by other staff, who are providing direct care or direct time spent on client training, intervention or supervision. Provider compliance with direct care staffing levels for residential habilitation services substantiates Medicaid billing requirements only; other provisions of this Handbook remain fully applicable to all providers.
Calculating Available Minimum Direct Care Staff Hours per Person per 24 Hour Day for the provision of Standard and Behavior Focus Residential Habilitation Services:
To determine minimum required staffing for each level of support for residential habilitation services, the minimum direct care staff hours per person per 24 hour day authorized for recipients receiving residential habilitation services are multiplied by the number of recipients receiving the service at that level in the home setting. All available staff hours per level are totaled to obtain a daily minimum total number of staff hours. The resulting total is then divided by 8 hours of staff work time to produce an FTE level per day. The number of all available staff hours is multiplied by seven to establish a weekly minimum total. For example: The calculation below is for six recipients receiving the service and living in the same home, all authorized at the Moderate Level of Supports. The minimum number of direct care staff hours per person per 24 hour day for the moderate level is 6 hours. The calculation is as follows:
6 recipients X 6 direct care staff hours per person per 24 hour day = 36 available direct care staff hours per day, or 252 available direct care staff hours per week. 36 direct care staff hours per day divided by an 8 hour staff working day = 4.5 Full Time Equivalents (FTEs) per day for minimum residential habilitation direct care staffing purposes.
Minimum Staffing Requirements for Standard and Behavior Focus Residential Habilitation Services Provided in a Licensed Facility, continued Minimum staffing requirements for Intensive Behavioral Residential Habilitation services shall be determined at the time the rate for the service is established. Minimum staffing for Live-In Residential Habilitation services is determined by the rate ratio authorized for the home.
Example of the application of 4.5 staff FTEs at the Moderate Level as calculated above:
The 4.5 FTEs generated using the calculation above may be used to establish a staffing pattern for standard or behavior focus residential habilitation providers and their employees of 1.5 staff per 8 hour shift over a 24 hour period. If recipients are engaged in the receipt of other services during a period of time during the day, the residential habilitation provider may modify the staffing pattern to maximize staff during the time that recipients are in the home and receiving the service, and to optimize coverage on the weekends and holidays.
Residential Habilitation with a Behavioral Focus:
Service characteristics for residential habilitation with a behavioral focus include:
- A Board Certified Behavior Analyst or Associate Analyst; or Florida Certified Behavior Analyst with a bachelor’s degree; or a person licensed under Chapter 490 or 491, F.S. provides on-site oversight for residential services.
- Integration of behavioral services throughout residential and community programs,
- No fewer than 75 percent of the provider’s direct service staff who work with the recipient(s) for whom the residential habilitation with a behavioral focus rate applies have completed at least 20 contact hours of face-to-face competency-based instruction with performance-based validation in the following content areas;
>Introduction to applied behavior analysis – basic principles and functions of behavior.
>Providing positive consequences, planned ignoring, and stop-redirectreinforce techniques.
>Data collection and charting.
- The service provides for comprehensive monitoring of staff skills and their implementation of required procedures. Monitoring for competence must occur at least once per month for 50 percent of direct service staff that have completed the training described above. Staff must be recertified in the training requirements yearly. The provider has a system that demonstrates and measures continuing staff competencies on the use of procedures that are included in each recipient’s behavior analysis services plan.
Provides for the eventual transitioning of behavioral improvement of the recipient, to a less intense service alternative, through formalized procedures incorporated into implementation plans.
In order for the provider to receive a residential habilitation with a behavioral focus rate for a recipient based on the Provider Rate Table, the provider must meet the specified staff qualifications for the service, and the recipient must exhibit the characteristics listed below. This rate level shall be approved only when it has been determined through use of the APD-approved assessment by a certified behavior analyst and the support planning process that a recipient requires residential habilitation services with a behavioral focus. The need for residential habilitation with a behavioral focus and the rate for the service shall be identified on the recipient’s support and cost plan and on the authorization for service submitted to the provider by the recipient’s support coordinator. Service authorization shall be based on established need and re-evaluated at least annually while the recipient is receiving the services. The provider must document evidence of continued need as well as evidence that the services are assisting the service provider in meeting the needs of the recipient so that transition to less restrictive services may be possible.
Recipients exhibiting one of the following characteristics may need residential habilitation with a behavioral focus services. Recipients receiving the service have behavioral challenges that fit one or both of the following two categories of behavioral problems:
- The person does not engage in an adaptive behavior that if not performed by the person or taught by a caregiver would result in a real and present threat of substantial harm to the person’s health or safety. This includes not engaging in adaptive behaviors such as following safety rules, responding in acceptable ways to conflict, performing daily living activities safely and maintaining basic health.
- The person has exhibited a problem with behavior during the past year or currently exhibits a problem with behavior that meets one of the criteria below:
> Requires visual supervision during all waking hours and intervention as determined by a certified behavior analyst or licensed behavior analysis professional.
> Is being addressed through the use of behavior analysis services and reviewed by the Local Review Committee (LRC).
> Has lead to the use of restraint or emergency medications within the past year.
> Has resulted in one or more of the following:
- Self-inflicted, detectable, external or internal damage requiring medical attention or the behavior is expected to increase in frequency, duration, or intensity resulting in self-inflicted, external or internal damage requiring medical attention. These types of behaviors include head banging, hand biting, and regurgitation.
- External or internal damage to other persons that requires medical attention or the behavior is expected to increase in frequency, duration or intensity resulting in external or internal damage to other persons that requires medical attention. These types of behavior include hitting others, biting others and throwing dangerous objects at others.
- Arrest and confinement by law enforcement personnel.
- Major property damage or destruction in excess of $500 for any one intentional incident.
- A life-threatening situation. Examples of these types of behaviors are excessive eating or drinking, vomiting, ruminating, eating non-nutritive substances, refusing to eat, swallowing excessive amounts of air, or severe insomnia.
Intensive Behavioral Residential Habilitation:
Intensive behavioral residential habilitation rates for a recipient must be approved and authorized through the prior service authorization process performed by the APD or an agent of the APD. Authorization shall require review by at least one board certified behavior analyst or a Florida certified behavior analyst with expanded privileges who holds a master’s degree with a primary emphasis in applied behavior analysis. The review process shall include evaluation of the proposed rates for the service being sought. Authorized rates for this service may vary across providers and recipients based on the specific service needs of the recipient. Service authorization shall occur prior to service delivery, for new services, within 30-days of the adoption of this rule for existing services and at least annually while the recipient is receiving the service. The provider must meet provider qualifications for this level of service. Further, the following recipient characteristics and service characteristics must be met in order to receive an intense behavioral residential habilitation rate. Service authorization shall be based on established need and re-evaluated at least annually while the recipient is receiving the services. The provider must document evidence of continued need as well as evidence that the service is assisting in meeting the needs so that transition to less restrictive services may be possible.
Intensive Behavioral Residential Habilitation Recipient Characteristics:
Intensive behavioral residential habilitation is for recipients who present problems with behavior that are exceptional in intensity, duration, or frequency and that meet one or more of the following conditions.
Within the past 6-months the recipient:
- Engaged in behavior that caused injury requiring emergency room or other inpatient care from a physician or other health care professional to self or others.
- Engaged in a behavior that creates a life-threatening situation. Examples of these types of behavior are excessive eating or drinking, vomiting, ruminating, eating non-nutritive substances, refusing to eat, swallowing excessive amounts of air, and severe insomnia.
- Set a fire in or about a residence or other facility in an unauthorized receptacle or other inappropriate location.
- Attempted suicide.
- Intentionally caused damage to property in excess of $1,000 in value for one incident.
- Engaged in behavior that was unable to be controlled via less restrictive means and necessitated the use of restraints, mechanically, manually or by commitment to a crisis stabilization unit, three or more times in a month or six times across the applicable six-month period.
- Engaged in behavior that resulted in arrest and confinement.
- Requires visual supervision during all waking hours and intervention as determined by a certified behavior analyst or licensed behavior analysis professional to prevent behaviors previously described above that were likely, given past behavior in similar situations, without such supervision.
- Engaged in sexual behavior with any person who did not consent or is considered unable to consent to such behavior, or engaged in public displays of sexual behavior (e.g. masturbation, exposure, peeping Tom, etc.)
- If the supervision and environment is such that the person lacks opportunity for engaging in the serious behaviors the behavior analyst providing oversight must determine that the behavior would be likely to occur at least every six months if the person is without the supervision or environment provided and document in the recipient’s records.
Intensive Behavioral Residential Habilitation Service Characteristics:
Intensive behavioral residential habilitation shall provide aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and related services that is directed toward: (1) the acquisition of the behaviors necessary for the recipient to function with as much self determination and independence as possible; and (2) the reduction or replacement of high risk, problems with behavior. Treatment may also include intensive medical oversight when warranted by the recipient’s specific concerns.
Individual goals must relate to the assessment, management, and replacement of problems with behavior. Goals also include, especially as treatment progresses and is effective, generalization and maintenance of new behavior and behavior reductions in settings that are increasingly similar to less intensive treatment settings, but within which continued treatment and maintenance services are included.
The problems with behavior and any related medical conditions are the central focus of treatment for these individuals. This means that all behavior change targets included in the treatment plan are linked to the initial problem statement. For example, if a problem with behavior were described as self-injury that occurs when the person is in the presence of aversive stimuli of a specific nature, then the targets for change would include alternatives to self-injury that would be controlled by the same stimuli. In addition, the recipient’s assessment might identify socially-skilled behavior deficits that make more likely the self-injury. These deficits might include communication and social skills necessary to independently function in other settings or basic self care skills.
Recipients in intensive residential habilitation programs are not able to function independently without continuous training, supervision, and support by the staff. Only near the end of treatment will a noticeable reduction in intensity occur. However, even at this stage, because the goal is to ensure that gains made are maintained in settings other than the treatment setting, services remain comprehensive and continuous.
Intensive Behavioral Residential Habilitation Special Considerations:
Treatment must also include the arrangement of contingencies designed to improve or maintain performance of activities of daily living. This would occur when a recipient, for example, does not bathe regularly and this is resulting in the person being socially isolated. The objective in this case would typically be to establish acceptable bathing routines in the absence of highly engineered contingencies. In these cases, incidental training is provided. For example, a person is provided instruction while getting dressed in order to assist the person in learning to select appropriate clothing for a specific job site. In this way, training on basic skills is provided as one component of active treatment.
Individual service plans for recipients receiving intensive behavioral residential habilitation will include a written plan to decrease services through improved behavior and when applicable, medical condition. Environmental changes or adjustments that are made as the person’s behavior and medical condition improves are tracked, measured and graphed.
The transition criteria for intensive residential habilitation define the conditions under which the treatment team must recommend a less structured, more open environment, including levels of involvement from direct care staff, staff supervisors and professional care providers. The goal of an intensive residential habilitation service is to prepare the person for full or partial reintegration into the community, with established behavioral repertoires, such as developing a healthy lifestyle, filled with engaging and productive activities.
Evaluation criteria for the recipient include:
- Living in a communal setting without harmful or dangerous behavior or significant conflict.
- Interacting safely in a wide range of social settings.
- Exhibiting stable work behavior.
- Participating appropriately in a high level of social activities.
- Identifying the set of services and supports, including minimal supervision, necessary to maintain performance and health.
Conditions for transition include:
- The behavioral excesses that made treatment necessary no longer occur in the presence of the environmental conditions that previously evoked those behaviors.
- The behaviors do not occur as a function of new environmental conditions.
- The behaviors intended to replace the problem behavior now reliably occur in the presence of the environmental conditions that previously evoked those behaviors that previously controlled the behavioral excesses.
- Caregivers reliably carry out the medical and behavioral strategies necessary to maintain or continue improvements in health and behavior without direct supervision from a nurse, behavior analyst or other professional care provider. The direct care providers and recipient no longer require the levels of oversight established within the exceptional services program for professional care providers including physicians, nurses, and behavior analysts.
- Direct care providers no longer require the levels established within the exceptional services program for direct supervision. Supervision is the same as that which is typically provided in the residential setting to which the person is most likely to move.
- The provider has determined the recommended transition levels of staff across all categories and the physical environment requirements needed for the recipient to maintain or to continue improvements.
When the conditions identified above are met, the recipient would no longer require intensive residential habilitation treatment. However, treatment would continue with the focus shifting to ensuring that the gains made maintain or continue to improve in settings that have more variability in the prevailing contingencies and afford greater access to unplanned, everyday encounters with untrained people.
Residential Habilitation Provider Requirements
Providers of residential habilitation services shall be transitional living facilities, licensed under Chapter 400, part V, F.S. and Chapter 429 F.S., or residential facilities licensed under Chapter 393, F.S. These services may be provided by a qualified independent vendor for which licensure, certification, or registration is not required.
Standard Residential Habilitation:
Direct care staff providing residential habilitation services must be at least 18 years of age and have a high school diploma or equivalent and one year of experience working in a medical, psychiatric, nursing or child care setting or in working with persons who have a developmental disability. College, vocational or technical training equal to 30 semester hours, 45 quarter hours, or 720 classroom hours can substitute for the required experience.
Behavioral Focus Residential Habilitation:
Providers of behavioral focus residential habilitation services shall meet the provider and staff qualifications identified above and in addition shall ensure that the following:
- No fewer than 75 percent of the provider’s direct service staff working with the recipient(s) for whom the behavioral focus residential habilitation rate applies have completed the following training: at least 20 contact hours of face-to-face instruction in the following content areas to include:
- Introduction to applied behavior analysis – basic principles and functions of behavior;
- Providing positive consequences, planned ignoring, and stop-redirect-reinforce techniques; and
- Data collection and charting. Certified Behavior Analyst or Associate Analyst, or Florida Certified Behavior Analyst with a bachelor’s degree, or a person licensed under Chapter 490 or Chapter 491, F.S., provides on-site oversight for residential services.
The 20 hours of training may be obtained by completing an in-service training program offered privately or through a college or university. Proof of training must be maintained on file for review and verification.
Other staff training can and should be provided in addition to the minimum hours and content areas described in the above training as appropriate for the setting or services provided.
There is a staff monitoring system that verifies that direct service staff continues to be competent in the use of the techniques listed in the training requirement above. Monitoring for competence must occur at least once per month for 50 percent of direct service staff that have completed the training. Staff must be re-certified in the training requirements yearly.
The provider has a system that demonstrates and measures continuing staff competencies on the use of procedures that are included in each person’s behavior analysis services plan.
Intensive Behavioral Residential Habilitation:
Providers of intensive behavioral residential habilitation services shall meet the behavioral focus provider and staff qualifications identified above, and in addition shall ensure:
- All adjunct services (behavioral, psychiatric, counseling, nursing) are included in the service, or billed to independent insurance policies or sources of reimbursement other than the Medicaid waiver program or APD;
- All direct care service needs are met without an addition to the approved rate;
- The Program or Clinical Services Director meets the qualifications of a Doctorate Level Board Certified Behavior Analyst or Masters Level Board Certified Behavior Analyst, or Florida Certified Behavior Analyst, under Chapter 393, F.S., with expanded privileges, or licensed under Chapter 490 and 491, F.S. The Program or Clinical Services Director must be in place at the time of designation of the organization as an intensive behavioral residential habilitation program;
- Staff responsible for developing behavior analysis services will meet at a minimum the requirements for a Florida Certified Behavior Analyst or Board Certified Associate Behavior Analyst under Chapter 393, F.S. or licensed under Chapter 490 and 491, F.S.;
- The ratio of behavior analysts to recipients is no more than one full-time analyst to 20 recipients; and
- All direct service staff will complete at least 20 contact hours of face-to-face competency-based instruction with performance-based validation, and comply with staff monitoring and the re-certification system as described for behavioral residential habilitation above.
Proof of training in the areas of Cardiopulmonary Resuscitation (CPR), HIV/AIDS and infection control is required within 90 days of initially providing residential habilitation 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.
Note: Refer to the Core Assurances in Appendix A for the provider training requirements.