15. Handrails, grab-bars, door handle adaptations, trapeze and mobility track systems for home ceilings;
16. Automatic door opener/doorbells;
17. Environmental controls incorporated into the house structure: voice-, light-, motion- activated and electronic devices;
18. Fire safety adaptations;
19. Medically necessary air filtering devices;
20. Medically necessary heating/cooling adaptations;
21. Glass substitutes for windows and doors;
22. Modified switches, outlets or environmental controls for home device; and
23. Alarm and alert systems or signaling devices.
2. SERVICE REQUIREMENTS
A. Referral and Assessment: Environmental Modifications services shall be coordinated with the individual, guardian, case managers, service providers, licensed contractors, members of the Interdisciplinary Team (IDT) and Developmental Disabilities Support Division (DDSD). All environmental modification projects may include repairs or modification to existing equipment. All services shall be provided in accordance with applicable state and local building codes.
B. Procedure for Obtaining Environmental Modification services: The following procedure must be undertaken by the IDT, Case Manager, and Occupational Therapist (OT) or Physical Therapist (PT) in order to obtain environmental modifications for an individual on the Developmental Disabilities Waiver (DDW):
1. The individual or any member of the individual’s IDT may request an assessment for environmental modifications through the Case Manager if it is determined that environmental modifications may be needed to enhance the individual’s health, safety or functionality.
2. Upon notification by the Case Manager, an OT shall complete the assessment. The assessment should outline the targeted medical, safety, or functional concerns and include general recommendations that incorporate the individual’s specific clinical and functional strengths and needs. If an OT is not available, the services of a PT or other qualified individual approved by the DDSD Regional Office may be substituted.
3. The OT or PT or other qualified individual shall submit the assessment report to the Case Manager. The Case Manager and therapist or other qualified individual are
NM DOH – 2013 DDSD Service Standards
Effective Date: April 23, 2013
ENVIRONMENTAL MODIFICATION SERVICE Page | 122
required to consider less costly alternative methods, including Assistive Technology and other funding sources that may be available to address the individual’s needs.
4. The Case Manager shall submit the individual’s contact information, the assessment report and the Freedom of Choice form to DDSD Regional Office and to the Environmental Modification Service Provider (EMSP).
5. Upon DDSD Regional Office approval, the EMSP must coordinate with the Therapist and/or qualified individual who provided the assessment to assure planned modifications will meet the individual’s clinical and functional needs. Coordination must occur at an in-person site evaluation.
C. The EMSP procedures:
1. Develop an Environmental Modification Plan;
2. Ensure that proper design criteria is addressed in planning and design of the adaptation;
3. Provide or secure licensed contractor(s) or vendor(s) to provide construction and/or remodeling services;
4. Provide administrative and technical oversight of construction projects;
5. Provide consultation to family members, waiver providers and contractors concerning environmental modification projects to the individual’s residence; and
6. Inspect the final environmental modification project to ensure that the adaptation(s) meet the approved plan submitted for environmental adaptation.
D. Service Limitations:
1. Environmental modification improvements or repairs to the existing home, which do not provide direct medical, safety, or functional benefit to the individual or that should be included as part of routine home maintenance, shall not be approved. Such non-covered adaptations, modifications or improvements include:
a. Carpeting is excluded with the exception of repairs to carpet needed due to permitted modification. For example repair to carpet in the area of a door widening;
b. Roof Repair;
c. Furnace Replacement;
d. Remodeling Bare Rooms; and
NM DOH – 2013 DDSD Service Standards
Effective Date: April 23, 2013
ENVIRONMENTAL MODIFICATION SERVICE Page | 123
2. No duplicate environmental modifications shall be approved. For example, if the individual has a safe and usable ramp, a replacement ramp shall not be approved.
3. New Construction: Environmental modifications cannot be used to fund new residential construction, even if the new dwelling is designed to accommodate the needs of individuals with disabilities.
4. Equipment covered under the State of New Mexico’s Medicaid program shall not be purchased under the DDW.
3. AGENCY REQUIREMENTS
A. Environmental Modification Request: The Environmental Modification Service Provider must submit the request to the Case Manager. The Case Manager submits the request and budget to the DDSD Regional Office for approval. The request must include:
1. The DDSD Regional Office Prior Approval Form completed with all required information regarding the individual receiving the service;
2. Current Individual Service Plan (ISP) indicating modifications being requested; the modifications must be addressed in the Health and Safety Section of the ISP;
3. IDT Meeting Minutes with signature page indicating team agreement;
4. An itemized quote of the total estimated and authorized amount that outlines detailed costs associated with the environmental modification;
5. A copy of the therapist’s assessment report; and
6. The home owner’s signed and dated written approval of the scope and project cost obtained by the Case Manager (subsequent materially significant project changes must be approved in writing).
B. Cost of Materials: Materials utilized in projects shall be of Medium Grade and meet industry construction standards while taking into account the personal preferences of the homeowner. DDW funds may not be used for upgrades in materials that do not offer functional benefits to the individual.
C. Use of Other Private Funding to Augment Environmental Modifications: Other non- DDW funding may be utilized to augment funding available under the DDW subject to the following restrictions:
1. Cost estimates, items and project plans are required to specifically identify the materials to be purchased and the labor costs associated with the expenditure of DDW versus non-DDW funds.
NM DOH – 2013 DDSD Service Standards
Effective Date: April 23, 2013
ENVIRONMENTAL MODIFICATION SERVICE Page | 124
2. DDW funds may not be utilized to upgrade fixtures or other construction materials solely on the basis of aesthetic qualities or personal preferences when compared to lower cost fixtures or materials that provide the same or similar functional benefit to the individual.
3. DDW funds cannot be used to repair environmental modification upgrades or other augmentations to environmental modifications when the original environmental modification was not covered by DDW funds.
4. Any augmentation or upgrade to the DDW funded portion of the environmental modification may void any warranties in place.
D. When one or more individual(s) in DDW services who are roommates will benefit from an environmental modification, each impacted roommate shall equally divide the cost of the environmental modification from their respective ISP budget.
E. General Requirements: Providers of environmental modification services must perform the following:
1. Ensure proper design criteria is addressed in planning and design of the modification;
2. Coordinate environmental modification pre-plan reviews with the individual, guardian, or other family members, case managers, service providers as applicable and the therapist who conducted the assessment report;
3. Interpret codes and clarify building procedures to the individual, guardian, homeowner or other family members, Case Manager, service providers, and DDSD prior to construction activities;
4. When requested, provide consultation to individual, guardian, homeowner or other family members, Case Managers, service providers, subcontractors and DDSD concerning environmental modification projects to the individual’s residence prior to or during construction activities;
5. Review plans submitted by sub-contractors, if applicable, for environmental modifications to ensure that the plans are architecturally sound and in compliance with state and local building codes and standards;
6. Environmental modifications to provider owned or leased homes must be compliant with the DDW Standards and the Americans with Disabilities Act (ADA) applicable guidelines;
7. Review accuracy of construction costs submitted by sub-contractors, if applicable;
8. Ensure inspection of the final environmental modifications to ensure compliance with all local, state and federal codes and requirements;
NM DOH – 2013 DDSD Service Standards
Effective Date: April 23, 2013
ENVIRONMENTAL MODIFICATION SERVICE Page | 125
10. Provide a written warranty of the work completed to individual, guardian, homeowner or other family members, Case Manager and DDSD Regional Office.
F. Environmental Modification Service Providers Qualifications: Environmental Modification Service Providers (EMSP) must demonstrate qualifications in the following areas:
1. Documentation must verify that the provider is a Bonded and Licensed Building Contractor who is authorized to complete the project by the State of New Mexico.
2. When a building permit is required for the environmental modification to meet local and state codes, the work must be performed by a licensed and bonded contractor.
3. EMSP shall obtain all necessary permits as required by local and state laws.
4. Demonstrable knowledge and work history showing the ability:
a. To interpret the principles and practices of architecture, building codes and standards, building materials and construction methods, structural, mechanical, plumbing and electrical systems;
b. To interpret and prepare architectural working drawings and specifications, mediate contractual problems and ensure compliance with all laws, rules and standards of the State of New Mexico, including the federal, state and local building codes;
c. To understand and implement contracting practices and procedures, construction cost estimating and knowledge of comparable costs to accomplish the adaptations;
d. To incorporate architectural design, standards and technical data relating to building design and construction; and
e. To interpret, implement and ensure that Federal ADA standards and applicable guidelines are followed in all environmental adaptations when applicable to the individual’s needs.
4. REIMBURSEMENT
A. All Environmental Modification Service Providers must maintain all records necessary to fully disclose the service, quality, quantity and clinical necessity of modifications furnished to individuals who are currently receiving DDW services. The EMSP records must be sufficiently detailed to substantiate the date, time, and individual name, servicing EMSP, nature of services and length of time of the service billed.
1. The documentation of the billable time spent on the job shall be kept on a written or electronic record that is prepared prior to a request for reimbursement from the
NM DOH – 2013 DDSD Service Standards
Effective Date: April 23, 2013
ENVIRONMENTAL MODIFICATION SERVICE Page | 126
Human Services Department (HSD). For each unit billed, the record shall contain the following:
a. Date, start and end time of each service or other billable service interval;
b. A description of what occurred during the service or service interval; and
c. The signature or authenticated name of individual providing the service.
B. The respective DDSD Regional Office shall have final approval regarding authorization of payment.
C. Withholding or denial of payment may occur if the individual in service or their guardian file a dispute to the respective DDSD Regional Office regarding the quality of work and the DDSD Regional Office agrees with the complaint.
D. Billable Unit:
1. The billable unit for environmental modification is a set dollar amount specified in the current Medicaid Supplement Rate Tables for the Developmental Disabilities Home and Community Based Services Waiver and is available every five years.
E. Billable Activities:
1. Permitted uses detailed in the Scope of Service.
2. Administrative costs of the EMSP not to exceed fifteen percent (15%) of the total cost of the environmental modification project managed by the Provider Agency.
3. Partial payment of up to fifty percent (50%) of the estimated project costs may be requested prior to the completion of the project based on report submitted by the EMSP; this request is subject to approval by DDSD Regional Office.
4. Environmental modifications cannot be billed as a separate service for individuals receiving Family Living.
F. Medicaid Eligibility Verification: Providers are required to verify Medicaid eligibility for services to assure eligibility of individual on the date(s) of services.
F. Records Retention: All records pertaining to services provided to an individual must be maintained for at least six (6) years from the date of payment, until ongoing audits are settled, or until involvement of the state Attorney General is completed in regard to settlement of any claim, whichever is longer. All records pertaining to Jackson Class members must be retained permanently and be available upon request, and upon provider agreement termination, expiration or withdrawal of provider agreement, to DDSD.