Tracking #2010-00427 
Final (permanent) adoption 8/6/10, eff. 10/1/10
(former Emergency #2010-00608, eff. 7/9/10) 

I:/10060202.rtf
[I:/10060202.doc]

(9 CCR 2503-1)

[Note: Statement of Basis and Purpose is incorporated with Tracking #2010-00426 (#10-4-29-1)] 

*****************

[Editorial note: Section 3.720.21 was deleted with emergency rule eff. 7/9/10.] 

*****************

[Instructions:  replace lines 2020762 through 2020766.] 
3.720.4  Services for HCA Recipients [Rev. eff. 10/1/10]
Services include: 
A.  The areas listed in Section 3.720.31; 
B.  Electronic monitoring; and, 
C.  One-time deep cleaning if referral is initiated by Adult Protective Services and determined necessary by the Single Entry Point case manager. 

***********************

[Instructions: replace lines 2020767 through 2020960.]
3.721  FUNCTIONS OF THE SINGLE ENTRY POINT AGENCIES FOR THE HOME CARE ALLOWANCE (HCA) AND ADULT FOSTER CARE (AFC) PROGRAMS 
3.721.1  CASE MANAGEMENT AND PROGRAM FUNCTIONS [Rev. eff. 10/1/10]
Case management and program functions for the Home care Allowance and Adult Foster Care programs shall be administered through the Single Entry Point agencies designated by the Colorado Department of Health Care Policy and Financing pursuant to Section 25.5-6-106, C.R.S. 
3.721.11  Definitions [Rev. eff. 10/1/10]
“Assessment” means a comprehensive evaluation by the case manager with the client and appropriate collaterals (such as family members, friends and/or caregivers) to determine the client's level of functioning, service needs, available resources, and necessity for paid care. The functional needs assessment shall be documented on the State prescribed assessment tool. 
“Care planning” means identifying client goals and choices for the care needed, services needed, appropriate service providers based on the client assessment and knowledge of the client and of community resources. The care plan shall be documented on the State prescribed care plan tool. 
“Case management” means the assessment of a client’s long-term care needs, development and implementation of a care plan, coordination and monitoring of the long-term care service delivery, evaluation of service effectiveness, and periodic reassessment of client needs. 
“Intake/screening/referral” means the initial contact with individuals by the Single Entry Point agency and shall include, but not be limited to, a preliminary screening in the following areas: an individual's need for long term care services, an individual's need for referral to other programs or services, an individual's eligibility for financial and program assistance, and the need for a comprehensive assessment. 
“Ongoing case management” means the evaluation of the effectiveness and appropriateness of services, on an ongoing basis, through contacts with the client, appropriate collaterals, and service providers. 
“Program” means a publicly funded program, including Adult Foster Care or Home Care Allowance. 
“Reassessment” means a comprehensive re-evaluation by the case manager with the client and appropriate collaterals (such as family members, friends and/or caregivers) to determine the client's level of functioning, service needs, available resources, potential funding resources, and necessity for paid care. The reassessment of functional needs shall be documented on the State prescribed assessment tool. 
“Single Entry Point (‘SEP’) agency” means the agency selected by the Colorado Department of Health Care Policy and Financing to provide case management functions for persons in need of long term care services within specific demographic areas. 
“State prescribed assessment tool” means the form approved by the Department for use in determining functional eligibility for the Home Care Allowance and Adult Foster Care programs. 
3.721.12  Allocations and Reimbursement [Rev. eff. 10/1/10]
A.  At the beginning of each fiscal year, the Department allocates funds for case management services provided by Single Entry Point agencies within the amount appropriated. Payments to Single Entry Point agencies shall not exceed this allocation unless additional funding is appropriated by the General Assembly. 
B.  The Department shall make monthly payments to each designated Single Entry Point agency based upon the methodology established by the Department. 
3.721.13  Audit [Rev. eff. 10/1/10]
Single Entry Point agencies may be audited by representatives of the Department, its designee, and/or independent audit firms in accordance with State rules. 
3.721.14  Service Functions of the Single Entry Points [Rev. eff. 10/1/10]
A.  The Single Entry Point agency shall provide case management services in compliance with rules by the Department. 
B.  If at any time throughout the case management process the case manager suspects an individual to be a victim of abuse, neglect or exploitation, the case manager shall immediately refer the individual for protective services to the county department of social/human services in the individual’s county of residence and/or the local law enforcement agency. 
3.721.2  CASE MANAGEMENT REQUIREMENTS 
3.721.21  Intake/Screening/Referral [Rev. eff. 10/1/10]
A.  The intake/screening/referral function of a Single Entry Point agency shall include, but not be limited to, the following activities: 
1.  The completion of the Department prescribed long term care Single Entry Point intake form; 
2.  The provision of information and referral to other agencies, as needed; 
3.  The determination of the appropriateness of a referral for a client assessment; 
4.  The identification of potential payment source(s), including the availability of private funding resources; and, 
5.  The implementation of a Single Entry Point agency procedure for prioritizing urgent inquiries. 
B.  If a referral to Single Entry Point long term care services is determined to be appropriate, the State prescribed intake form shall be completed with the applicant or applicant's representative within two (2) working days of the referral. 
C.  When reimbursement for long term care services are requested through the Home Care Allowance or Adult Foster Care programs, the Single Entry Point staff shall: 
1.  Verify the applicant's current financial eligibility status; 
2.  Refer the applicant to the county department of social/human services of the client's county of residence for application; or, 
3.  Refer other community resources that can assist in the process of completing the application; and, 
4.  Document follow-up on return of forms. 
D.  The determination of the applicant's financial eligibility shall be completed by the county department of social/human services for the county in which the applicant resides. 
E.  Single Entry Point staff shall obtain the client’s or representative's signature on the intake form. 
F.  The SEP shall notify the applicant, at the time of his or her application for publicly funded long term care services, of the right to request a fair hearing before an Administrative Law Judge in accordance with Section 3.850, and to appeal adverse actions of the SEP, county department of social/human services, or contractors acting on behalf of the Department. 
3.721.22  Assessment [Rev. eff. 10/1/10]
A.  The Single Entry Point (SEP) case manager shall complete an assessment when the county department of social/human services provides the Medicaid application date for the client. If the client is being discharged from a hospital or nursing facility, the Single Entry Point case manager shall complete the assessment regardless of whether the Medicaid application date has been provided by the county department. 
B.  The SEP case manager shall complete an assessment within the following time frames: 
1.  For a client who is being transferred from a hospital to the Home Care Allowance or Adult Foster Care program, the SEP case manager shall complete the evaluation within two (2) working days after notification. 
2.  For a client who is being transferred from a nursing facility to the Home Care Allowance or Adult Foster Care program, the SEP case manager shall complete the evaluation within five (5) working days after notification. 
3.  For an individual who is not being discharged from a hospital or a nursing facility, the client evaluation shall be completed within ten (10) working days. 
C.  The SEP case manager shall conduct the following activities for a client assessment: 
1.  Determine the client's functional capacity during an evaluation, with observation of the client and family, if appropriate, in his or her residential setting and determine the functional capacity score in each of the areas on the State prescribed assessment tool. 
2.  Determine the need for paid care for Home Care Allowance (HCA) clients to determine the monthly HCA authorized amount in accordance with Section 3.720.32. 
3.  Determine if the Home Care Allowance services provided by a caregiver living with the client are above and beyond the workload of the normal family/household routine. If services are not beyond normal family/household routine, the client may not be scored as needing paid care for that service. 
4.  For HCA, score children age zero (0) through thirteen (13) years in both functional capacity and need for paid care according to the following age appropriate criteria: 
a.  Toileting: a child age 0 to 36 months will not be scored for bowel and bladder incontinence. 
b.  Mobility and positioning: a child age 0 to 36 months will not be scored for mobility and positioning. 
c.  Dressing: a child age 0 to 60 months will not be scored for dressing. 
d.  Bathing and hygiene: a child 0 to 60 months will not be scored for bathing and hygiene. 
e.  Eating: a child 0 to 48 months will not be scored for eating. 
f.  Transfers: a child 0 to 48 months will not be scored for transfers. A child 0 to 60 months will not be scored for car seat, highchair, or crib transfers. 
5.  Determine the ability and appropriateness of the client's caregiver(s) who must be at least eighteen (18) years of age or older to provide the client assistance in activities of daily living; 
6.  Determine the client's service needs, taking into consideration services available, or already being received, from all funding sources; 
7.  If an out-of-home placement is required, review placement options based on the client's needs, the potential funding sources, and the availability of resources; 
8.  Maintain appropriate documentation of the authorization for Home Care Allowance or Adult Foster Care program eligibility; 
9.  Refer the client to alternative services, if the client does not meet the eligibility requirements for Home Care Allowance or Adult Foster Care programs administered by the Department; 
10.  The State prescribed assessment form and the appropriateness of placement form shall be completed to determine eligibility for the Adult Foster Care program. 
3.721.23  Care Planning [Rev. eff. 10/1/10]
A.  The SEP case manager shall develop the care plan after completion of the client assessment and prior to the arrangement for services.  The SEP case manager shall complete the care plan using the State prescribed care plan form within ten (10) working days after determination of program eligibility. 
B.  Care planning shall include, but not be limited to, the following tasks: 
1.  The identification and documentation of care plan goals and client choices; 
2.  The identification and documentation of services, including type, duration and frequency; 
3.  The formalization of the care plan agreement, including appropriate signatures, in accordance with program requirements; 
4.  For the Adult Foster Care clients, The arrangement for services by contacting service providers, coordinating service delivery, negotiating with the provider and the client regarding service provision, and formalizing provider agreements in accordance with program rules; 
5.  The completion of program requirements for authorization of services; 
6.  Referral to community resources as needed and development of resources for individual clients if a resource is not available within the client's community; 
7.  The explanation of complaint procedures to the client as listed on the care plan document; 
8.  The explanation of appeals process to the client, if necessary. 
C.  Authorization of Home Care Allowance 
1.  The case manager shall negotiate with the applicant or recipient and care provider to arrive at the total number of paid care hours to be provided monthly. The applicant, recipient or designated representative and the provider shall sign the state prescribed provider agreement. Each party shall receive a copy of the agreement. 
2.  In all cases, Home Care Allowance payments shall be made directly to the applicant, recipient or designated representative who is responsible for paying the provider the agreed upon, authorized amount monthly. No portion of the authorized HCA amount shall be withheld by the recipient for personal use and must be spent for HCA services each month. 
3.  The case manager shall send a signed copy of the assessment instrument to the county eligibility worker authorizing payment of the Home Care Allowance. 
D.  Prudent Purchase of Services 
1.  The case manager shall meet the client's needs, with consideration of the client's choices, using the most cost effective methods available. 
2.  When services are available to the client at no cost from family, friends, volunteers, or others, these services shall be utilized before the purchase of services, providing these services adequately meet the client's needs. 
3.  When public dollars must be used to purchase services, the case manager shall encourage the client to select the lowest cost provider of service when quality of service is comparable. 
4.  The case manager shall assure there is no duplication in services provided by Single Entry Point programs and any other public or privately funded services. 
3.721.24  Ongoing Case Management [Rev. eff. 10/1/10]
A.  The case manager shall: 
1.  Monitor the quality of care provided to clients; 
2.  Identify and resolve any problems with service delivery, including corrective action processes, as appropriate; 
3.  Identify changes in the client's needs that may require a full reassessment or a change in the care plan; and, 
4.  Make changes in service plans as appropriate to client needs. 
B.  Ongoing case management shall include, but not be limited to, the following tasks: 
1.  Review of the client's assessment, care plan, and service agreements to include changes in client functioning, service effectiveness, appropriateness, and cost-effectiveness; 
2.  Contact with service providers concerning service coordination, effectiveness and appropriateness, as well as concerning any complaints raised by the client or others; 
3.  Contact with appropriate individuals in the event any issues or complaints have been presented by the client or others; 
4.  Conflict resolutions and/or crisis intervention, as needed; 
5.  Notification of appropriate law enforcement and/or protective services agencies, as needed; and, 
6.  Referral to community resources as needed. 
C.  The case manager shall immediately report to the appropriate agency any information that indicates an overpayment, incorrect payment or misuse of any public assistance benefit, and shall cooperate with the appropriate agency in any subsequent recovery process in accordance with the rules in Section 3.810. 
D.  The case manager shall complete a review of the client’s current assessment or reassessment and the care plan with the client six months following the assessment or reassessment.  The review shall be conducted by telephone, at the client’s place of residence, at the place of service or other appropriate setting as determined by the client’s needs. A face-to-face home visit shall be completed when significant changes in the client’s condition are identified. 
E.  The case manager shall contact the service providers to monitor service delivery as determined by the client's needs or as required by the specific service requirements.
3.721.25  Reassessment [Rev. eff. 10/1/10]
A.  The case manager shall complete a face-to-face reassessment with the client within twelve (12) months of the initial client assessment and every twelve months thereafter. A reassessment shall be completed sooner if the client's condition changes. 
B.  The case manager shall update the information provided at the previous assessment or reassessment, utilizing the State prescribed assessment tool. When a new assessment is completed for a Home Care Allowance or Adult Foster Care client, a copy shall be sent to the county department of human/social services within thirty (30) days of the reassessment. 
C.  Reassessment shall include, but not be limited to, the following activities: 
1.  For Adult Foster Care clients, obtain diagnoses from the client's medical provider at least annually, or sooner if the client's condition changes; 
2.  Assess client's functional status face-to-face at the client's place of residence; 
3.  Review the care plan, service agreement, and provider contract or agreement; 
4.  Evaluate service effectiveness, quality of care, and appropriateness of services; 
5.  Verify continuing financial and program eligibility; 
6.  Annually, or more often if indicated, complete new care plan and service agreement; 
7.  Refer the client to community resources, as needed; 
8.  For Adult Foster Care clients, a State prescribed appropriateness of placement form must be completed. 
3.721.3  CASE DOCUMENTATION AND PROGRAM EVALUATION 
3.721.31  Case Documentation [Rev. eff. 10/1/10]
A.  Documentation of contacts and case management activities shall be entered into the data system(s) prescribe d by the State within five (5) working days of the contact or activity. 
B.  All information related to intake, assessment, and care planning shall be thoroughly documented within ten (10) working days of the intake, assessment or care planning using forms and data system(s) prescribed by the State. 
C.  Additional documentation that cannot be entered into the data system(s) prescribed by the State shall be maintained in the case file. 
3.721.32  Completion of Single Entry Point Forms [Rev. eff. 10/1/10]
The SEP case manager shall notify applicants and clients of their services status using the State prescribed form at the time of initial eligibility, when there is a significant change in the client's payment or services, when an adverse action is taken, or at the time of discontinuation. 
3.721.4  Denials or Discontinuations [Rev. eff. 10/1/10]
Clients shall be denied or discontinued from the Home Care Allowance or Adult Foster Care programs if they are determined ineligible and shall be informed of appeal rights in accordance with rules under Section 3.850, et seq. 
A.  Financial Eligibility 
The county department of social/human services shall notify the applicant or client of denial for reasons of financial eligibility. The SEP case manager shall not attend the appeal hearing for a denial or discontinuation based on financial eligibility unless subpoenaed or requested by the State. 
B.  Level of Care 
The Single Entry Point agency shall notify the applicant or client of denial for reasons of level of care when: 
1.  Home Care Allowance functional capacity and/or need for paid care scores do not meet minimum requirements. 
2.  Adult Foster Care appropriateness for placement criteria is not met. 
3.  Persons who are developmentally disabled or who are receiving, or are eligible to receive, services administered by the Colorado Department of Human Services, Division of Developmental Disabilities, are not eligible for AFC. 
The case manager shall attend the appeal hearing to defend a denial or discontinuation. 
C.  Receipt of Services 
The SEP case manager shall notify the current client of denial for reasons of receipt of service when the client or authorized representative: 
1.  Has not received services for one month; 
2.  Has refused to schedule an appointment for an initial assessment, six-month review, or reassessment twice within a thirty (30) day consecutive period; 
3.  Has failed to keep three (3) scheduled appointments within a thirty (30) consecutive day period; 
4.  Has refused to schedule an appointment for a required visit after an inter-district transfer; 
5.  Refuses to use the Home Care Allowance or Adult Foster Care payment to pay for services or uses the payment for services not identified in the service agreement; or, 
6.  Refuses to sign the intake form, care plan, or other documents and forms required to receive services. 
The case manager shall attend the appeal hearing to defend the denial or discontinuation. 
D.  Institutional Status 
The SEP case manager shall notify the applicant or current client of denial or discontinuation for reasons of institutional status when: 
1.  The applicant is a resident of a nursing facility, hospital, or other institution; 
2.  The current client enters a hospital for treatment and hospitalization continues for thirty (30) days or more; 
3.  An applicant for Home Care Allowance (HCA) is residing in an Adult Foster Care or alternative care facility; or, 
4.  A current client receiving HCA has resided in such a facility more than thirty (30) days.
The case manager shall attend the appeal hearing to defend the denial or discontinuation. 
E.  Service Limitations Related to Safety or Cost Effectiveness 
The SEP case manager shall notify the applicant or client of denial or discontinuation when the case manager determines that the applicant or client cannot be safely served given the type and/or amount of services available or the level of service need is not cost effective under the Home Care Allowance or Adult Foster Care programs. 
1.  The case manager shall attend the appeal hearing to defend the denial or discontinuation. 
2.  To support a denial or discontinuation for safety reasons related to service limitations, the case manager shall document the limitations and evidence of safety concerns, when available, including, but not limited to: 
a.  The results of an adult protective services assessment; 
b.  A statement from the client's physician attesting to diminished mental capacity; 
c.  Lack of available services and/or providers; 
d.  Assessment score indicating a level of need for services in excess of those available under the Home Care Allowance or Adult Foster Care programs; 
e.  Other available information or evidence that will support the determination that the client’s safety is at risk. 
3.  To support a denial or discontinuation due to cost effectiveness the case manager shall document the level of service need and more cost effective alternatives.
F.  Living Arrangements 
The SEP case manager shall notify the applicant or client of denial for reasons of living arrangements when: 
1.  A Home Care Allowance applicant or client is residing in a licensed or unlicensed facility. 
2.  An Adult Foster Care (AFC) applicant or client is residing anywhere other than an approved AFC facility.
G.  Move Out of State 
The SEP case manager shall notify the client of discontinuation when the client has moved out of state. Discontinuation shall be effective the day after the date of the move. Clients who leave the state on a temporary basis with intent to return to Colorado within thirty (30) calendar days shall not be discontinued. 
H.  Voluntary Withdrawal from the Program 
The SEP case manager shall notify the client of discontinuation from the program effective upon the day after the date on which the client requests withdrawal from the program. 
I.  Death 
A client shall be discontinued from the program effective upon the day after the date of death. No notice of discontinuation shall be sent. 
3.721.41  Referrals and Notifications Upon Denial or Discontinuation [Rev. eff. 10/1/10]
In the case of denial or discontinuation, the case manager shall: 
A.  Provide appropriate referrals to other community resources, as needed, within one (1) working day of discontinuation. 
B.  The case manager shall notify all providers on the care plan within one (1) working day of discontinuation. 
C.  The case manager shall notify the county department of human services within one (1) day of discontinuation. 
3.721.42  Notification to the County Department [Rev. eff. 10/1/10]
The Single Entry Point agency shall notify the income eligibility section of the appropriate county department of social/human services: 
A.  At the same time that it notifies the applicant or client of the adverse action; 
B.  When the applicant or client has filed a written appeal with the Single Entry Point agency; or, 
C.  When the applicant or client has withdrawn the appeal or a final agency decision has been entered.
3.721.5  Communication Requirements [Rev. eff. 10/1/10]
In addition to any communication requirements specified elsewhere in these rules, the case manager shall be responsible for the following communications: 
A.  Informing the income maintenance technician of any and all changes effecting the client's participation in the Home Care Allowance or Adult Foster Care programs, including changes in income, within one working day after the case manager learns of the change. 
B.  Informing the client’s adult protective services caseworker, if applicable, of the client's status.  The case manager shall participate in mutual staffing of the client's case. 
C.  Reporting to the Colorado Department of Public Health and Environment any congregate facility that is not licensed.
3.721.6  CASE TRANSFERS 
3.721.61  Intercounty Transfers [Rev. eff. 10/1/10]
Single Entry Point agencies shall complete the following procedures to transfer case management clients to another county: 
A.  Notify the income maintenance technician of the client's plans to relocate to another county and the date of transfer and instruct the technician to follow the procedures for intercounty transfers (see Section 3.140.3). 
B.  If the client's current service providers do not provide services in the area where the client is relocating make arrangements, in consultation with the client, for new service providers. 
C.  If an Adult Foster Care client is moving from one county to another county to enter a new facility, forward copies of the following client records to the facility prior to the client’s admission to the facility: 
1.  Current client assessment; 
2.  Verification of Medicaid eligibility status.
3.721.62  Interdistrict Transfers [Rev. eff. 10/1/10]
Single Entry Point agencies shall complete the following procedure in the event a client transfers from one Single Entry Point district to another single entry point district: 
A.  The transferring Single Entry Point agency shall contact the receiving Single Entry Point agency by telephone to give notification that the client is planning to transfer, to negotiate a transfer date, and to provide information. 
B.  If the transfer is from one county to another county, the transferring Single Entry Point agency shall notify the income maintenance technician of the client's plans to relocate to another county and the date of transfer, and instruct the technician to follow the procedures for intercounty transfers (see Section 3.140.3). 
C.  The transferring Single Entry Point agency shall forward copies of the client's case records, including forms required by the publicly funded program, to the receiving Single Entry Point agency prior to the relocation, if possible, but in no case later than five (5) working days after the client's relocation. 
D.  If the client is moving from one Single Entry Point district to another Single Entry Point district to enter an Adult Foster Care facility, the transferring Single Entry Point agency shall forward copies of client records to the facility prior to the client's admission to the facility in accordance with the procedures for intercounty transfers. 
E.  The receiving Single Entry Point agency shall complete a face-to-face meeting with the client and a case summary update within ten (10) working days after notification of the client's relocation, in accordance with assessment procedures (see Section 3.721.22) for Single Entry Point agency clients. 
F.  The receiving Single Entry Point agency shall review the care plan and the assessment tool and change or coordinate services and providers, as necessary. 
G.  If indicated by changes in the care plan, the receiving Single Entry Point agency shall revise the care plan and service authorization forms as required by the publicly funded program. 

***********************

[Instructions:  replace lines 2020963 through 20209071] 
3.730.3  FUNCTIONAL ASSESSMENT [Rev. eff. 10/1/10]
Refer to Section 3.721.22 for functional assessment responsibilities of the Single Entry Point agencies. 
3.730.4  ADMISSION PROCEDURE
3.730.41  Applicant Intake [Rev. eff. 10/1/10]
Refer to Section 3.721 for the Adult Foster Care intake responsibilities of the Single Entry Point agencies. 
3.730.42  Assessment [Rev. eff. 10/1/10] 
Refer to Section 3.721 for the Adult Foster Care assessment responsibilities of the Single Entry Point agencies. 
A.  After the State prescribed assessment form and the Appropriateness of Placement forms have been completed by the case manager, the information from these forms shall be used in determining if the applicant or recipient is functionally eligible for Adult Foster Care (AFC). 
B.  If determined functionally eligible, the recipient cannot be placed and the AFC payment cannot begin until an appropriate AFC facility is found. 

**********************

[Instructions:  replace lines 2020990 through 2020994.]
3.730.6  SINGLE ENTRY POINT AGENCY FUNCTIONS [Rev eff. 10/1/10]
Refer to Section 3.721, et seq. 
3.730.7  NOTIFICATION OF ACTION AND APPEAL RIGHTS [Rev. eff. 10/1/10]
Refer to Sections 3.830, et seq., and 3.850, et seq.