DHS 73.03(9)(9) “Medical assistance” means the assistance program operated by the department under ss. 49.43 to 49.497, Stats. DHS 73.03(10)(10) “Medical assistance waiver” means a waiver granted to the department by the secretary of the U.S. department of health and human services under 42 USC 1396n (c), authorizing the department to provide home and community-based services as part of the medical assistance program. DHS 73.03(11)(11) “Participant” means a person receiving an assessment, case plan or supportive home care services funded under a medical assistance waiver. DHS 73.03(12)(12) “Participant’s representative” means a person designated in writing by the participant to act on behalf of the participant in making decisions about or directing the provision of services received by the participant. DHS 73.03(13)(13) “Primary caregiver” means the person providing the majority of unpaid, informal care to the participant. DHS 73.03(15)(15) “Respite care” means care and supervision to a participant in a homelike environment for purposes of giving the primary caregiver temporary relief, relieving the primary caregiver of the stress of giving continuous support. DHS 73.03(16)(16) “Service provider” means an individual employed to provide supportive home care services to a participant, whether that individual is employed by the participant, the participant’s representative, a county department or a vendor agency. DHS 73.03(17)(17) “Supportive home care” means the provision of services except nursing care that are intended to maintain participants in independent or supervised living in the participant’s own home or the home of the participant’s friends or relatives, which help the participant meet his or her daily living needs, address the participant’s needs for social contact, ensure the participant’s well being, and reduce the likelihood that the participant will have to move to a nursing home or other alternate living arrangement. DHS 73.03(17m)(17m) “Terminally ill” means a medical prognosis that an individual’s life expectancy is less than 12 months. DHS 73.03(18)(18) “Vendor agency” means an agency from which a county department purchases supportive home care services for participants. DHS 73.03 HistoryHistory: Cr. Register, January, 1993, No. 445, eff. 2-1-93; emerg. cr. (3m) and (8m), eff. 1-1-96; cr. (3m), (8m) and (17m), Register, May, 1996, No. 485, eff. 6-1-96; correction in (6) made under s. 13.92 (4) (b) 6., Stats., Register November 2008 No. 635; CR 22-026: r. (4), am. (5), (8m), (11), (14) Register May 2023 No. 809, eff. 6-1-23; correction in (14) made under s. 35.17, Stats., Register May 2023 No. 809. DHS 73.04(1)(1) Assessment. Within the limits of state and federal funds, a county department shall carry out an assessment of any person residing in a nursing home who wants to be assessed for eligibility to receive support services within the community rather than within the nursing home, any person seeking admission to or about to be admitted to a nursing home for whom community services represent an alternative to nursing home residence or any person whom the county department judges would otherwise require nursing home care in the absence of comprehensive community services. The assessment shall include a face-to-face discussion with the person or the person’s guardian and any appropriate family members and caregivers. The assessment shall result in an outline of what would be required to enable the person to live at home or in a homelike setting integrated with the community and to meet the person’s preferences for location, type and manner of services provided. DHS 73.04(2)(2) Case plan. The county department shall develop a case plan for non-institutional community services for a person who is assessed and for whom services are feasible, can be financed with available state and federal funds and are preferred to nursing home care by the person or the person’s guardian. The case plan shall specify the types and amounts of services to be provided, the manner of service delivery and the assistance to be provided by informal community supports and shall incorporate the participant’s preferences to the maximum extent possible. DHS 73.04 HistoryHistory: Cr. Register, January, 1993, No. 445, eff. 2-1-93; correction in (1) made under s. 13.93 (2m) (b) 7., Stats., Register August 2001 No. 548; CR 22-026: am. (1) Register May 2023 No. 809, eff. 6-1-23. DHS 73.06DHS 73.06 Development of service agreements. DHS 73.06(1)(1) Requirement for negotiated agreement. Except when a county department expects services to be provided for less than 30 days, after an assessment and case plan have been completed and within 2 weeks after the initiation of service by the service provider, an agreement or agreements on services to be provided the participant shall be negotiated. DHS 73.06(2)(2) Participant employment of service provider. If the service provider is employed by the participant or participant’s representative, there shall be 2 service agreements unless the county department and the participant or participant’s representative decide that a single agreement is preferable. A single agreement involving the county department, participant or participant’s representative and service provider shall cover all required items in the 2 agreements. If there are 2 agreements, they shall be the following: DHS 73.06(2)(a)(a) A signed agreement between the county department and the participant or participant’s representative, which shall set out in writing: DHS 73.06(2)(a)4.4. A requirement that any service provider employed by the participant or participant’s representative shall be qualified on the basis of experience, training or both to perform required tasks, and that any training needed by the service provider shall be completed within 6 months after beginning employment or after February 1, 1993 whichever is later; and DHS 73.06(2)(a)5.5. That the county department or a vendor for the county department shall act as fiscal agent for the participant or participant’s representative for the purpose of performing the tasks required to comply with wage, benefit and tax laws applicable to the employer, unless the participant or participant’s representative makes an informed, knowing and voluntary waiver of the use of a fiscal agent; and DHS 73.06(2)(b)(b) Except as provided in sub. (3), a signed agreement between the participant or participant’s representative and the service provider, which shall set out in writing: DHS 73.06(2)(b)2.2. The service provider’s normal schedule of work or a specification of how scheduling will be accomplished; DHS 73.06(2)(b)3.3. When and how any training needed by the service provider will be furnished and completed; DHS 73.06(3)(3) Exemptions. The service agreement between the participant or participant’s representative and service provider under sub. (2) (b) is not required when: DHS 73.06(3)(b)(b) The services are provided by the spouse of the participant or by the parent of a minor participant; or DHS 73.06(3)(c)(c) The services are for the purpose of providing respite care. DHS 73.06(4)(4) County department or vendor agency employment of service provider. DHS 73.06(4)(a)(a) If the service provider is employed by the county department or a vendor agency, there shall be either a single signed agreement among the participant or participant’s representative, the county department and, where applicable, the vendor agency, or separate signed agreements, one between the participant or participant’s representative and the county department and the other between the participant or participant’s representative and the vendor agency. DHS 73.06(4)(b)(b) The agreement or agreements required under par. (a) shall contain at least the content specified in sub. (2) (a) 1. to 4. and (b), except that verification and payment procedures under sub. (2) (b) 5. and training arrangements under sub. (2) (b) 3. may be omitted if these do not directly involve the participant and are covered elsewhere either in written policy of the county department or in its contract with the vendor agency. DHS 73.06 HistoryHistory: Cr. Register, January, 1993, No. 445, eff. 2-1-93. DHS 73.08DHS 73.08 Supervisory review of payment decisions. DHS 73.08(1)(1) The county department shall develop and implement written procedures for supervisory review of staff decisions regarding the competence of a participant to receive funds to pay a service provider and appropriateness of the levels of funds based upon the needs identified in the participant’s assessment and services authorized in the case plan for the participant. DHS 73.08(2)(2) In conducting a review of a case in which a participant or participant’s representative receives funds, the supervisor shall examine: DHS 73.08(2)(a)(a) The capability of the participant or participant’s representative to manage funds and act as employer of the service provider; DHS 73.08(2)(b)(b) The adequacy of the funds provided compared to the level of need identified in the participant’s assessment; and DHS 73.08(2)(c)(c) The adequacy of any training provided to the participant or the participant’s representative to enable the participant or participant’s representative to manage funds and serve as an employer. DHS 73.08(3)(3) The supervisor’s review shall occur within 3 months after the initial disbursement of funds to a participant who receives funds for the first time on or after February 1, 1993 and within 9 months after February 1, 1993 for a participant who was receiving payments prior to February 1, 1993, and thereafter whenever there is a substantial change to the participant’s condition or need for services. Alternatively, the county department may conduct a supervisor’s review on a random sample of at least 10% of cases or 25 cases, whichever is greater, in which a participant receives funds. County departments with fewer that 25 cases shall review all cases. This review shall be completed within 12 months after February 1, 1993 and within every 12 months thereafter. DHS 73.08(4)(4) A county department may contract with a third party for supervisory review under this section. DHS 73.08 HistoryHistory: Cr. Register, January, 1993, No. 445, eff. 2-1-93. DHS 73.09DHS 73.09 Documentation that services have been provided. DHS 73.09(1)(1) If a participant or the participant’s representative employs a service provider, the county department shall verify the type and amount of service for which reimbursement is sought. A verification form developed and available from the county department shall either be submitted to the county department by the participant or participant’s representative or be reviewed by the case manager at the participant’s residence at least every 6 months. DHS 73.09(2)(2) The completed verification form shall include the following information: DHS 73.09(2)(b)(b) The number of hours of service provided in the past month or, if the service provider lives in the residence of the participant, the number of days of service provided in the past month; DHS 73.09(2)(e)(e) The dated signature of the participant or participant’s representative; and DHS 73.09(3)(3) The county department may provide in the form under sub. (2) that the information in sub. (2) (b) does not have to be maintained or reported if: DHS 73.09(3)(b)(b) The services are for the purpose of providing respite care; or DHS 73.09(3)(c)(c) The services are provided by the spouse of the participant or by the parent of a minor participant. DHS 73.09(4)(4) If a county department directly provides services or purchases services from a vendor agency, the county department and vendor agency, if any, shall establish procedures sufficient to document the amount of services provided to each participant each month. DHS 73.09 HistoryHistory: Cr. Register, January, 1993, No. 445, eff. 2-1-93. DHS 73.10DHS 73.10 Individual hardship exceptions to limits on funding for CBRF care. DHS 73.10(1)(1) Limitation on funding. Each county shall annually establish limits on spending for services for persons who reside in CBRFs from the allocations received under s. 46.277 (5), Stats., for community long-term support services. DHS 73.10(2)(2) Limitation on eligibility. If the projected cost of the services for an individual who is residing or intending to reside in a CBRF and initially applies for services to a county department would cause the county department to exceed a limit on spending for services provided to persons who reside in CBRFs under sub. (1), the individual is not eligible for those services using funds allocated under s. 46.277 (5), Stats. DHS 73.10 HistoryHistory: Emerg. cr. eff. 1-1-96; cr. Register, May, 1996, No. 485, eff. 6-1-96; CR 00-056: am. (1), Register August 2001 No. 548, eff. 9-1-01; CR 22-026: am. (1), (2), r. (3) Register May 2023 No. 809, eff. 6-1-23. DHS 73.11DHS 73.11 Criteria for determination of the infeasibility of in-home services. DHS 73.11(1)(1) A county may use long-term support funds under s. 46.277, Stats., to provide services to a person residing in a CBRF if the county department or aging unit has determined that all 5 conditions under s. 46.277 (5) (d) 1n., Stats., have been met. DHS 73.11 NoteNote: The five conditions are: the completion of an assessment before the person’s admission; determination of the infeasibility of in-home care; determination that the CBRF is the person’s preferred residence; determination that the CBRF provides a quality environment and quality care services; and determination that the CBRF is cost-effective when compared to other residential options.
DHS 73.11(2)(2) To determine in-home care is infeasible, the county department or aging unit shall document in writing that all of the following have occurred: DHS 73.11(2)(a)(a) A change has occurred in the individual’s condition, functioning, living situation or supports so that arrangements that were in place and adequate to maintain the individual’s health, safety and well-being are no longer sufficient to provide or ensure the provision of what the individual needs. DHS 73.11 NoteNote: Examples include, but are not limited to, when a spouse or other family member who has been a major caregiver dies or for some other reason can no longer provide care, or when there is a major change in the medical condition of a program participant such as a stroke or heart attack and there is need for more care and support but the additional funds or needed caregivers are for some reason not available.
DHS 73.11(2)(b)(b) Options for supporting the individual in his or her own home and community have been explored or attempted but have either failed or been found to be unavailable or not possible. DHS 73.11 NoteNote: Examples of efforts include, but are not limited to, other relatives, friends, neighbors or volunteers have been contacted; professional workers from a home health agency have been recruited and have attempted unsuccessfully to work with the individual in his or her home; and other options such as modifying the home and providing adaptations and aids to enable the individual to be more independent or obtaining nutritional services, adult day care and transportation are not available, feasible or cost-effective.
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Chs. DHS 30-100; Community Services
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