Section 51.3. Definitions

The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:

AWC/FMS—Agency with choice/financial management service provider—A type of financial management service provider.

Abuse—The allegation or actual occurrence of the infliction of injury, unreasonable confinement, intimidation, punishment, mental anguish, sexual abuse or exploitation.

Additional individualized staffing—Additional staffing as part of the licensed waiver residential habilitation services to meet the long-term needs of a participant when those needs cannot be met as a part of the usual residential habilitation staffing pattern.

Adult Autism Waiver—A Federally-approved 1915(c) waiver under section 1915(c) of the Social Security Act (42 U.S.C.A. § 1396n(c)) designed to help participants with Autism Spectrum Disorder who are 21 years of age and older to live more independently in their homes and communities.

Agency provider—An entity that employs staff to provide an HCBS.

Annual review ISP—The document that outlines the results of the annual review meeting.

Applicant—An individual provider, SSW or agency provider in the process of enrolling as an HCBS provider with the Department.

Approved program capacity—The maximum number of participants who are authorized by the Department to receive services in a waiver residential habilitation service location.

Assessed need—A documented need of a participant.

Assessment—Instruments and documents used by the ISP team and the Department to identify a participant’s specific needs for HCBS.

Back-up plan—

(i) A strategy developed by a provider to ensure the HCBS the provider is authorized to provide is delivered in the amount, frequency and duration as specified in the participant’s ISP.

(ii) The term is referred to as a contingency plan in the Adult Autism Waiver.

Base-funded services—A State-funded HCBS.

Behavioral specialist HCBS—Support to a participant that demonstrates behavioral challenges through specialized interventions that assist a participant to increase adaptive behaviors to replace or modify challenging behaviors that prevent or interfere with the participant’s inclusion in the community.

Behavioral support plan—A set of interventions to be used by people coming into regular contact with the participant to increase and improve the participant’s adaptive behaviors, consistent with the outcomes identified in the participant’s ISP.

CAP—Corrective Action Plan—

(i) A plan developed by a provider to resolve noncompliance and avoid recurrence of noncompliance.

(ii) The term is referred to as a Plan of Correction in the Adult Autism Waiver.

Chemical restraint—A drug used to control acute, episodic behavior that restricts the movement or function of a participant.

Common law employer—The person under the vendor fiscal/employer agent FMS option who is the legal employer.

Conflict of interest—A situation in which a person, corporation or entity has a personal or professional relationship which is able to be exploited by that person, corporation or entity for personal, professional or financial benefit or gain.

Consolidated Waiver—A Federally-approved 1915(c) waiver under section 1915(c) of the Social Security Act designed to help participants with an intellectual disability 3 years of age and older to live more independently in their homes and communities.

DCAP—Directed Corrective Action Plan—A document developed or approved by the Department or the Department’s designee to resolve noncompliance.

Department—The Department of Human Services of the Commonwealth.

Department designee—An entity designated by the Department to perform specific administrative functions on behalf of the Department.

EPLS—Excluded Parties List System—A database maintained by the United States General Services Administration that provides information about parties that are excluded from receiving Federal contracts, certain subcontractors and certain Federal financial and nonfinancial assistance and benefits.

FMS—Financial management service—An entity that fulfills specific employer or employer agent responsibilities for a participant that has elected to self-direct some or all of their HCBS.

Finding—An identified violation of this chapter, Chapter 1101 (relating to general provisions) or other Federal or State standards.

Grievance—The formal expression of dissatisfaction with the provision of a waiver service or a provider’s delivery of a waiver service.

HCBS—Home and Community-Based Services—An array of medical, financial and social services or goods not covered by third-party medical resources or other funding sources that are necessary and paid for by the Department to assist a participant to live in the community.

HCSIS—Home and Community Services Information System—A secure web-enabled information system which manages information regarding participants and providers of waiver services.

ISP—Individual support plan—The comprehensive plan for each participant that includes HCBS, risks and mitigation of risks and individual outcomes for a participant.

ISP team—A group of people designated by the participant or required to participate in supporting the participant’s outcomes.

Incident—An occurrence or allegation of an action or situation that may negatively affect a participant’s health, welfare, safety or rights.

Incident investigation—The process of identifying, collecting and assessing facts from a reportable incident in a systemic manner by a person certified by the Department’s approved Certified Investigation Training Program.

Incident target—The person who may have caused the incident to occur.

Individual outcome—

(i) The level of achievement the participant is working towards.

(ii) The term is referred to as goal in the Adult Autism Waiver.

Individual provider—A person who is not employed by an agency and who directly provides the HCBS, including an individual practitioner, independent contractor or SSW provider.

Integrated and dispersed in the community in noncontiguous locations—Waiver residential habilitation service locations that are located throughout the community, surrounded by individuals and businesses that are not funded by the Office of Developmental Programs, are not next to each other, side-by-side or back-to-back. Locations that share one common party wall are not considered contiguous.

Intellectual disability—Documented subaverage general intellectual functioning that occurs prior to the participant’s 22nd birthday and is accompanied by significant limitations in adaptive functioning in at least two areas.

Invoice—A bill for an HCBS rendered that is submitted through the Department’s designated MMIS billing system.

LEIE—List of Excluded Individuals/Entities—A database maintained by the United States Department of Health and Human Services, Office of Inspector General, for use by health care providers, the public and the government which provides information relating to parties excluded from participation in Medicare, Medicaid or other Federal health care programs.

MA—Medical Assistance.

MMIS—Medicaid Management Information System—The Department’s claims processing system.

Managing employer—The person who enters into a joint employment arrangement with the AWC/FMS.

Mechanical restraint—A device used to control acute, episodic behavior that restricts the movement or function of a participant or portion of a participant’s body. Examples include anklets, wristlets, camisoles, helmets with fasteners, muffs and mitts with fasteners, poseys, waist straps, head straps, restraining sheets and similar devices.

Medicheck—A Departmental list identifying providers, individuals and other entities precluded from participation in the MA Program.

Natural supports—Supports provided by friends, family, spiritual organizations, neighbors, local businesses and civic organizations that are not funded under the waivers.

ODP—The Office of Developmental Programs.

OHCDS—Organized Health Care Delivery System—An arrangement in which a provider that renders at least one direct MA waiver service also chooses to offer a different vendor HCBS by subcontracting with a vendor to facilitate the delivery of vendor goods or services to a participant.

Outcomes—Levels of achievement as described in the ISP.

P/FDS—Person/Family Directed Support—A Federally-approved 1915(c) waiver under section 1915(c) of the Social Security Act designed to support participants with an intellectual disability 3 years of age and older to live more independently in their homes and communities.

Participant—A person receiving HCBS.

Participant-directed services—A service managed by an eligible participant who has elected to self-direct through one of the FMS options.

Performance measure—Data results collected systematically over time to indicate provider performance.

Preventable incident—An event that may have been avoided if preventive measures were designed and implemented to reduce the likelihood of an incident occurring.

Preventive measures—Strategies or actions designed to reduce the likelihood of known factors that can result in an adverse event or outcome for a participant.

Private home—A home that is not agency owned, leased or operated and is leased or owned by a participant.

Prone position manual restraint—A method used to control acute, episodic behavior by holding the participant so that the front of the body is turned toward the supporting surface.

Provider—An individual or agency that provides HCBS.

Provider monitoring—A scheduled or unscheduled review conducted by the Department, or the Department’s designee, to determine a provider’s compliance with regulations and the MA and waiver provider agreements.

Provider performance review data—Performance data that may be used by the provider to devise QM plans while at the same time giving the provider an early indication of performance below Statewide averages.

QM plan—Quality Management plan—A written document describing how the provider will measure and remediate its performance to provide quality services and comply with the approved applicable waiver, including approved waiver amendments and this chapter.

Qualification documentation—Documentation that supports that a provider or applicant meets the provider qualification requirements for each service as prescribed in the approved applicable waiver, including approved waiver amendments.

Quarterly summary report—Information from providers of HCBS that provide services to a particular participant during the previous 3 months that detail the participant’s progress towards goals and objectives included in the participant’s ISP.

Remediation—Actions that are taken to correct deficiencies as a result of an incident or finding.

Residential habilitation enhanced staffing—An enhancement to the licensed residential habilitation service which can be residential habilitation services provided by a licensed nurse, supplemental habilitation staffing or additional individualized staffing. A licensed nurse can also provide residential enhanced staffing in an unlicensed residential habilitation service location.

Residential habilitation service—Support in the general areas of self-care, communication, fine and gross motor skills, mobility, socialization and use of community resources for participants that reside in a residential habilitation service location.

Respite care—Supervision and support to a participant on a short-term basis due to the absence or need for relief of those persons normally providing care to the participant.

Risk—The likelihood of some undesirable event or negative outcome occurring to a participant.

Risk factors—Attributes, behaviors, health conditions, features of the environment, actions, events or other determinants that increase the probability of an incident or negative outcome for a participant.

Risk mitigation strategies—Proactive action steps to avoid an incident.

SC—Supports coordinator—A person providing supports coordination services to a participant.

SCA—Supports coordination agency—A provider that delivers supports coordination services under the Adult Autism Waiver.

SCO—Supports coordination organization—A provider that delivers:

(i) Supports coordination services under the Consolidated and P/FDS Waivers.

(ii) Targeted services management and base-funded supports coordination.

SCO monitoring—Ongoing oversight of the participant’s services to ensure services are implemented as specified in a participant’s ISP.

SSW—Support service worker—An individual provider hired by a participant who is self-directing HCBS through the vendor fiscal/employer agent FMS option.

SSW agreement—The standard agreement that the SSW signs prior to delivering HCBS to a self-directing participant in the vendor fiscal/employer agent FMS option.

Satisfaction survey—A survey designed to measure a participant’s approval of HCBS.

Seclusion—Placing a participant in a locked room with any type of locking device, such as a key lock, spring lock, bolt lock, foot pressure lock or physically holding the door shut.

Self-direction—A participant’s management of some or all of the participant’s approved and authorized services using the assistance of the vendor fiscal/employer agent FMS or agency with choice FMS.

Service location—The address identified in HCSIS by an HCBS provider where HCBS are provided or managed.

Staff—Employees, contractors or consultants that provide an HCBS through direct contact with a participant, or are responsible for the provision of an HCBS.

Supplemental habilitation staffing—Additional staffing as part of the licensed residential habilitation service to meet the temporary medical or behavioral needs of a participant.

Supports coordination—A service that includes locating, coordinating and monitoring needed HCBS and other supports for a participant.

Surrogate—A person identified under State law to make decisions for a participant who is incompetent or incapacitated or a person designated by a participant that is self-directing HCBS in one of the FMS options.

TSM—Targeted services management—Supports coordination services funded through the MA State Plan for individuals receiving MA who are not enrolled in a Medicaid waiver.

Target objective—The level of performance a provider desires to achieve within a specified period of time.

Third-party medical resource—MA, Medicare, CHAMPUS, workers’ compensation, for-profit and nonprofit health care coverage and insurance policies, and other forms of insurances that are required to cover a participant’s HCBS.

Vendor fiscal/employer agent FMS—A nongovernmental entity that is a fiscal agent for a participant who is self-directing using the vendor fiscal/employer agent FMS option.

Waiver—The Adult Autism, Consolidated and Person/Family Directed Support Home and Community-Based Waivers approved by the Centers for Medicare and Medicaid Services under section 1915(c) of the Social Security Act.

Notation

Cross References

This section cited in 55 Pa. Code § 51.14 (relating to residential habilitation service providers); and 55 Pa. Code § 51.17 (relating to incident management).