Community Living Options. 1. The Commonwealth shall serve individuals in the target population in the most integrated setting consistent with their informed choice and needs. 2. The Commonwealth shall facilitate individuals receiving HCBS waivers under this Agreement to live in their own home, leased apartment, or family’s home, when such a placement is their informed choice and the most integrated setting appropriate to their needs. To facilitate individuals living independently in their own home or apartment, the Commonwealth shall provide information about and make appropriate referrals for individuals to apply for rental or housing assistance and bridge funding through all existing sources, including local, State, or federal affordable housing or rental assistance programs (tenant-based or project-based) and the fund described in Section III.D.4 below. 3. Within 365 days of this Agreement, the Commonwealth shall develop a plan to increase access to independent living options such as individuals’ own homes or apartments. The Commonwealth undertakes this initiative recognizing that comparatively modest housing supports often can enable individuals to live successfully in the most integrated settings appropriate to their needs. a. The plan will be developed under the direct supervision of a dedicated housing service coordinator for the Department of Behavioral Health and Developmental Services (“DBHDS”) and in coordination with representatives from the Department of Medical Assistance Services (“DMAS”), Virginia Board for People with Disabilities, Virginia Housing Development Authority, Virginia Department of Housing and Community Development, and other organizations as determined appropriate by DBHDS. b. The plan will establish, for individuals receiving or eligible to receive services through the HCBS waivers under this Agreement: i. Baseline information regarding the number of individuals who would choose the independent living options described above, if available; and ii. Recommendations to provide access to these settings during each year of this Agreement. 4. Within 365 days of this Agreement, the Commonwealth shall establish and begin distributing, from a one-time fund of $800,000 to provide and administer rental assistance in accordance with the recommendations described above in Section III.D.3.b.ii, to as many individuals as possible who receive HCBS waivers under this Agreement, express a desire for living in their own home or apartment, and for whom such a placement is the most integrated setting appropriate to their needs. 5. Individuals in the target population shall not be served in a sponsored home or any congregate setting, unless such placement is consistent with the individual’s choice after receiving options for community placements, services, and supports consistent with the terms of Section IV.B.9 below. 6. No individual in the target population shall be placed in a nursing facility or congregate setting with five or more individuals unless such placement is consistent with the individual’s needs and informed choice and has been reviewed by the Region’s Community Resource Consultant and, under circumstances described in Section III.E below, by the Regional Support Team. 7. The Commonwealth shall include a term in the annual performance contract with the CSBs to require case managers to continue to offer education about less restrictive community options on at least an annual basis to any individuals living outside their own home or family’s home (and, if relevant, to their authorized representative or guardian).
Appears in 3 contracts
Samples: Settlement Agreement, Settlement Agreement, Settlement Agreement
Community Living Options. 1. The Commonwealth shall serve individuals in the target population in the most integrated setting consistent with their informed choice and needs.
2. The Commonwealth shall facilitate individuals receiving HCBS waivers under this Agreement to live in their own home, leased apartment, or family’s home, when such a placement is their informed choice and the most integrated setting appropriate to their needs. To facilitate individuals living independently in their own home or apartment, the Commonwealth shall provide information about and make appropriate referrals for individuals to apply for rental or housing assistance and bridge funding through all existing sources, including local, State, or federal affordable housing or rental assistance programs (tenant-based or project-based) and the fund described in Section III.D.4 below.
3. Within 365 days of this Agreement, the Commonwealth shall develop a plan to increase access to independent living options such as individuals’ own homes or apartments. The Commonwealth undertakes this initiative recognizing that comparatively modest housing supports often can enable individuals to live successfully in the most integrated settings appropriate to their needs.
a. . The plan will be developed under the direct supervision of a dedicated housing service coordinator for the Department of Behavioral Health and Developmental Services (“DBHDS”) and in coordination with representatives from the Department of Medical Assistance Services (“DMAS”), Virginia Board for People with Disabilities, Virginia Housing Development Authority, Virginia Department of Housing and Community Development, and other organizations as determined appropriate by DBHDS.
b. . The plan will establish, for individuals receiving or eligible to receive services through the HCBS waivers under this Agreement:
i. : Baseline information regarding the number of individuals who would choose the independent living options described above, if available; and
ii. and Recommendations to provide access to these settings during each year of this Agreement.
4. Within 365 days of this Agreement, the Commonwealth shall establish and begin distributing, from a one-time fund of $800,000 to provide and administer rental assistance in accordance with the recommendations described above in Section III.D.3.b.ii, to as many individuals as possible who receive HCBS waivers under this Agreement, express a desire for living in their own home or apartment, and for whom such a placement is the most integrated setting appropriate to their needs.
5. Individuals in the target population shall not be served in a sponsored home or any congregate setting, unless such placement is consistent with the individual’s choice after receiving options for community placements, services, and supports consistent with the terms of Section IV.B.9 below.
6. No individual in the target population shall be placed in a nursing facility or congregate setting with five or more individuals unless such placement is consistent with the individual’s needs and informed choice and has been reviewed by the Region’s Community Resource Consultant and, under circumstances described in Section III.E below, by the Regional Support Team.
7. The Commonwealth shall include a term in the annual performance contract with the CSBs to require case managers to continue to offer education about less restrictive community options on at least an annual basis to any individuals living outside their own home or family’s home (and, if relevant, to their authorized representative or guardian). Community Resource Consultants and Regional Support Teams The Commonwealth shall utilize Community Resource Consultant (“CRC”) positions located in each Region to provide oversight and guidance to CSBs and community providers, and serve as a liaison between the CSB case managers and DBHDS Central Office. The CRCs shall provide on-site, electronic, written, and telephonic technical assistance to CSB case managers and private providers regarding person-centered planning, the Supports Intensity Scale, and requirements of case management and HCBS Waivers. The CRC shall also provide ongoing technical assistance to CSBs and community providers during an individual’s placement. The CRCs shall be a member of the Regional Support Team in the appropriate Region. The CRC may consult at any time with the Regional Support Team. Upon referral to it, the Regional Support Team shall work with the Personal Support Team (“PST”) and CRC to review the case, resolve identified barriers, and ensure that the placement is the most integrated setting appropriate to the individual’s needs, consistent with the individual’s informed choice. The Regional Support Team shall have the authority to recommend additional steps by the PST and/or CRC. The CRC shall refer cases to the Regional Support Teams for review, assistance in resolving barriers, or recommendations whenever: The PST is having difficulty identifying or locating a particular community placement, services and supports for an individual within 3 months of the individual’s receipt of HCBS waiver services. The PST recommends and, upon his/her review, the CRC also recommends that an individual residing in his or her own home, his or her family’s home, or a sponsored residence be placed in a congregate setting with five or more individuals. The PST recommends and, upon his/her review, the CRC also recommends an individual residing in any setting be placed in a nursing home or ICF. There is a pattern of an individual repeatedly being removed from his or her current placement. By July 2012, the Commonwealth will have implemented Discharge and Transition Planning processes at all Training Centers consistent with the terms of this Section, excluding other dates agreed upon, and listed separately in this Section. To ensure that individuals are served in the most integrated setting appropriate to their needs, the Commonwealth shall develop and implement discharge planning and transition processes at all Training Centers consistent with the terms of this Section and person-centered principles. Discharge Planning and Discharge Plans Discharge planning shall begin upon admission. Discharge planning shall drive treatment of individuals in any Training Center and shall adhere to the principles of person-centered planning. Individuals in Training Centers shall participate in their treatment and discharge planning to the maximum extent practicable, regardless of whether they have authorized representatives. Individuals shall be provided the necessary support (including, but not limited to, communication supports) to ensure that they have a meaningful role in the process. The goal of treatment and discharge planning shall be to assist the individual in achieving outcomes that promote the individual’s growth, well being, and independence, based on the individual’s strengths, needs, goals, and preferences, in the most integrated settings in all domains of the individual’s life (including community living, activities, employment, education, recreation, healthcare, and relationships). The Commonwealth shall ensure that discharge plans are developed for all individuals in its Training Centers through a documented person-centered planning and implementation process and consistent with the terms of this Section. The discharge plan shall be an individualized support plan for transition into the most integrated setting consistent with informed individual choice and needs and shall be implemented accordingly. The final discharge plan (developed within 30 days prior to discharge) will include: Provision of reliable information to the individual and, where applicable, the authorized representative, regarding community options in accordance with Section IV.B.9; Identification of the individual’s strengths, preferences, needs (clinical and support), and desired outcomes; Assessment of the specific supports and services that build on the individual’s strengths and preferences to meet the individual’s needs and achieve desired outcomes, regardless of whether those services and supports are currently available; Listing of specific providers that can provide the identified supports and services that build on the individual’s strengths and preferences to meet the individual’s needs and achieve desired outcomes; Documentation of barriers preventing the individual from transitioning to a more integrated setting and a plan for addressing those barriers. Such barriers shall not include the individual’s disability or the severity of the disability. For individuals with a history of re-admission or crises, the factors that led to re-admission or crises shall be identified and addressed. Discharge planning will be done by the individual’s PST. The PST includes the individual receiving services, the authorized representative (if any), CSB case manager, Training Center staff, and persons whom the individual has freely chosen or requested to participate (including but not limited to family members and close friends). Through a person-centered planning process, the PST will assess an individual’s treatment, training, and habilitation needs and make recommendations for services, including recommendations of how the individual can be best served. Discharge planning shall be based on the presumption that, with sufficient supports and services, all individuals (including individuals with complex behavioral and/or medical needs) can live in an integrated setting. For individuals admitted to a Training Center after the date this Agreement is signed by both parties, the Commonwealth shall ensure that a discharge plan is developed as described herein within 30 days of admission. For all individuals residing in a Training Center on the date that this Agreement is signed by both parties, the Commonwealth shall ensure that a discharge plan is developed as described herein within six months of the effective date of this Agreement. In developing discharge plans, PSTs, in collaboration with the CSB case manager, shall provide to individuals and, where applicable, their authorized representatives, specific options for types of community placements, services, and supports based on the discharge plan as described above, and the opportunity to discuss and meaningfully consider those options. The individual shall be offered a choice of providers consistent with the individual’s identified needs and preferences. PSTs and the CSB case manager shall coordinate with the specific type of community providers identified in the discharge plan as providing appropriate community-based services for the individual, to provide individuals, their families, and, where applicable, their authorized representative with opportunities to speak with those providers, visit community placements (including, where feasible, for overnight visits) and programs, and facilitate conversations and meetings with individuals currently living in the community and their families, before being asked to make a choice regarding options. The Commonwealth shall develop family-to-family and peer programs to facilitate these opportunities. PSTs and the CSB case managers shall assist the individual and, where applicable, their authorized representative in choosing a provider after providing the opportunities described above and ensure that providers are timely identified and engaged in preparing for the individual’s transition. The Commonwealth shall ensure that Training Center PSTs have sufficient knowledge about community services and supports to: propose appropriate options about how an individual’s needs could be met in a more integrated setting; present individuals and their families with specific options for community placements, services, and supports; and, together with providers, answer individuals’ and families’ questions about community living. In collaboration with the CSBs and community providers, the Commonwealth shall develop and provide training and information for Training Center staff about the provisions of this Agreement, staff obligations under the Agreement, current community living options, the principles of person-centered planning, and any related departmental instructions. The training will be provided to all applicable disciplines and all PSTs. Person-centered thinking training will occur during initial orientation and through annual refresher courses. Competency will be determined through documented observation of PST meetings and through the use of person-centered thinking coaches and mentors. Each Training Center will have designated coaches who receive additional training. The coaches will provide guidance to PSTs to ensure implementation of the person-centered tools and skills. Coaches throughout the state will have regular and structured sessions with person-centered thinking mentors. These sessions will be designed to xxxxxx additional skill development and ensure implementation of person-centered thinking practices throughout all levels of the Training Centers. In the event that an individual or, where applicable, authorized representative opposes the PST’s proposed options for placement in a more integrated setting after being provided the information and opportunities described in Section IV.B.9, the Commonwealth shall ensure that PSTs: Identify and seek to resolve the concerns of individuals and/or their authorized representatives with regard to community placement; Develop and implement individualized strategies to address concerns and objections to community placement; and Document the steps taken to resolve the concerns of individuals and/or their authorized representatives and provide information about community placement. All individuals in the Training Center shall be provided opportunities for engaging in community activities to the fullest extent practicable, consistent with their identified needs and preferences, even if the individual does not yet have a discharge plan for transitioning to the community. The State shall ensure that information about barriers to discharge from involved providers, CSB case managers, Regional Support Teams, Community Integration Managers, and individuals’ ISPs is collected from the Training Centers and is aggregated and analyzed for ongoing quality improvement, discharge planning, and development of community-based services. In the event that a PST makes a recommendation to maintain placement at a Training Center or to place an individual in a nursing home or congregate setting with five or more individuals, the decision shall be documented, and the PST shall identify the barriers to placement in a more integrated setting and describe in the discharge plan the steps the team will take to address the barriers. The case shall be referred to the Community Integration Manager and Regional Support Team in accordance with Sections IV.D.2.a and f and IV.D.3 below, and such placements shall only occur as permitted by Section IV.C.6.
Appears in 1 contract
Samples: Settlement Agreement
Community Living Options. 1. The Commonwealth shall serve individuals in the target population in the most integrated setting consistent with their informed choice and needs.
2. The Commonwealth shall facilitate individuals receiving HCBS waivers under this Agreement to live in their own home, leased apartment, or family’s home, when such a placement is their informed choice and the most integrated setting appropriate to their needs. To facilitate individuals living independently in their own home or apartment, the Commonwealth shall provide information about and make appropriate referrals for individuals to apply for rental or housing assistance and bridge funding through all existing sources, including local, State, or federal affordable housing or rental assistance programs (tenant-based or project-based) and the fund described in Section III.D.4 below.
3. Within 365 days of this Agreement, the Commonwealth shall develop a plan to increase access to independent living options such as individuals’ own homes or apartments. The Commonwealth undertakes this initiative recognizing that comparatively modest housing supports often can enable individuals to live successfully in the most integrated settings appropriate to their needs.
a. . The plan will be developed under the direct supervision of a dedicated housing service coordinator for the Department of Behavioral Health and Developmental Services (“DBHDS”) and in coordination with representatives from the Department of Medical Assistance Services (“DMAS”), Virginia Board for People with Disabilities, Virginia Housing Development Authority, Virginia Department of Housing and Community Development, and other organizations as determined appropriate by DBHDS.
b. . The plan will establish, for individuals receiving or eligible to receive services through the HCBS waivers under this Agreement:
i. : Baseline information regarding the number of individuals who would choose the independent living options described above, if available; and
ii. and Recommendations to provide access to these settings during each year of this Agreement.
4. Within 365 days of this Agreement, the Commonwealth shall establish and begin distributing, from a one-time fund of $800,000 to provide and administer rental assistance in accordance with the recommendations described above in Section III.D.3.b.ii, to as many individuals as possible who receive HCBS waivers under this Agreement, express a desire for living in their own home or apartment, and for whom such a placement is the most integrated setting appropriate to their needs.
5. Individuals in the target population shall not be served in a sponsored home or any congregate setting, unless such placement is consistent with the individual’s choice after receiving options for community placements, services, and supports consistent with the terms of Section IV.B.9 below.
6. No individual in the target population shall be placed in a nursing facility or congregate setting with five or more individuals unless such placement is consistent with the individual’s needs and informed choice and has been reviewed by the Region’s Community Resource Consultant and, under circumstances described in Section III.E below, by the Regional Support Team.
7. The Commonwealth shall include a term in the annual performance contract with the CSBs to require case managers to continue to offer education about less restrictive community options on at least an annual basis to any individuals living outside their own home or family’s home (and, if relevant, to their authorized representative Authorized Representative or guardian). Community Resource Consultants and Regional Support Teams The Commonwealth shall utilize Community Resource Consultant (“CRC”) positions located in each Region to provide oversight and guidance to CSBs and community providers, and serve as a liaison between the CSB case managers and DBHDS Central Office. The CRCs shall provide on-site, electronic, written, and telephonic technical assistance to CSB case managers and private providers regarding person-centered planning, the Supports Intensity Scale, and requirements of case management and HCBS Waivers. The CRC shall also provide ongoing technical assistance to CSBs and community providers during an individual’s placement. The CRCs shall be a member of the Regional Support Team in the appropriate Region. The CRC may consult at any time with the Regional Support Team. Upon referral to it, the Regional Support Team shall work with the Personal Support Team (“PST”) and CRC to review the case, resolve identified barriers, and ensure that the placement is the most integrated setting appropriate to the individual’s needs, consistent with the individual’s informed choice. The Regional Support Team shall have the authority to recommend additional steps by the PST and/or CRC. The CRC shall refer cases to the Regional Support Teams for review, assistance in resolving barriers, or recommendations whenever: The PST is having difficulty identifying or locating a particular community placement, services and supports for an individual within 3 months of the individual’s receipt of HCBS waiver services. The PST recommends and, upon his/her review, the CRC also recommends that an individual residing in his or her own home, his or her family’s home, or a sponsored residence be placed in a congregate setting with five or more individuals. The PST recommends and, upon his/her review, the CRC also recommends an individual residing in any setting be placed in a nursing home or ICF. There is a pattern of an individual repeatedly being removed from his or her current placement. By July 2012, the Commonwealth will have implemented Discharge and Transition Planning processes at all Training Centers consistent with the terms of this Section, excluding other dates agreed upon, and listed separately in this Section. To ensure that individuals are served in the most integrated setting appropriate to their needs, the Commonwealth shall develop and implement discharge planning and transition processes at all Training Centers consistent with the terms of this Section and person-centered principles. Discharge Planning and Discharge Plans Discharge planning shall begin upon admission. Discharge planning shall drive treatment of individuals in any Training Center and shall adhere to the principles of person-centered planning. Individuals in Training Centers shall participate in their treatment and discharge planning to the maximum extent practicable, regardless of whether they have Authorized Representatives. Individuals shall be provided the necessary support (including, but not limited to, communication supports) to ensure that they have a meaningful role in the process. The goal of treatment and discharge planning shall be to assist the individual in achieving outcomes that promote the individual’s growth, well being, and independence, based on the individual’s strengths, needs, goals, and preferences, in the most integrated settings in all domains of the individual’s life (including community living, activities, employment, education, recreation, healthcare, and relationships). The Commonwealth shall ensure that discharge plans are developed for all individuals in its Training Centers through a documented person-centered planning and implementation process and consistent with the terms of this Section. The discharge plan shall be an individualized support plan for transition into the most integrated setting consistent with informed individual choice and needs and shall be implemented accordingly. The final discharge plan (developed within 30 days prior to discharge) will include: Provision of reliable information to the individual and, where applicable, the Authorized Representative, regarding community options in accordance with Section IV.B.9; Identification of the individual’s strengths, preferences, needs (clinical and support), and desired outcomes; Assessment of the specific supports and services that build on the individual’s strengths and preferences to meet the individual’s needs and achieve desired outcomes, regardless of whether those services and supports are currently available; Listing of specific providers that can provide the identified supports and services that build on the individual’s strengths and preferences to meet the individual’s needs and achieve desired outcomes; Documentation of barriers preventing the individual from transitioning to a more integrated setting and a plan for addressing those barriers. Such barriers shall not include the individual’s disability or the severity of the disability. For individuals with a history of re-admission or crises, the factors that led to re-admission or crises shall be identified and addressed. Discharge planning will be done by the individual’s PST. The PST includes the individual receiving services, the Authorized Representative (if any), CSB case manager, Training Center staff, and persons whom the individual has freely chosen or requested to participate (including but not limited to family members and close friends). Through a person-centered planning process, the PST will assess an individual’s treatment, training, and habilitation needs and make recommendations for services, including recommendations of how the individual can be best served. Discharge planning shall be based on the presumption that, with sufficient supports and services, all individuals (including individuals with complex behavioral and/or medical needs) can live in an integrated setting. For individuals admitted to a Training Center after the date this Agreement is signed by both parties, the Commonwealth shall ensure that a discharge plan is developed as described herein within 30 days of admission. For all individuals residing in a Training Center on the date that this Agreement is signed by both parties, the Commonwealth shall ensure that a discharge plan is developed as described herein within six months of the effective date of this Agreement. In developing discharge plans, PSTs, in collaboration with the CSB case manager, shall provide to individuals and, where applicable, their Authorized Representatives, specific options for types of community placements, services, and supports based on the discharge plan as described above, and the opportunity to discuss and meaningfully consider those options. The individual shall be offered a choice of providers consistent with the individual’s identified needs and preferences. PSTs and the CSB case manager shall coordinate with the specific type of community providers identified in the discharge plan as providing appropriate community-based services for the individual, to provide individuals, their families, and, where applicable, their Authorized Representative with opportunities to speak with those providers, visit community placements (including, where feasible, for overnight visits) and programs, and facilitate conversations and meetings with individuals currently living in the community and their families, before being asked to make a choice regarding options. The Commonwealth shall develop family-to-family and peer programs to facilitate these opportunities. PSTs and the CSB case managers shall assist the individual and, where applicable, their Authorized Representative in choosing a provider after providing the opportunities described above and ensure that providers are timely identified and engaged in preparing for the individual’s transition. Nothing in this Agreement shall prevent the Commonwealth from closing its Training Centers or transferring residents from one Training Center to another, provided that, in accordance with Virginia Code 37.2-837(A)(3), for as long as it remains effective, no resident of a Training Center shall be discharged from a Training Center to a setting other than a Training Center if he or his Authorized Representative chooses to continue receiving services in a Training Center. If the General Assembly repeals Virginia Code 37.2-837(A)(3), the Commonwealth shall immediately notify the Court, the United States, and the Intervenors. The Parties agree that repeal or alteration of Virginia Code 37.2-837(A)(3) justifies consideration of relief under Fed. R. Civ. P 60(b)(6). The Commonwealth shall ensure that Training Center PSTs have sufficient knowledge about community services and supports to: propose appropriate options about how an individual’s needs could be met in a more integrated setting; present individuals and their families with specific options for community placements, services, and supports; and, together with providers, answer individuals’ and families’ questions about community living. In collaboration with the CSBs and community providers, the Commonwealth shall develop and provide training and information for Training Center staff about the provisions of this Agreement, staff obligations under the Agreement, current community living options, the principles of person-centered planning, and any related departmental instructions. The training will be provided to all applicable disciplines and all PSTs. Person-centered thinking training will occur during initial orientation and through annual refresher courses. Competency will be determined through documented observation of PST meetings and through the use of person-centered thinking coaches and mentors. Each Training Center will have designated coaches who receive additional training. The coaches will provide guidance to PSTs to ensure implementation of the person-centered tools and skills. Coaches throughout the state will have regular and structured sessions with person-centered thinking mentors. These sessions will be designed to xxxxxx additional skill development and ensure implementation of person-centered thinking practices throughout all levels of the Training Centers. In the event that an individual or, where applicable, Authorized Representative opposes the PST’s proposed options for placement in a more integrated setting after being provided the information and opportunities described in Section IV.B.9, the Commonwealth shall ensure that PSTs: Identify and seek to resolve the concerns of individuals and/or their Authorized Representatives with regard to community placement; Develop and implement individualized strategies to address concerns and objections to community placement; and Document the steps taken to resolve the concerns of individuals and/or their Authorized Representatives and provide information about community placement. All individuals in the Training Center shall be provided opportunities for engaging in community activities to the fullest extent practicable, consistent with their identified needs and preferences, even if the individual does not yet have a discharge plan for transitioning to the community. The State shall ensure that information about barriers to discharge from involved providers, CSB case managers, Regional Support Teams, Community Integration Managers, and individuals’ ISPs is collected from the Training Centers and is aggregated and analyzed for ongoing quality improvement, discharge planning, and development of community-based services. In the event that a PST makes a recommendation to maintain placement at a Training Center or to place an individual in a nursing home or congregate setting with five or more individuals, the decision shall be documented, and the PST shall identify the barriers to placement in a more integrated setting and describe in the discharge plan the steps the team will take to address the barriers. The case shall be referred to the Community Integration Manager and Regional Support Team in accordance with Sections IV.D.2.a and f and IV.D.3 below, and such placements shall only occur as permitted by Section IV.C.6.
Appears in 1 contract
Samples: Settlement Agreement