CMS provides long-awaited guidance about HCBS for those with dementia

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Person-centered care plans, staffing, activities and environmental design are the keys for residential and adult day settings seeking reimbursement for services provided to Medicaid beneficiaries of home- and community-based services who exhibit unsafe wandering or exit-seeking behavior, the Centers for Medicare & Medicaid Services said in recently published FAQs.

Senior living organizations and others had been seeking the guidance since CMS issued a final rule in 2014 that changed HCBS reimbursement criteria in an effort to enable Medicaid beneficiaries to receive services in settings integrated into the community rather than in skilled nursing facilities. Under the rule, certain settings are presumed ineligible for the Medicaid waiver program unless they meet a heightened standard of proof. All states and all HCBS settings must be in compliance with the final rule by March 17, 2019.

In FAQs published Dec. 15, CMS indicated that residential and adult day settings must demonstrate that their operations are driven by person-centered planning. Toward that end, CMS said, a person-centered care plan must be developed for each individual served, with input from the person with dementia as well as his or her representatives, as appropriate.

Settings in which egress is controlled should document the individual's choices about, need for and understanding of safety measures. “Home and community-based settings should not restrict a participant within a setting unless such restriction is documented in the person-centered plan, all less-restrictive interventions have been exhausted and such restriction is reassessed over time,” CMS said.

Any restrictions to egress should not be based on staff convenience, and individuals who are not at risk of wandering should be accommodated, according to the agency. “For example, spouses or partners who are not at risk for exit-seeking and who reside in the same setting should have the ability to come and go by having the code to an electronically controlled exit,” the document stated. “Technological solutions, such as unobtrusive electronic pendants that alert staff when an individual is exiting, may be used for those at risk, but may not be necessary for others who have not shown a risk of unsafe exit-seeking.”

Additionally, all staff members serving those who wander must be trained on how to communicate with them as well as on how to participate in planned and spontaneous activities with the individuals. Activities, according to CMS, should be stimulating and easily accessible; should promote wellness, mobility and interaction; and should be tailored to a person's interests.

“Memory care units should attempt to implement as many options as possible that are outlined within this guidance regarding staffing, activities and environmental design to assure optimal community integration for HCBS beneficiaries,” CMS said.

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