December 11, 2017

From:  Self-Directed Advocacy Network of Maryland, Inc. (SDAN)

The Self-Directed Advocacy Network (SDAN) urges DDA to make the waiver as flexible as possible while remaining within CMS guidelines. SDAN stresses the importance of preserving the choice of the participant so that the services are truly person-centered. SDAN strongly believes that all waiver participants can self-direct their services, along with their legal guardian, if applicable.  Individual participants only vary in how much support they need to do so.

Self-Directed Services, through person-centered planning, is predicated on a team approach, and the participant, with or without a legal guardian, is necessarily the central member of that team. The self-directed team should include the participant, their legal guardian, if applicable, along with other advocates (family and/or friends) designated by the participant, the Coordinator of Community Services, and the Support Broker. Usually, the team includes at least one family member who has intimate knowledge of the participant’s needs, strengths and desires.  When a participant requires assistance with self-advocacy, including assistance with self-direction, the team collectively provides it. It is understood that each team member has designated roles and responsibilities; however, all team members must work cooperatively and in close coordination to develop, implement and maintain a plan that truly reflects the participant’s desires, abilities, and needs.

Self-directed services were designed to be led by the person with a disability with support from family members or other individuals in the person’s circle who has the willingness and the commitment to help the person with a disability design his or her life according to his or her desires.  It must remain family-oriented and not become so professionalized as to just be another traditional service.  We have concerns about the following sections in the proposed waiver:

 Making Informed Choices

Appendix E-1 f.  Participant Direction by a Representative:

DDA indicated that both legal and non-legal representation are allowed.  SDAN applauds the addition of allowing the non-legal option “freely chosen by an adult participant.”

Appendix E-1 a“The DDA offers the Self-Directed Service Model for participants, or their authorized representative, capable of making informed decisions  regarding how services are provided such that there is: (1) no lapse or decline in the quality of care; and (2) no increased risk to the health or safety of the participant.” (emphasis added)Appendix E-1 a(b)“Criteria for participation in the Self-Directed Service Model, the DDA must ensure, with recommendations by the CCS and team, that the participant, or his or her authorized representative, is capable of making informed decisions regarding how services are provided such that there is: (1) no lapse or decline in the quality of care; and (2) no increased risk to the health or safety of the participant. The CCS with input from the team will share information with the participant about the rights, risks, and responsibilities of managing his/her own services and managing and using an individual budget. This process is documented with the Self-directed Services Agreement to indicate the participant is capable of making informed decisions.”  (emphasis added)

SDAN Recommendations:

Remove all references, everywhere in the waiver document, to the requirement that the participant be “capable of making informed decisions.”  This would include removing the entire second paragraph in E-1 a(b).

There should be no requirement for a non-legal representative or guardian for a participant to self-direct services, although the participant may elect to choose one. If an individual requires assistance in implementing or administering any aspect of his or her self-directed plan, team members must include those needs and the tools for addressing them in the plan itself. People providing assistance with employer authority and/or budget authority must be identified in the plan and must sign the plan documents with the rest of the team.

On page 199 of the CMS Technical Guidelines they state, “CMS urges states not to impose restrictions based on the assessment of “ability” or “capacity” that have the effect of denying opportunity to direct their services based on disability.”

If the requirement to have an authorized representative remains, it will have a profoundly negative impact on many current participants who utilize family members as staff.   IF the participant is deemed by DDA to be incapable of making informed decisions AND a non-family member is not willing to take on the responsibilities and liabilities of becoming the authorized representative, then the most likely candidate to be an authorized representative would be a parent or other close relative.  Sections C-2d. and e. then prohibit any family member from working as paid staff when another family member serves as the authorized representative.  The extended definition of family member in this waiver proposal (as discussed below in our comments) will make it virtually impossible to find a non-family authorized representative.  It is doubtful that friends or other third-parties would be willing to assume the legal responsibility of being the employer of record and directing the plan as the employer.  This situation would particularly have a severe negative impact on participants whose single parent is their direct-care staff and the only person available to be the authorized representative.  SDAN suggests three potential remedies to this issue:

1. Remove the requirement for an authorized representative as recommended above.
2. Eliminate the prohibition of having family members work as direct-care staff when another family member is the authorized representative and allow a direct-care staff member to also be an authorized representative with the understanding that the role of the authorized representative has to be restricted in that someone else must sign the timesheet for participant-employer.
3. Restore the Support Broker’s role so that they can act as the agent for the participant and sign the timesheets of any direct-care family member, especially one who is also the authorized representative.

Family as Staff

SDAN supports DDA’s desire to preserve plan integrity and prevent fraud when family is staff.  We support strong emphasis on the team approach, including a non-family support broker when other family members serve as staff. 

SDAN recognizes the lifelong role of the family supporting and advocating for their relative with the disability.  SDAN supports their inclusion as direct support staff regardless of who is the legal guardian or authorized representative.  There should be no restriction on family as paid staff and in decision-making roles, with the specific stipulation that an individual may not sign a timesheet as both employee and employer.  In these situations, another team member must be authorized to sign the timesheet.

Appendix C-2 d. Provision of Personal Care or Similar Services by Legally Responsible Individuals.

AND

Appendix C-2 e.  Other State Policies Concerning Payment for Waiver Services Furnished by Relatives/Legal Guardians.

Both of these sections have the following language: 

Definition of Relative:   “For purposes of this waiver, a relative is defined as parents, step parents, siblings, uncles, aunts, grandparents, cousins, child of the participant, nieces and nephews.”

CIRCUMSTANCES WHEN PAYMENT MAY BE MADE states, “Participant enrolled in the Self-Directed Services Delivery Model (as provided in Appendix E) may use their legally responsible person [or relative/legal guardian as in section e.] to provide services in the following circumstances, as documented in the participant’s Person-Centered Plan (PCP): 

1. The proposed provider is the choice of the participant, which is supported by the team;
2. There is a lack of qualified providers to meet the participants needs;
3. When a relative or spouse is not also serving as the participant’s Support Broker or authorized representative directing services on behalf of the participant;
4. The legally responsible person [or relative/legal guardian as in section e.] provides no more than 40-hours per week of the service that the DDA approves the legally responsible person [or relative/legal guardian as in section e.] to provide; and
5. The legally responsible person [or relative/legal guardian as in section e.] has the unique ability to meet the needs of the participant (e.g. has special skills or training, like nursing license).

As provided in subsection 3 above, when a legally responsible person, legal guardian, or relative is the Support Broker or authorized representative who exercises decision making authority for the participant, then other legal guardians and relatives are not allowed to provide services noted above.

SDAN Recommendations:

Return to the definition of relative shown on page 159 of the current waiver:  (1) A family member (defined as a parent, step-parent, or sibling, or a guardian).  The restrictions placed on relatives working as staff should only pertain to the closest relatives (immediate family) of the participant.

In Appendix C-2, d and Appendix C-2, e   in the section listing CIRCUMSTANCES WHEN PAYMENT MAY BE MADE,

• Remove from #3:  “or authorized representative directing services on behalf of the participant.”
• Remove #2 and #5 entirely, because the only condition needed for a family member to work as staff is included in #1, “The proposed provider is the choice of the participant, which is supported by the team;”
• Remove the paragraphs highlighted above entirely as they appear in both sections d. and e.

Support Broker’s Role

Appendix E-1 a(c), Support by Entities for Participants in the Self-Directed Service Model:  Support Brokers do not make any decision for the participant, sign off on service delivery or timesheets, or hire or fire workers.

AND

  Support Broker services are optional and not required.

SDAN’s Recommendations:  Restore the Support broker role as a required member of the team with all the duties and responsibilities in the current waiver.   The role of the support broker is much broader than “the human resource support.”

SDAN Comments:

Support brokers currently do not make any decision for the participant; they assist the participant in decision making and in the hiring and firing of workers.  However, in current practice, based on the authority given to them by the participant in the plan, support brokers routinely sign employee timesheets and vendor payment forms (except their own).  This authority should be maintained.  

SDAN contends that the support broker role is essential to the successful implementation of a person-centered, self-directed plan and should be required.  It is a service that is critical in the initial planning and plan implementation. The support broker provides an important check and balance to ensure the participant’s plan is implemented faithfully.  The importance of the support broker’s work should reflect a minimum of 12 hours annually, with the guiding principal being the needs of the participant.

It has been a long standing requirement of CMS for individuals in self direction to have a support broker.

From CMS guidance:

“A supports broker/consultant/counselor must be available to each individual who elects the self-direction option. The supports broker/consultant/counselor supports the individual in directing their services, and serves as a liaison between the individual and the program, assisting individuals with whatever is needed to identify potential personnel requirements, resources to meet those requirements, and the services and supports to sustain individuals as they direct their own services and supports. The supports broker/ consultant/ counselor acts as an agent of the individual and takes direction from the individual.”  (emphasis added)

https://www.medicaid.gov/medicaid/ltss/self-directed/index.html

Page 176 of the CMS Technical Guidelines addresses potential overlaps:

“This service may include the performance of activities that normally overlap the provision of case management services; in general, such overlap does not constitute duplicate provision of services.  For example, a “support broker” may assist a participant during the development of person-centered plan to ensure that the participant’s needs and/or preferences are clearly understood even though a case manager is responsible for the development of the service plan.  Duplicate provision of services generally only arises when exactly the same activity is performed and billed on behalf of a waiver participant.  Where the possibility of duplicate provision of services exists, the participant’s service plan should clearly delineate responsibilities for the performance of activities.”

Since September of 2016, SDAN has been consistent in our recommendations to DDA regarding the role of support brokers.  At this point, it is the Support Broker (not the CCS) that is able to assist the participant to make the best plan to have a “good life” because they know the participant better than the CCS.  It is the Support Broker who is around to see that the plan is being implemented.  It is the Support Broker who can best detect fraud through review of bi-weekly timesheets and vendor invoices and consistent contacts.  It is the Support Broker who understands SDS and the participant.  It is the Support Broker who is the best line of defense against any fraud by staff or others providing services to the participant.   Weakening this role will weaken the oversight of the program.  Support Brokers are the primary advocate for the participant.

Support Broker As An Administrative Function

Appendix E-1 j:  Administrative Activity.

            (b) How Supports are Procured and Compensation:      Support Broker services will be identified or selected by the participant and paid under the FMS contract.  Support Brokers are independent contractors and not employees of the FMS.  Compensation is established by the DDA based on the Bureau of Labor Statistics.”        

SDAN recommends:

Support broker services are not administrative in nature.  Support broker services include crisis management, mentoring, staff development, succession management, plan development and implementation and advocacy.  There is concern that by moving support brokers from a waiver service to administration, the independence of support brokers will be compromised.  Deputy Secretary Simons has confirmed that support brokers will remain independent and will not be employees of the FMS.

SDAN understands that the intention of moving support broker services to the financial management service is to allow funding for support broker services to no longer come out of participants’ budgets.   The move also intends that participants who currently have unpaid support brokers will have additional funding for support broker services under the waiver renewal.

This section also states, “Compensation is established by the DDA based on the Bureau of Labor Statistics.”  This takes away the ability of the participant and support broker to establish a reasonable rate for these services, which should be customized based on the needs of each participant.  Support Broker rates should be “at negotiated market rates” and within the usual and customary range currently used by DDA and as updated yearly.  Support Brokers need to retain their complete autonomy to act in their role as the primary agent and advocate for each participant. 

In acknowledging the conflict of interest questions inherent in using participant advocates who are actually employees of state contractors such as support broker agencies, CCS agencies, or FMS agencies, the National Association of State Directors of Developmental Disabilities Services, Inc. declares the following:

There are not obvious answers to these questions.   It is clear that support brokerage requires an independent level of work and a primary allegiance to the consumer.  It is less clear, however, that the only way this independence can be assured is through an organized design that totally separates the various functions of funding, coordination of supports, and service provision.  http://www.nasddds.org/uploads/documents/IssuesInSupportBrokerage.pdf

If DDA determines that support broker services should remain as a waiver service, then funding equal to what would have been provided as an administrative function should be added to each participant’s waiver funding so that having these essential services does not take away from direct supports and other needs.

Appendix E-1 j:  Administrative Activity.

            (c)  Repeats the support broker role and duties discussed in section E-1 a(c) above.

Appendix E-1 j:  Administrative Activity.

            (e) Entities Responsible for Assessing Performance —  Coordinators of Community Services.

SDAN Recommends:

Change “Coordinators of Community Services” to “The participant and his/her support team, which includes the Coordinator of Community Services.”

SDAN Comments:

Per CMS guidelines as quoted above, “The supports broker/consultant/counselor acts as an agent of the individual and takes direction from the individual.”  The support broker is therefore accountable to the participant.  The CCS should not act as the supervisor nor be the only evaluator of the support broker. All team members, except the support broker, should have formal opportunities to assess the performance of the support broker. Likewise, all team members, except the CCS staff, should have formal opportunities to assess the performance of the CCS. This is a person-centered process and, ultimately, the service to the participant is what is being assessed.

Self-Directed and Traditional Services

 Appendix E-1 d:  Election of Participant Direction.  (second box checked)

The waiver is designed to afford every participant (or the participant’s representative) the opportunity to elect to direct waiver services. Alternate service delivery methods are available for participants who decide not to direct their services.

SDAN recommends:

SDAN recommends that the third box in this section be selected with the following criteria:

The waiver is designed to offer participants (or their representatives) the opportunity to direct some or all of their services, subject to the following criteria specified by the State. Alternate service delivery methods are available for participants who decide not to direct their services or do not meet the criteria. (emphasis added)

Specify the criteria: It has been determined by the team that a combination of Self-Directed Services and Traditional Services are in the best interest of the participant.

Approximately 9% of participants are currently self-directing some of their services while also receiving non-self-directed services through traditional providers (based on data received from DDA via a MPIA in February 2017).  Participants should be able to continue to receive services from both models and not have to choose all of one over all of another.  A mix of services should be allowed.

Participant Employer Authority:

Appendix E-1 g regarding Employer Authority:  In the current waiver, participants have employer authority over all services that can be self-directed.  This authority should be returned to all such services, but at a minimum to Employment Discovery & Customization, Employment Services, Housing Support Services, all three nursing services, and Supported Living, and any other services where it is possible to have the service performed by a directly hired employee.

Participant Budget Authority: 

Appendix E-2 b.ii.3 — Participant-Directed Budget:  3.  A dollar value will be assigned to the plan using payment rates from the traditional service delivery system less an appropriate administrative fee to cover the cost of the Fiscal Management Services (FMS).

SDAN Recommendation:

SDAN is concerned with how the term “rates from the traditional service delivery system” will be applied.  In meetings with Deputy Secretary Simons, he indicated that the administrative costs associated with self-direction, FMS and Support Brokers, would be ADDED to participants’ current budgets.  If “rates from the traditional service delivery system” means the TOTAL amount paid to traditional providers (which includes the cost of direct waiver service and all four standard cost components used to develop the provider rate), then SDAN accepts the current wording with these additions:  “……less an appropriate, person-centered-determined administrative fee to cover the costs of the Fiscal Management Services (FMS) and Support Broker services.”

However, if this term means that the rate will be the same as payment to traditional providers without the addition of employment-related expenses, program support, and general/administrative costs, as is the practice now, then SDAN expects that the word “less” will be changed to “plus” in this section.  In other words, all funds DDA expends on a participant in self-direction will not be less than the total funds that DDA would expend on that same participant if he/she had selected to receive all of the same services through traditional providers.

Budget Flexibility:

Appendix E-2 b.iv. Participant Exercise of Budget Flexibility:  Currently the first box is checked:

Modifications to the participant directed budget must be preceded by a change in the service plan.

SDAN Recommendation:

Check the second box:  “The participant has the authority to modify the services included in the participant directed budget without prior approval. “  Specification of how changes will be made:

With the exception of funds designated for Fiscal Management Services, individuals may move funds between already approved line items so long as the changes are in accordance with their plan of care and do not pose a risk to health and safety. The individual’s CCS must assure that line-item modifications do not affect the individual’s health and safety by signing the required Budget Modification form which is sent to the FMS.  Only the addition of a waiver service will require a plan and budget modification document that must be signed by all team members and approved by DDA regional staff.

SDAN Comments:

It is common for organizations to shift funds between approved line items as needed as long as the annual budget amount is not exceeded. Currently, and in the provisions of the renewal waiver, every time funds are shifted from one line item to another, a modification must be made to the plan and budget, and these modifications must be approved by the regional office. The participant should have the authority to modify services included in his/her approved budget without prior approval as this is the essence of self direction. As long as the team is in agreement, and the shift in funds between approved items does not negatively impact the health, safety or well being of the participant, it should be possible to move funds without the formal processes recommended.   This movement of funds should be allowed at any point within the plan year and especially at the end of the plan year to prevent shortages within categories when funds are available in others.

Financial Management Service

Appendix E-1 i.: Provision of Financial Management Services

SDAN believes that more than one FMS should be selected moving forward. Choice and accountability are very important. If there is only one FMS provider, participants have nowhere to go when services are inadequate. Allowing more than one FMS provider should naturally create incentives for strong FMS   performance.

Attachment #1 in section labeled Appendix A: 

1. There is no mention that DDA is imposing a vetting process, “capable of making informed decisions,” on individuals to be able to self-direct.  This is a significant change and should be included in the summary of changes.
2. There is no mention that Support Brokers are now an option and the role has been significantly reduced.  In Attachment #2, when discussing the current waiver in SECTION 1:  ASSESSMENT OF MARYLANDS HCBS PROGRAMS COMMUNITY PATHWAYS WAIVER BACKGROUND it specifically states, “Under self-direction, individuals are required to obtain the services of a Support Broker and Fiscal Management Services provider, …” This is a significant change and should be included in the summary of changes.

Appendix C:  Transportation:

Including transportation costs embedded in the rate for other specific services may work for Traditional Services, but Self-Directed Services rates are not set by the new rate study.  Extending this requirement to Self-Direction will require the current Transportation budgets to be split between any and all services in the participant’s plan that has Transportation embedded in the Traditional rate.  Self-Directed participants do not live their lives in segments of waiver services.  Their beginning and ending point of each trip to one or more destinations is their home.  Artificially dividing those trips’ transportation costs into multiple categories will significantly increase the recording-keeping burden on the participant and their staff without any benefit to the participant’s program.  In fact, the extra record keeping is likely to reduce the amount of staff time available for direct supports of the participant.

Appendix C:  Personal Supports:

Service Requirement C.2.  Any benefit and leave time offered by the participant must comply with any and all applicable federal, State, or local laws.

Add the word “employment” before the word “laws.”

Service Requirement G.3.:  Personal Support Services includes the costs associated with staff training such as First Aid and CPR.

This wording does not seem to be in other employee-provided services, such as Community Development Services, Supported Employment, etc.  It should be.

Personal Supports Retainer Fee:This seems to be missing from this section.  It is important for participants to have this category available to them in order to retain employees when the participant is not available for the employee to work, such as when in a hospital.  This kind of retainer fee should be available under any service category in which the participant can hire employees.

Specify applicable (if any) limits on the amount, frequency, or duration of this service:

1. Personal Support services are limited to 82 hours per week unless otherwise preauthorized by the DDA.

This restriction was taken out of the current waiver by Amendment 1 for participants who self-direct their services.  At the beginning of this statement add:  “For individuals not self-directing their services,…”  as is in the current waiver so that self-direction is exempt from this restriction.

Appendix C:  Individual and Family Directed Goods & Services:

Cap on Services — SDAN applauds DDA for adding $500 to each participant’s budget for staff recruitment and increasing the cap from $2000 to $5000.  However, it should be up to the participant and the team to allocate funding to these services, not limited by DDA.  If an individual needs personal, employment, and community supports and these are provided gratuitously by family or others in their lives and the health and safety of the participant is not adversely affected, then he/she should be able to allocate as much of their support budget as they prefer to this service area.   Recommend no cap on this service. 

Therapies — The services that could also be provided under the CMS Service Category:  Other Health & Therapeutic Services should be added in this category or a separate category created for these supports.  These included services would be, among others, habilitative PT and OT; therapeutic riding; music therapy; and other therapies listed in that taxonomy.  These specific supports are NOT provided by the State Medicaid Plan where the focus is on rehabilitative supports.  Individuals receiving these waiver services often need these ongoing, intensive habilitative supports because the need is caused by their disability, which is not going to go away.

Service Requirement D states, “Individual and Family Directed Goods and Services must be clearly noted and linked to an assessed participant need established in the Person-Centered Plan.”  However, in Section D of the Service Definitions, the listed services that require such recommendations are stated as such.  Several of the other services do not seem to require such an assessment, nor should they, because by definition they are beneficial to the participant; for example, fitness memberships; fitness items that can be purchased at most retail stores, toothbrushes or electric toothbrushes; and weight loss program services other than food.  It seems as if the items that do need professional recommendations have already been listed.  This section may not be required.

Service Requirement F regarding items NOT included in this category:

1. Fees associated with telecommunications – Internet and phone services are critical for community integration as well as health and safety in many cases. Many waiver participants may not be able to have these communication options and supports unless funded by the waiver.  It should be the participant’s option to include those fees in his/her plan.

1. Vacation expenses – Expenses associated with staff that needs to accompany an individual on a vacation (such as additional room and meals) should be included in this category or elsewhere in the waiver. Staff should not be expected to incur these expenses from their salaries and participants often do not have enough personal funds to pay for this needed support, yet participants should be able to take vacations as done by their typical peers who do not have to bring along support staff.

1. Tickets and related cost to attend recreational events – The admission cost of staff to attend these events in the support of the participant should be covered by the waiver. If not covered, it will discourage community integration.  Staff should not be expected to incur these expenses from their salaries and participants often do not have enough personal funds to pay for this needed support. In many cases, the participant will then be prohibited from attending community activities.

1. Personal trainers; spa treatments –Self-directing participants should be able to hire a “Professional Health Trainer/Coach” because of the 1:1 supports individuals with disabilities need to facilitate exercise.

1. Staff bonuses and housing subsidies – Staff bonuses (one method of staff retention) are an important employee benefit and should be included in the benefits section of each waiver service that has employer authority.

Appendix C:  Remote Monitoring:

This service is currently not checked as a service that can be self-directed.  It should be.  A self-directing participant should also have the ability to hire any service available to the general public for such monitoring and not be required to use only a provider approved by DDA.

Appendix C:  Respite:

Service Requirement C:  A neighbor or friend may provide services under the same requirements as defined in Appendix C-2-e.

This is essentially saying that a neighbor or a friend will be treated the same as a relative, which means they would not be able to be paid for more than 40 hours a week or work if a family member is the authorized representative.  Neighbors and friends should be treated like any other employee of the participant, regardless of what waiver service they are providing.

Service Requirement F:  Services can be provided at an hourly rate for 8 hours or less; or at the day rate for over 8 hours, daily. 

Unless they have contracted with a provider as a contractor/vendor, individuals who self-direct their services hire employees to provide respite services.  Employment law would not allow an employer to pay an hourly rate for 8 hours and then switch to a day rate for anything over that amount.  By law, employees need to be compensated at their rate of pay and receive overtime pay for any hours over 40 in one week.  Add to the beginning of this section:  “For individuals not self-directing their services, ….”   This can only be a provision for provider agencies.

Service Requirement H:  If respite is provided in a private home, the home must be licensed, unless it is the participant’s home or the home of a relative, neighbor, or friend. 

This requirement should only apply to provider agencies and not individuals who are providing services to self-directing participants.  Only the participant and the team should have to determine if the home where services are to be provided is appropriate and safe for the participant regardless of whether it is the home of a relative, neighbor, or friend.

Appendix C – Shared Living

The proposed language does not allow this service to be Self-Directed.  Along with the provision of not directing some services and having other Traditional services, this service would be unavailable to anyone who self-directs their program.  SDAN recommends that this service be something participants can self-direct. 

Service Definition A:  Shared Living emphasizes the long-term sharing of lives, forming caring household, and close personal relationships between a participant and the Host Home.  It is an arrangement in which a couple or a family in the community share their home and life’s experiences with a person with a disability.  The approach is based on a mutual relationship where both parties agree to share their lives.

SDAN Recommends:

1. This service category should include siblings or other family members other than parents.
2. The Host Home should not be REQUIRED to be located through an agency
3. Individuals should be able to self-direct the hiring of an agency as a vendor or a contractor who provides this kind of matching service to the general public or locate their Host Home on their own.
4. No ongoing supports should be needed by an agency other than the general oversight provided by the team.

Service Definition C:  Host Home supports assure that the participant is safe and free from harm and has the support that he or she needs to take risks and to work and participate in community activities.  The primary responsibility of a Host Home is to make a real home where the family or couple providing the home and the participant has a mutually satisfying and meaningful relationship.

SDAN contends that real families make real homes, too, and should not be excluded from this service under self-direction.  It is important for the health and safety of the participant that they be able to receive these supports in all viable homes.  Homes of family members are often the best home for participants.  Any and all options to support a family member in taking on the responsibilities of  caring for a relative with a disability should be encouraged and supported by DDA.  This kind of stipend might be all that is needed to encourage this support.

Appendix C – Transition Services:   

Service Definition A.  Transition Services provides funding for allowable expenses related to the participant moving from an institutional setting or a community residential provider to either:  (1) a private residence in the community, for which the participant or his or her legal representative will be responsible; or (2) another community residential provider site. 

Under the New Directions Waiver, this service could be used to move to your own home from the participant’s family home.  It was apparently changed when the waivers merged.  Recommend that option be restored to the waiver.

Other Areas of Concern:

Appendix C:  Relatives Performing Services:   When a relative or legal guardian, other than a spouse or the parent of a minor child, is qualified to perform a waiver service, such as Assistive Technology Services, Behavior Supports, Environment Assessment, Environmental Modification, Housing Support Services, Nursing Services, or Vehicle Modification, among others, they should be allowed to provide that service if they are lowest cost choice available to the participant and the participant wishes to receive their services.  This can be accomplished, by checking the box in section C-2 e that states, “Relatives/legal guardians may be paid for providing waiver services whenever the relative/legal guardian is qualified to provide services as specified in Appendix C-1/C-3.

Provider Requirements:   Except for passing a background check and successful completion of CPR/FA certification, only the participant and their team should determine employee qualifications.  No specific DDA provider agreement should be needed nor should any specific certifications DDA determines necessary be imposed on the choice of the participants.  If the participant and their team determine an employee to be able to perform the duties of the service, even an employee without a GED or HS Diploma, the employee should be able to be hired.  Participant/team choice and decision-making should be the key determinant to hiring decisions.

For the provision of professional services, such as Behavior Supports, providers/vendors should only need licenses or certifications required by the State of Maryland to provide those services to the general population. No additional DDA certifications or agreements should be necessary to provide that service to the SDS participant.  Nor should a vendor/contractor need to meet what are otherwise employee requirements, such as CPR/FA certifications, pass a criminal background check, or possess a valid driver’s license and automobile insurance, especially when most of these professionals would never drive the participant or have them in their vehicle.