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

UT
0439
ACCEPTED
Waiver Year:
Report Type:
$18,942 <= $42,455
Level/s of Care:
Note: Average Per Capita (APC)
Annual Number of Section 1915c Waiver Recipients and Expenditures:
(Specify each service as in the approved waiver)
Service Name Level of Care Expenses Participants
Adult Day Care (social model) NF $0 0
Adult Residential Care
If Other, specify:
Adult Host Homes
NF $0 0
Adult Residential Care
If Other, specify:
Assisted Living Facilities
NF $7,092,965 517
Adult Residential Care
If Other, specify:
Certified Residential Care / Alzheimer Secured Unit
NF $1,122,086 77
Adult Residential Care
If Other, specify:
Licensed Community Residential Care
NF $70,107 12
Assistive Technology NF $0 0
Attendant Care NF $73,162 63
-- Other
If Other, specify:
Caregiver Training
NF $0 0
Case Management NF $1,650,584 604
Chore / Home Maintenance NF $2,613 2
-- Other
If Other, specify:
Consumer Preparation Services
NF $0 0
Environmental Adaptations / Home Modifications NF $0 0
Vehicle Modifications NF $0 0
Fiscal/Employer Agent/Management Services NF $3,168 14
Habilitation [use only when subcategory not provided] NF $7,289 13
Home Delivered Meals NF $481 3
Homemaker NF $18,549 19
-- Other
If Other, specify:
Institutional Transition Services
NF $7,221 20
Medication Management NF $16,045 32
-- Other
If Other, specify:
Personal Budget Assistance
NF $47,569 196
Personal Emergency Response System (PERS)
If Other, specify:
Installation, Testing & Removal, Base
NF $30 1
Personal Emergency Response System (PERS)
If Other, specify:
Purchase, Rental & Repair
NF $30 1
Personal Emergency Response System (PERS)
If Other, specify:
Response Center Service
NF $3,210 19
Respite Care
If Other, specify:
15 Minute
NF $0 0
Respite Care
If Other, specify:
Daily
NF $0 0
Respite Care
If Other, specify:
Out Of Home/Room And Board Included
NF $0 0
Behavior Management
If Other, specify:
Level I
NF $0 0
Behavior Management
If Other, specify:
Level II
NF $0 0
Behavior Management
If Other, specify:
Level III
NF $0 0
Specialized Medical Equipment and Supplies NF $22,176 78
-- Other
If Other, specify:
Supportive Maintenance
NF $0 0
Transportation
If Other, specify:
Mile
NF $0 0
Transportation
If Other, specify:
One Way Trip
NF $7,337 57
Transportation
If Other, specify:
Public Transit Pass
NF $0 0
Assurances:
Documentation:
Findings of Monitoring:
Certification:
I, do certify that the information shown on the Form CMS-372(S) is correct to the best of my knowledge and belief:
Contact Information (optional):