BHDD directive 700-09-DD: Determining need for residential services

Document Information

Reference Number: 700-09-DD Title of Document: Determining Need for Residential Services Date of Issue: September 15, 2022 Date of Last Revision: September 15, 2022 (NEW) Effective Date: December 1, 2022 Applicability: All DSN Boards and Contracted Service Providers

GENERAL

The Department of Disabilities and Special Needs (DDSN) must ensure that those who are eligible for its services are provided with needed services and supports, including residential services, in the most timely and equitable manner possible. For the purpose of this document, the terms "DDSN-sponsored Residential Services" and "Residential Services" are used as collective terms for Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) services, Residential Habilitation services funded by the Intellectual Disabilities and Related Disability (ID/RD) Waiver or the Head and Spinal Cord Injury (HASCI) Waiver and/or Residential Habilitation services funded solely by DDSN.

The purpose of this Directive is to establish:

Minimum criteria which must be met before DDSN-sponsored Residential Services may be offered.
Definitions of the types Residential Services.
A Committee responsible for reviewing requests for Residential Services.
Procedures for evaluating requests and communicating the decisions.
Procedures for requesting the need for Residential Services be determined.
Procedures for requesting a change to an approved Residential Service.
Procedure for notifying DDSN of the termination of Residential Habilitation or discharge from an ICF/IID.
Procedure when seeking a different Residential Services provider.
Procedure for notifying DDSN of an anticipated need for Residential Services.
Repository of information about Residential Services options and Residential Services seekers.

MINIMUM CRITERIA FOR RESIDENTIAL SERVICES

Only those who are eligible for DDSN services and are determined by DDSN to be experiencing circumstances that jeopardize their health and safety will be determined to need DDSN-sponsored Residential Services. Circumstances that jeopardize health and safety are defined as:

Life-threatening situations that requires immediate action, and/or
Situations that present imminent risk of jeopardizing the person's health, safety and welfare.

Situations that are life threatening or pose an imminent risk of becoming life-threatening are typically limited to situations in which the person:

Has been recently abused/neglected/exploited by the primary caregiver;
Is homeless (to include situations where the individual is being discharged from an alternative placement and is unable to return to a family member's home or live independently);
Has seriously injured self or others and continues to pose a threat to the health and safety of self or others;
Has been judicially admitted to DDSN;
Has recently lost a primary caregiver or is at imminent risk of losing a primary caregiver; or
Has a primary caregiver who is 80 years of age or older with diminished ability to provide care that is likely to continue indefinitely due to the caregiver's physical or mental status and lack of an alternative caregiver. Care is being provided now, but it is clear that the need for services is imminent, because the caregiver will soon be unable to provide care and no other caregivers are available.

Additionally, to be determined by DDSN to be experiencing circumstances that jeopardize health and safety, when appropriate, all efforts to address the situation through the use of other services and supports, including Home and Community Based (HCB) Waiver services, must have been exhausted. The refusal of other supports and services may not necessarily constitute the presence of circumstances that jeopardize health and safety. Additionally, residing with relatives, friends, or alone with supports must be ruled out prior to someone being considered homeless.

TYPES OF DDSN-SPONSORED RESIDENTIAL SERVICES

There are two (2) types of DDSN-sponsored Residential Services, Intermediate Care Facilities for individuals with Intellectual Disability (ICF/IID) and Residential Habilitation. Each type is described below along with the settings and levels or tiers of service associated with each type.

1. Intermediate Care Facilities for individuals with Intellectual Disability (ICF/IID)

Facilities licensed by the state to provide comprehensive and individualized health care and habilitation services to individuals to promote their functional status and independence. ICF/IID services are available to those who need active treatment. Active treatment is the aggressive, consistent implementation of a program of specialized and generic training, treatment and health services. ICF/IID services are not appropriate for those who are generally independent, able to function with little supervision and/or do not require a continuous program of habilitation services. ICF/IID services can be delivered in two (2) kinds of settings, a Regional Center setting or a community-based setting.

Regional Centers are operated by DDSN and typically provide a campus-like environment with multiple ICF/IID living units, spaces/buildings for most professional resident services and spaces/buildings for most recreational pursuits such as gymnasiums, chapels, greenspace on the grounds of the campus.
Community-based ICFs/IID are operated by some Disabilities and Special Needs (DSN) Boards. While more than one ICF/IID living unit may be located in close proximity to another, community-based ICFs/IID are typically located in neighborhoods or near community businesses. Community-based ICF/IID residents seek professional services from community businesses in locations away from the ICF/IID living unit.

2. Residential Habilitation

Is a specifically defined service that must be provided in non-institutional settings that are licensed or certified by the state and chosen by the person. The setting may be owned by the person, rented by the person from a third party, or be a unit or physical space that is occupied under a legally enforceable agreement between the person and the Residential Habilitation provider. Residential Habilitation does not include room and board. It is specifically defined as care (e.g., assistance with personal care, medication administration), supervision (oversight and guidance proportionate to the specific needs and preferences of the person) and skills training (e.g., adaptive skill building, activities of daily living, community inclusion, access and use of transportation, educational supports, social and leisure skill development) provided to support the person to live as independently as possible and exert positive control over his/her life.

Residential Habilitation is offered through different tiers of service. A tier of service is a combination of the model (see Appendix A) through which Residential Habilitation is delivered and the degree of support the person will require when Residential Habilitation is delivered in that model. There are nine (9) tiers of service which are described below.

High Management (Intensive Support Residential Habilitation) is delivered through the Community Training Home II (CTH-II) model which is shared by up to three (3) people who have a brain injury, spinal cord injury or similar disability or those who have a diagnosis of intellectual disability/related disabilities and display extremely challenging behaviors.
Tier 4 (Intensive Support Residential Habilitation) is delivered through the CTH-II model which is shared by up to four (4) people who may have been involved with the criminal justice system and individuals with severe behaviors requiring heightened staffing levels.
Tier 3 (Intensive Support Residential Habilitation) is delivered through the CTH-II model which is shared by up to four (4) people or CRCF model which is shared by up to twelve (12) people who have a diagnosis of brain injury, spinal cord injury or similar disability or those who have a diagnosis of intellectual disability/related disabilities and display extremely challenging behaviors. Includes people being discharged from a DDSN Regional Center (ICF/IID) or community ICF/IID. Also includes people who need additional supports to prevent or delay institutional placement and to participate in community life due to: behavioral health concerns, physical health conditions, medical support needs, and/or limitations in physical abilities which impact the person's ability to perform Activities of Daily Living without support from another.
Tier 2 is delivered through the CTH-II model which is shared by up to four (4) people or CRCF model which is shared by up to twelve (12) people. It includes people who need additional supports (greater than included in Tier 1) to prevent or delay institutional placement and to participate in community life due to: behavioral health concerns, physical health conditions, medical support needs, and/or limitations in physical abilities which impact the person's ability to perform Activities of Daily Living without support from another.
Tier 1 is delivered through the CTH-II model which is shared by up to four (4) people or CRCF model which is shared by up to twelve (12) people. It includes people who need support to live in and participate in their community. Those supports include a degree of care, supervision, and skills training provided throughout the day.
Supervised Living Program (SLP) II: includes people who need support to live in and participate in their community. The supports delivered include a degree of care, supervision, and skills training provided throughout the day. SLP-II is delivered in a licensed SLP-II setting that is typically single or double-occupancy residence.
CTH Tier 2: delivered to waiver participants who need additional supports (greater than included in CTH Tier) to enable them to live in the setting and participate in community life due to: behavioral health concerns, physical health conditions, medical support needs, and/or limitations in physical abilities which impact the person's ability to perform activities of daily living without support. Those additional supports are typically services/supports specifically intended to provide relief/assistance to the supports provider and are necessary due to the amount/intensity of supports the person requires. CTH Tier 2 services are delivered to up three (3) people in the CTH-I licensed home of the support provider.
CTH Tier 1: delivered to waiver participants who need support to live in and participate in their community. CTH Tier 1 services are delivered to up three (3) people in the CTH-I licensed home of the support provider.
Supervised Living Program (SLP) I: delivered to waiver participants who need support in their own apartment or home setting. Support is provided through a 15 minute-unit and support is available 24 hours per day by phone. An annual assessment is completed for each participation to verify support needs in their own setting.

RESIDENTIAL SERVICES REVIEW COMMITTEE

To ensure appropriate consideration is given to all requests/notifications for Residential Services (both initial and requests for change), DDSN will empanel a Residential Services Review Committee (Committee) to review all thorough and complete requests submitted to the agency. The Committee will be comprised of DDSN staff who are appointed by the State Director. Committee members must have expertise at least one of the following areas: Case Management, Residential Habilitation, ICF/IID Services, or Fiscal. The Committee will meet as often as necessary in order to comply with the established deadlines. At a minimum, three (3) Committee members must actively participate in the review of each request.

Documentation of the date of the Committee's decision must be maintained and include the name of each person whose request is considered, the name of the case manager submitting the request, and the names of the Committee members reviewing the request. All Committee decisions must be made in recognition of the mission, values and principles of DDSN. The Committee must determine the degree of support the person requires and consider those support needs in light of the model that is preferred by the person and most appropriate to deliver those supports.

INITIAL REQUEST FOR DETERMINATION OF NEED FOR RESIDENTIAL SERVICES

When someone who is eligible for DDSN services has been assessed by his/her case manager to need support with housing, care, supervision and skills training and the person desires to receive DDSN – sponsored Residential Services, the case manager must make a request to DDSN. Requests must be submitted to DDSN via Therap SComm to "DDSN, Residential Service Requests." All requests must be thorough and complete. DDSN will utilize information available in the person's electronic health record and specific forms/information submitted to evaluate each request. At a minimum, the following information/completed forms must be available for review:

Residential Services Request/Notification (form) (Attachment 1).
Evidence that the case manager saw the person in his/her home or current location (e.g., hospital, homeless shelter, etc.).
Evidence that the case manager explained the following to the person and/or his/her representative:
- The minimum criteria for residential services (as defined in this document),
- The process to be followed for a decision to be made,
- The possible decisions that could be made by DDSN, and
- The right the person has to request reconsideration of or appeal a decision with which he/she disagrees.
Assessment of Need for Residential Services/Residential Habilitation (form) (Attachment 2)
Evidence of continued contact with the person while the request is pending.

DDSN must complete a review and acknowledge receipt of requests/notifications submitted via Therap SComm to "DDSN, Residential Service Requests" within three (3) business days of submission. This review will be completed only to ensure the required information is available for evaluation. When acknowledging the submission, DDSN will indicate if the submission is:

Thorough and complete and will be evaluated,
Incomplete, is being returned/rejected and will not be evaluated, or
Being held pending clarification.

As soon as possible, but no later than five (5) business days of receipt of a thorough and complete request, the Residential Review Committee will evaluate the submitted and available documentation. The Committee may, at its discretion, before making a decision, determine that a face-to-face visit with the person in his/her current residence/location or face-to-face visit with this person's caregiver is needed to better understand the circumstances. These face-to-face visits will be conducted by DDSN staff with assistance, as needed, from the person's case manager.

Following the evaluation, the Committee must, when determining if Residential Services are needed, decide if:

a. The criteria for Residential Services has not been met (must explain why, and if appropriate, offer alternative solutions and /or designate as Priority 1), or

b. The criteria for Residential Services has been met; and i. The type Residential Services approved (ICF/IID or Residential Habilitation), 1. If the type is ICF/IID, the setting (Regional Center or Community-based), or 2. If the type is Residential Habilitation, the tier of service (see Appendix B).

DDSN must communicate the Committee's decision in writing within two (2) business days. The written communication must be transmitted via certified mail to the person and his/her representative (if appropriate). The person's case manager will be copied. The communication must include written notice of the person's right to appeal or request reconsideration of the decision.

REQUEST FOR CHANGE TO RESIDENTIAL SERVICES (INCLUDING TYPE AND SETTING OR TIER)

Each person who is receiving a DDSN-sponsored Residential Service has been approved for a specific Residential Service type and setting or tier. As the agency in the state which has authority over all of the state's services and programs for people with intellectual disability, related disabilities, head injuries, and spinal cord injuries, including Residential Services, DDSN must approve or be notified of any change to the Residential Services being delivered prior to any change being made. Examples include:

From one DDSN Regional Center to another DDSN Regional Center.
From one ICF/IID to another ICF/IID within the same DDSN Regional Center.
From a DDSN Regional Center to a Community-based ICF/IID.
From a Community-based ICF/IID to another Community-based ICF/IID.
From an ICF/IID (any setting) to Residential Habilitation (any tier).
From any tier of service to another tier of service.
From the current setting for Residential Habilitation (any tier) to another setting for Residential Habilitation (same tier) [e.g., from Tier 1 at Miles Rd. CTH-II to Tier 1 at Rose Circle CTH-II].
From a model for a tier of service to a different model for the same tier of service (e.g., from Tier 2 at Delta CRCF to Tier 2 at Dixie Rd. CTH-II).

In order to receive prior approval for a change in Residential Services, the change must be requested. A request for a change must be submitted by the person's case manager or Qualified Intellectual Disabilities Professional (QIDP) and must only be submitted with the consent of the person, his/her legal guardian, or client representative. Thorough and complete requests must be submitted to DDSN via Therap SComm to "DDSN, Residential Service Requests." All requests must explain the reason for the requested change (e.g., provider's request, person's request, person's desire for a less restrictive setting). Documentation that supports the reason for the change must be submitted or available. At a minimum, the following information must be submitted or available:

Residential Services Request/Notification (form) (Attachment 1).
Evidence the person has been informed of the request for change and consents to its submission.
For anyone approved for Residential Habilitation, evidence supporting the person is aware of the terms his/her legally enforceable residential agreement (lease) and the how the change will impact it.
When the Residential Habilitation provider owns/controls the residence/setting in which the person lives, evidence the provider has or will comply with the terms of the residential agreement.
A thorough explanation of the reason the change is being requested.
Evidence that the change is for good cause and is in the best interest of the person.
Evidence supporting/demonstrating the reason for the change. Evidence must be current, specific to the person and specific to the circumstances necessitating the request for change. Examples of the kinds of evidence which, depending on the circumstances, could support a request for a change include but are limited to:
- A statement of an ICF/IID resident's interest in and capacity for receiving needed services outside of an ICF/IID.
- A statement of a Residential Habilitation recipient's interest in receiving Residential Habilitation through a different model.
- Residential Habilitation plan(s) or Individual Program Plan(s) (IPPs) and amendments covering at least the last twelve (12) months. The plans must include the interventions implemented to address the circumstances necessitating the change.
- Data showing the person's response to the planned interventions.
- Behavior Support Plan(s) covering the past twelve (12) months and data showing the person's response to the implementation of its interventions.
- Other data/information such as T-Logs, General Event Reports (GERs), Reports of Unusual Behavior (UBRs), etc.
- Medical information, progress notes including changes to medications prescribed for behavior.
- The level and pattern of staff support provided over the past twelve (12) months in the setting/model, including alternative levels or patterns tried and the outcome.
- The level and/or pattern of staffing thought to be needed for the person and why.

Requests for change must be submitted to DDSN via Therap SComm to "DDSN, Residential Service Requests." All requests must be thorough and complete. DDSN will utilize information available in the person's electronic health record and specific forms/information submitted to DDSN to evaluate each request. Submitted requests will be acknowledged by DDSN within three (3) business days of submission and will include an initial review to ensure the required information is available. When acknowledging the submission, DDSN will indicate if the submission is complete and will be evaluated or if information or clarification will be needed.

Within five (5) business days of the receipt, the Residential Review Committee will evaluate the submitted and available information. The Committee may at any time request additional information or clarification. Using the submitted and available information the Committee will decide to approve or deny the request. If approved, the Committee must document the type Residential Services (ICF/IID or Residential Habilitation) and either the ICF/IID setting or tier of service.

DDSN must communicate the Committee's decision in writing within two (2) business days. The written communication must be transmitted via certified mail to the person, and his/her representative (if appropriate). The person's case manager will be copied. The communication must include written notice of the person's right to appeal or request reconsideration of the decision.

NOTIFICATION OF TERMINATION OF RESIDENTIAL HABILITATION OR DISCHARGE FROM ICF/IID

Termination of Residential Habilitation by the residential services provider or discharge from the ICF/IID must be for good cause and, when possible, well planned. DDSN must be notified of all terminations or discharges. The "Residential Services Request/Notification" form (Attachment 1) must be used to notify DDSN of termination/discharges. Upon completion, this form must be submitted to DDSN via Therap SComm to "DDSN, Residential Service Requests."

NOTIFICATION OF DESIRED CHANGE OR ANTICIPATED NEED

People eligible for DDSN services must be supported, as appropriate, to exercise positive control over their lives especially as it relates to where and with whom they live. To that end, when a change to the person's current living arrangement is desired or likely to be needed, DDSN must be notified. Examples of changes of which DDSN must be notified include:

The person's current living situation is sufficient but DDSN-sponsored residential supports will likely be needed within the next 24 months.
The person lives in an ICF/IID and based on his/her annual assessment, is interested in and has the capacity for receiving needed services outside of an ICF/IID.
The person desires Residential Services from a different provider.
The person desires Residential Services in a different city or county.
The person desires a different type of ICF/IID Services.
The person desires to receive Residential Habilitation through a different model.

When notification to DDSN is required and with the person's consent, notification must be submitted by the person's case manager or QIDP using the "Residential Services Request/Notification" (form). "Residential Services Request/Notification" form must be thoroughly completed and submitted to DDSN via Therap SComm to "DDSN, Residential Service Requests." Within five (5) business days of receipt, DDSN will acknowledge receipt of the information and confirm that information about the person and his/her preferences has been included in the Residential Services Information Repository.

RESIDENTIAL SERVICES INFORMATION

In order to facilitate the connection between those needing DDSN-sponsored Residential Services and providers of Residential Services who may be able to deliver those needed services, DDSN will maintain information about those determined by the agency to need residential services for the first time and those determined to need a different kind of residential service. Additionally, information about ICF/IID residents who wish to receive their needed services in community-based settings instead of the institutional setting will be maintained as well as information about anyone approved for DDSN Residential Services who may be seeking the same services in a different location or from a different provider.

This information will be available in the "Portal Access Reports" application of the DDSN Application Portal. Confidentiality will be maintained with all person-specific data available. Until appropriate consent is obtained from the person, only non-specific information about the person will be shared (e.g., initials, age in years). Specific information such as full name, date of birth, current address will only be shared with specific provider(s) and only with appropriate consent.

In addition to information about people seeking Residential Services, DDSN will maintain information about the current and anticipated Residential Services openings or opportunities throughout the state. This information will be available in the "Portal Access Reports" application of the DDSN Application Portal. Information about openings or opportunities must be reported to DDSN by the Residential Services providers. Before posting the information about an actual opening, DDSN will verify the opening complies with the licensed capacity of the setting.

Information about anticipated openings can be submitted to DDSN via Therap SComm to "DDSN, Residential Service Requests." using the Notification of Anticipated Residential Availability form. Within three (3) business days of receipt of the completed form, DDSN will share the information.

Signed: Barry D. Malphrus, Vice Chairman

Appendices and Attachments

Appendix A: Description of Residential Habilitation Models
Appendix B: Residential Habilitation Tiers of Service
Attachment 1: Residential Services Request/Notification Form
Attachment 2: Assessment of Need for Residential Services
Attachment 3: Notification of Anticipated Residential Availability

To access the attachments, see the agency website page "Current Directives" at: https://ddsn.sc.gov/providerslddsn-directives-standards-and-manuals/current-directives

Note: This entry includes the full body of the directive as issued. The appendices themselves (Appendix A and B content) and the attachment forms (Attachments 1–3) are not reproduced here, as they are separate documents hosted on the DDSN website linked above rather than text within this directive.