CMS 372 Report - OMB Control Number: 0938-0272

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

State:

Waiver Base:

0158

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':

$40,647 <= $81,820

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: Non-medical transportation, one way trip	ICF/IID	$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, LPN	ICF/IID	$174,766	268

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	ICF/IID	$71,002	177

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	ICF/IID	$356,577	1,436

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 monthly	ICF/IID	$8,602	46

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	ICF/IID	$30	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 Emergency Response System purchase	ICF/IID	$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 facility based-DCFS	ICF/IID	$1,976,909	40

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	ICF/IID	$70,830,759	1,422

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 Professional Parent/Host Home	ICF/IID	$6,754,313	186

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 Professional Parent DCFS	ICF/IID	$4,603,315	125

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	ICF/IID	$2,463,326	800

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	ICF/IID	$1,189,509	566

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-Group Daily	ICF/IID	$129,826	61

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-Out of home/R&B included	ICF/IID	$241,667	98

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 Group/R&B included	ICF/IID	$10,860	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 Intensive 15 minute	ICF/IID	$264,627	89

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 Intensive Daily	ICF/IID	$83,073	49

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 Intensive Out of home/R&B included Daily	ICF/IID	$34,674	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: Respite Care Weekly	ICF/IID	$1,162,716	387

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 monthly	ICF/IID	$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 purchase	ICF/IID	$26,046	26

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	ICF/IID	$2,740,243	424

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	ICF/IID	$1,742,370	266

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 15 Minute	ICF/IID	$13,956,986	1,501

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	ICF/IID	$118,708	72

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	ICF/IID	$3,914,293	2,342

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	ICF/IID	$110,000	140

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: Waiver Support Coordination	ICF/IID	$10,323,281	4,448

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 Services I	ICF/IID	$396,993	637

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 Services II	ICF/IID	$1,123,579	978

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 Services III	ICF/IID	$554,335	290

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 15 minute	ICF/IID	$99,680	58

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	ICF/IID	$189,897	50

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 Daily	ICF/IID	$136,786	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: Day Supports (site/non-site)Daily	ICF/IID	$24,532,893	2,260

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)	ICF/IID	$71,094	36

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)	ICF/IID	$23,194	4

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	ICF/IID	$1,165,548	262

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: Family Training and Preparation	ICF/IID	$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: Family and Individual Training and Preparation	ICF/IID	$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	ICF/IID	$592,098	1,348

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 Services	ICF/IID	$69,348	28

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	ICF/IID	$1,073	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: Massage Therapy	ICF/IID	$335,203	171

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 Care - 15 minute	ICF/IID	$929,576	235

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 Care - Daily	ICF/IID	$189,323	51

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, RN	ICF/IID	$430,722	765

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) - 15 Minute	ICF/IID	$1,611,966	128

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, Non-Medical-Daily, Utah Transit Authority provided	ICF/IID	$18,213	76

HCBS Taxonomy:

Category 1:	Subcategory 1:
Category 2:	Subcategory 2:
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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:

Baseline Review and Evidence Summary The SMA and OA completed its comprehensive review of years one and two of the Community Supports waiver program. The draft response from CMS has indicated that the state has demonstrated compliance with the 6 main assurance categories. The state is currently preparing its response to the additional questions/recommendations made by CMS and should have those available shortly. Critical Incidents/Events The SMA tracks and investigates all critical incidents/events that involve participants receiving services from the Utah Community waiver. Appropriate safeguards are put in place following these investigations to prevent recurrence. A total of 113 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):

During the completion of the reviews for year one and year two, the state observed decreased compliance in specific areas. Additional research was conducted to understand the reasons for the decline in compliance. Qualified Providers c1 – The state identified a concern in how this measure was being evaluated during the review. The measure is to evaluate the number and percentage of provider staff who have completed all required training, however it was being evaluated on an agency by agency basis. Should an agency have 10 individuals on staff, and one failed to have all items completed, the agency was marked as non-compliant. Going forward, staff will be recorded individually, making this measure more meaningful and likely leading to higher compliance. Health and Welfare 6 – Improving upon the quality of back-up plans has been an emphasis during provider reviews the last several years. Between years one and two, more stringent requirements were put in place. In year one, the back-up plan needed to have been in place, however in year two, not only did the plan have to be documented, a comprehensive review of the plan was completed to verify its appropriateness. Through corrective action plans and provider education, it is expected that compliance with this measure will improve.
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:

Efforts to remedy problem areas were described above along with the deficient measures.

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: