CMS 372 Report - OMB Control Number: 0938-0272

372 - Annual Report on Home and Community-Based Services Waivers

State:

Waiver Base:

0292

Report Status:

SUBMITTED

Begin Date:

End Date:

Initial Submission Date:

Report Period Year:

Report Type:

Initial Report

Lag Report

TE Report

Unduplicated Participants:

Days of Waiver Enrollment:

Average Length of Stay:

Total Waiver Expenditures:

Total Reported Expenditures:

APC Waiver Services (Factor D):

APC for State Plan Services (D'):

APC Total (D + D'):

Factor G Value:

Factor G' Value:

APC Total if no waiver (G + G'):

D + D' <= G + G':

$35,563 <= $55,604

Level/s of Care:

ICF/IID

Hospital

Additional Information (use if needed):

Note: Average Per Capita (APC)

Annual Number of Section 1915c Waiver Recipients and Expenditures:

(Specify each service as in the approved waiver)

Service

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Companion Services - Daily (6 hrs +)	NF	$1,497	2

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Companion Services - 15 minute	NF	$18,870	3

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Respite Care - Daily (6 hrs +)	NF	$7,561	7

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Respite Care - 15 minute	NF	$16,259	5

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Respite Care - Room and Board Included - Daily (6 hrs +)	NF	$0	0

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Consumer Preparation Services	NF	$0	0

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Specialized Medical Equipment/Supplies/Assistive Technology - Purchase	NF	$825	1

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Supported Living	NF	$973,725	73

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Environmental Adaptations - Vehicle	NF	$0	0

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Environmental Adaptations - Home	NF	$0	0

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Speech-Language Services Extended State Plan	NF	$0	0

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Financial Management Services - Low Tier	NF	$0	0

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Financial Management Services - High Tier	NF	$8,853	23

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Occupational Therapy Extended State Plan	NF	$0	0

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Specialized Medical Equipment/Supplies/Assistive Technology- Monthly Fee	NF	$390	3

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Extended Living Supports	NF	$1,900	1

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Behavior Consultation I	NF	$920	2

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Behavior Consultation II	NF	$15,296	12

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Behavior Consultation Service III	NF	$13,704	5

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Living Start-Up Costs	NF	$0	0

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Transportation - Mileage	NF	$0	0

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Transportation - Daily (flat rate for all trips needed for the day)	NF	$56,973	37

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Transportation - Bus Pass Purchase	NF	$9,840	11

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Residential Habilitation - Facility Based (6 hrs +)	NF	$926,316	19

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Residential Habilitation - Facility Based - DCFS (6 hrs +)	NF	$0	0

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Residential Habilitation - Host Home (6 hrs +)	NF	$43,516	1

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Residential Habilitation - Host Home - DCFS (6 hrs +)	NF	$0	0

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Cognitive Retraining - Speech	NF	$0	0

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Cognitive Retraining - Occupational	NF	$0	0

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Professional Medication Monitoring	NF	$6,365	12

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Homemaker	NF	$2,160	1

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Personal Budget Assistance - 15 minute	NF	$2,055	5

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Personal Budget Assistance - Daily (6 hrs +)	NF	$3,805	17

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: ABI Waiver Support Coordination	NF	$219,077	99

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Day Supports (Site/Non-site) - Hourly	NF	$32,861	2

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Day Supports (Site/Non-site) - Daily (6 hr avg)	NF	$298,676	31

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Personal Emergency Response System - Service Fee Monthly	NF	$2,860	14

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Personal Emergency Response System - Installation	NF	$230	2

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Personal Emergency Response System - Purchase	NF	$0	0

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Chore Services	NF	$151	1

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Physical Therapy Extended State Plan	NF	$0	0

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Supported Employment - 15 minute	NF	$68,417	11

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Supported Employment - Daily	NF	$15,026	2

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Non-medical transportation, one way trip	NF	$0	0

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Service Name (no longer a required field):	Level of Care	Expenses in $	Participants	Service Category Name
-- Other If Other, specify: Transportation - Per Trip (UTA)	NF	$0	0

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
Category 3:	Subcategory 3:
Category 4:	Subcategory 4:

Assurances:

Assurances were submitted with the initial report. (If you are submitting a lag report this item must be checked.)
All provider standards and health and welfare safeguards have been met and corrective actions have been taken where appropriate
All providers of waiver services were properly trained, supervised, and certified and/or licensed, and corrective actions have been taken where appropriate.

Documentation:

Provide a brief description of the process for monitoring the safeguards and standards under the waiver:

Claims Review The SMA and OA completed a review of a representative sample of claims to verify maximum budgets authorized were not exceeded. Any associated recoupments have been completed. Critical Incidents/Events The SMA tracks and investigates all critical incidents/events that involve participants receiving services from the Acquired Brain Injury waiver. Safeguards are put in place (where applicable) in order to prevent recurrence of these incidents, and to better protect the health and safety of all waiver recipients. A total of 16 incidents were reviewed by the SMA and OA during the year.

Findings of Monitoring:

No deficiencies were detected during the monitoring process;
Deficiencies were detected.

Provide a summary of the significant areas where deficiencies were detected, (Note: Individual reports or assessment forms for waiver individuals and/or providers disclosing deficiencies and which document the summary are not necessary):

N/A
Deficiencies have been, or are being corrected.

Provide an explaination of how these deficiencies have been, or are being corrected as well as an explanation of what steps have been taken to ensure the deficiencies do not recur:

N/A

Certification:

I, do certify that the information shown on the Form CMS-372(S) is correct to the best of my knowledge and belief:

Signature:

Date:

Phone Number:

Contact Information (optional):

Contact Person:

Phone Number: