CMS 372 Report - OMB Control Number: 0938-0272

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

State:

Waiver Base:

0331

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':

$29,418 <= $62,874

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: Home Care Training to Client (Per 15 Min)	NF	$163	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: 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: Emergency Response System (Per Month)	NF	$11,786	66

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: Supports Brokerage Self Directed (Per 15 Min)	NF	$33,873	102

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: Attendant Care Services (Per 15 Min)	NF	$1,823,626	126

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: Attendant Care Services (Daily)	NF	$31,546	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: Financial Management Services Low (Per Month)	NF	$54,093	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: Financial Management Services High (Per Month)	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: Personal Emergency Response Systems, Installation & Testing	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:

Preparation for Evidence Package Reporting The SMA and OA have established the sample size and selected the individuals who will be reviewed for the Evidence Package due in September. A review of year one is near completion and year two is currently in process. 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 Physical Disabilities 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 5 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:

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