Purchase of Service Guidelines
These standards are approved by the California Department of Developmental Services to assure that they conform with the Lanterman Act.
The Purchase of Service Guidelines below provides direction regarding the types of services that RCOC may purchase for persons served.
Purchase of Service Guidelines
- Cover Letter – May 13, 2019
- Introduction
- Principles of POS Guidelines
- Prenatal Diagnostic Evaluation
- Early Intervention Services
- Therapy Services
- Respite Care Services – revised February 2, 2019
- Child Care Services
- Adult Day Program
- Support Services: Day Program
- Transportation Services
- Residential Services
- Support Services: Residential
- Psychological, Counseling and Behavioral Services
- Medical and Dental Services
- Equipment and Supplies
- Social and Recreational Services
POS Guidelines
Introduction
It is the intent of the Lanterman Legislation (Welfare & Inst. Code 4500 et seq.) that regional centers assist persons with developmental disabilities and their families in securing those services and supports which maximize opportunities and choices in living, working, learning and recreating in the community.
It is the intent of the Legislature to ensure that the provision of services and supports by the regional center system is centered on the individual and the family of the individual with developmental disabilities and takes into account the needs and preferences of the individual and the family, where appropriate, as well as promoting community integration, independent, productive, normal lives and stable and healthy environments. It is the further intent of the Legislature to ensure that the provision of services to consumers and their families be effective in meeting the goals stated in the Individual Program Plan and Individualized Family Service Plan, reflect the preferences and choices of the consumer and family and reflect the cost-effective use of public resources (WIC 4646 (a)). RCOC will work together with the consumer, family and others to develop and implement either an Individual Program Plan, or an Individualized Family Service Plan.
The Regional Center of Orange County will continue to implement innovative, cost effective methods of service delivery, which include, but are not limited to, vouchers, consumer or parent service coordinators, increased administrative efficiencies and alternative sources of payment for services (WIC 4648 and 4659, and Title 17, Section 52109).
The RCOC Board of Directors have adopted a Purchase of Service Policy from which are derived these Purchase of Service Guidelines, which RCOC staff will follow when authorizing service requests from consumers, families or advocates. These Guidelines have been established in accordance with the Lanterman Act and Early Start program which authorizes the regional centers to develop and apply service standards while, at the same time, considering the consumer’s individual needs when authorizing the service request (WIC 4624, 4651, 4648). If at the time of the planning meeting a final agreement cannot be reached regarding which services will be purchased by the Regional Center, then a subsequent meeting may be convened within 15 days to discuss the request and a decision made to either authorize or deny the service or develop other alternatives. Exceptions to the Guidelines may be made on a case-by-case basis.
Principles of POS Guidelines
The Lanterman Legislation identified the following principles upon which services are to be based and which were considered in the development of the Board policy and Purchase of Service Guidelines:
1. The right of individuals with developmental disabilities to make choices in their own lives requires that regional centers shall respect the choices of consumers or where appropriate, their parents, legal guardian or conservator and provide relevant information in an understandable form to aid the consumer in making his or her choice (WIC 4502.1).
2. Regional Centers’ funds shall not be used to supplant the budget of any agency which has a legal responsibility to serve all members of the general public and is receiving public funds for providing such services (WIC 4648 (a) 8). In addition, funds will not be used if services can be funded by private third party source such as insurance and trusts in accordance with the Lanterman Act and Early Start, Title 17 Regulations. If a service request is modified, terminated, or denied, consumers and families shall be provided with information regarding their right to appeal the Regional Center’s decision per the Lanterman Act (WIC 4701-4715) and Early Start, Title 17 Regulations (Sec. 52172, 73-74).
3. Regional Center shall first consider services and supports provided in the natural community, home, work, and recreational settings. Services and supports shall be flexible and individually tailored to the consumer, and if appropriate, his or her family (WIC 4648(a) 2).
4. No service or support provided by any agency or individual shall be continued unless the consumer or, if appropriate, his or her parents, legal guardian, or conservator, agree that planned services and supports have been provided, and reasonable progress toward objectives has been made (WIC 4648(a) 7).
5. The determination of which services and supports are necessary for each consumer shall be made through the Individual Program Plan or the Individualized Family Service Plan process. The determination shall be made on the basis of the needs and preferences of the consumer or, if appropriate, the consumer’s family, and shall include consideration of a range of service options proposed by the Multidisciplinary/Planning Team participants, the effectiveness of each option in meeting the goals stated in the individual program or family plan, and the cost-effectiveness of each option (WIC 4512(b)).
6. Services purchased must be related to the developmental disability or be identified per Early Start Regulations. Exceptions may be made on a case-by-case basis.
7. Under ordinary circumstances, the starting date for authorized services will normally be thirty days from the date of authorization. This allows for appropriate coordination of services by the family, RCOC staff, and service providers.
8. The Multidisciplinary/Planning Team shall consider all of the following when selecting a provider of consumer services and supports (WIC 4648 (a)6):
(A) A provider’s ability to deliver quality services or supports which can accomplish all or part of the consumer’s Individual Program Plan or Individualized Family Service Plan.
(B) A provider’s success in achieving the objectives set forth in the Individual Program Plan or Individualized Family Service Plan.
(C) Where appropriate the existence of licensing, accreditation, or professional certification.
(D) The cost of providing services or supports of comparable quality by different providers, if available.
(E) The consumer’s or, if appropriate, the parents, legal guardian, conservator or designated representative’s choice of providers.
PRENATAL DIAGNOSTIC EVALUATION
Definition: Prenatal diagnostic evaluations are defined as those tests, e.g., amniocentesis, ultrasound, etc., which are provided to persons determined to be at risk of parenting an infant with a developmental disability. RCOC will provide financial assistance for prenatal diagnostic evaluations when residents are not eligible for assistance from generic or private resources.
Guidelines
A. Criteria
Any resident of Orange County who is at risk of parenting an infant with a developmental disability is eligible for RCOC funding for prenatal diagnostic evaluations providing there is no generic resource for such payment.
Parents with any of the following types of pregnancies/anticipated pregnancies are eligible. Exceptions may be made on a case-by-case basis.
1. Mother is age 35 or older at time of conception.
2. Any person under age 35 with a history of two or more spontaneous abortions (SAB’s).
3. Either parent has had a child with recurring genetic defect which is predictable by prenatal diagnosis and which may cause a developmental disability.
4. Either parent is the carrier of a chromosomal or autosomal trait which is predictable by prenatal diagnosis and which may cause developmental disability.
5. Mother is carrier of an X-linked disorder, which may cause a developmental disability.
6. An immediate family member has a child with a neural tube defect.
7. Fetus is diagnosed with congenital abnormality or chromosome abnormality and requires additional diagnostic confirming tests or genetic counseling.
In addition:
1. It is expected that, for the most part, referring genetic centers would do initial screening for Medi-Cal/CAL-OPTIMA eligibility before making referral to RCOC for funding.
2. When an applicant has health insurance, RCOC does not normally fund genetic services.
3. When an applicant has health insurance without maternity benefits, RCOC will fund for genetic services.
4. If the applicant has health insurance with a deductible greater than $2,000, RCOC may waive the deductible and fund for genetic services.
5. Some exceptions may be made in regard to funding the deductible for applicants who do have insurance coverage. Exceptions would include:
a. Family circumstances are such that prenatal diagnosis would not be done without funding. Exceptions would be made with approval from the RCOC physician or RN.
b. When insurance pays a flat fee, which is less than the Medi-Cal/CAL-OPTIMA rate, RCOC will fund the balance.
B. Levels of Service
Prenatal diagnostic evaluations provided will be based on the medical needs of the individual.
C. Period of Service/Renewal
1. Purchase of Service authorization shall be authorized and written for the time period in which it is anticipated the service will be provided.
2. When eligibility for Medi-Cal/CAL-OPTIMA has not been determined, RCOC staff will complete the intake form and complete Purchase of Service authorization with “Bill Medi-Cal/CAL-OPTIMA First”.
3. All Purchase of Service authorizations for applicants with insurance will be written “Bill Insurance First”. In exceptional situations where Regional Center funds need to be expended prior to the receipt of insurance reimbursement due to health or safety reasons, then the provider of service or family shall reimburse Regional Center upon receipt of insurance reimbursement.
4. All applicants who request funding for genetic services must complete the Insurance Information Form before RCOC will process for payment.
5. Renewals for service authorizations shall be written if the original service was not provided as scheduled, due to unforeseen circumstances.
EARLY INTERVENTION SERVICES
Definitions: Early Intervention Services (e.g., infant stimulation programs) are defined as a coordinated program of assessment and developmental services for infants from birth to age three, who are at risk for or have been identified as having a developmental disability. The overall goal is to assist each child in attaining appropriate developmental milestones, and to provide parents the opportunity or information to participate in the program which helps meet the special needs of their child. RCOC may fund those services which have been identified as necessary to meet the goals and objectives of the IPP and IFSP within the guidelines of the Lanterman Act and Early Start regulations. Mandated Early Start services are provided at no cost to the family
Guidelines
A. Criteria
The individual needs of the child will be reviewed by the Multidisciplinary Team as part of the IFSP process to determine whether early intervention services are needed. The following criteria are to be considered when RCOC staff authorize the request for services. If RCOC staff are not able to authorize the requested service given regulations, best practice or difference of opinion, then RCOC staff will discuss with the family any concerns or identify other options. Exceptions may be made on a case-to-case basis.
1. Referrals for services, e.g., evaluations, program, etc., will be made to generic resources by RCOC staff when appropriate, e.g., RCOC psychologist will make a referral to the school district.
2. Generic and private resources (e.g., insurance) are to be utilized when available. Use of private insurance for early intervention services must be voluntary where the parents would incur a financial cost, e.g., a decrease in lifetime coverage, an increase in premiums, or an out of pocket expense such as a deductible or co-pay.
3. Denials must be obtained from the appropriate generic and private resources in conjunction with requesting RCOC funding. Services will be approved pending the denial process to facilitate the provision of Early Start services as soon as possible.
4. Early intervention services are provided until the child is 36 months of age or younger if the child’s development is within normal limits.
5. The service coordinator will discuss the program options with the family and discuss the family’s preferences with RCOC staff if the request is an exception to the guidelines.
B. Levels of Service
RCOC staff may review the recommendations of the Multidisciplinary Team to ensure that Purchase of Service Guidelines are met. If RCOC staff are unable to authorize the level of service requested by the family, based on RCOC’s criteria, or best practice, then RCOC staff will discuss with the consumer and/or family other options. The following services options may be funded by RCOC; exceptions may be made on a case-by-case basis:
1. Evaluations
a. Assessment of an infant/toddler will be completed by RCOC staff or a contracted vendor. Assessments are normally needed in order to make an informed decision regarding a service request. RCOC will fund for an assessment if it is needed to determine eligibility or the child’s programming needs.
2. Early Intervention Programs
a. If an infant/toddler exhibits delays in all five areas of development, parents will be given at least three referrals to global infant development programs which meet the needs of the child and family.
b. RCOC may fund for a child under three who is waiting to be enrolled in an Early Intervention program through the school district. If an opening develops within the school district after RCOC has started funding a program, the family will be given a choice as to whether they wish to change programs.
c. Global programs, which are in-center, generally offer an all-inclusive program of occupational/physical therapy, speech therapy, as well as direct consultation with a speech therapist.
d. The type of services available for an in-home program vary from program to program and referrals will be made based on the child’s developmental and medical needs.
e. The frequency and amount of service funded by RCOC depends on the following:
• Developmental needs of the child.
• Age of the child.
• Medical fragility and/or medical clearance.
• Standards of the community/best practice.
f. School districts in Orange County which have early intervention programs offer one time a week programs for children under one year of age, and two to three times per week for children twelve months to three years. If a child is enrolled in a global infant program that provides intervention in all areas of development, RCOC does not normally fund additional PT/OT or speech, as this would be a duplication of service. If the program staff identifies a severe discrepancy in one area of development in relation to all other developmental areas, RCOC may consider funding additional intervention on a time-limited basis.
g. If parents wish to have their child in a regular preschool, RCOC may assist in supplementing additional consultation services based on the needs of the child.
h. If a child is showing no delays, but has a high-risk condition, RCOC may fund monthly consultations through a contracted vendor, or an RCOC service coordinator may provide monitoring on a 6-month basis.
C. Period of Service/Renewal
1. POS authorizations are normally written for a 6-month period. Regional centers are the payers of last resort after all public and private sources for payment have been reviewed to determine if a referral should be made to a generic or private resource.
2. Prior to the POS expiration date, the vendor is required to submit a progress report and recommendations. RCOC requires that the progress report include developmental levels, what progress the child has or has not made the previous 6 months, the amount of parental training and home program, and goals and outcomes for the next six months. Based on the program’s progress reports and the Multidisciplinary Team’s recommendations, RCOC Eligibility Health Resources Group (EHRG) will review continued eligibility for Early Start and/or if the program is still meeting the needs of the child. If there is a recommendation for a change of program, the child’s progress will be discussed with the family by the service coordinator, as well as other program options that might be more appropriate for the child.
3. If RCOC’s EHRG recommends to discontinue or modify services based on the information supplied by the program, the service coordinator will discuss the staff’s recommendations with the family and offer to meet with the family to discuss the issue or any additional information the family may want to present. It is the service coordinator’s responsibility to set up the meeting and involve the appropriate RCOC staff. If the issue of funding by RCOC for a particular service is not resolved, the family shall be provided with a thirty day notice regarding the action the Regional Center proposes to take, along with the parents’ request forms for a local meeting or State Level mediation/due process hearing, and parents’ rights information. If the dispute involves a current ongoing service funded by Regional Center, the service shall continue at the same level until the issue is resolved.
4. All services provided to children under the Early Start program will terminate at age three if the children are determined not eligible for Regional Center services under the Lanterman Act’s eligibility criteria. The school district is responsible for the child’s educational program at age three if they qualify for Special Education services. A transition plan and an IEP need to be developed which identifies the services which will be provided and the funding source for those children who turn three and will no longer be eligible for Regional Center services. Alternative resource information will be provided to the family if the child is not eligible for Regional Center or the school district program. The school district has a responsibility to assess the child and have an IEP meeting prior to the child’s third birthday if the child turns three during a period when school is not in session.
5. The school district is responsible for providing an educational program for a child who turns three in May or June (prior to summer school) and who continues to be eligible for Regional Center services. The school district is responsible for funding and having an IEP in place for the summer. It is the Regional Center service coordinator’s and the school district’s responsibility to discuss options at the transition meeting with the family. Parents are encouraged to request specific services at the transition and/or IEP meeting especially if the request is for a service not typically provided by the school, e.g., services during vacation break, a greater number of program hours than are typically provided by the school or a private school setting.
6. Children who turn three during the summer and are not eligible for summer school, but are eligible for RCOC after three, may be funded until the beginning of the school year.
THERAPY SERVICES
Definitions: Therapy services are defined as those services, e.g., physical therapy, occupational therapy, speech therapy, and feeding therapy, which are provided to the consumer to address significant deficits in the areas of fine motor skills, gross motor skills and language development. In addition, therapy services may also include evaluations, which are needed to assess the consumer’s current level of functioning and the need for services. RCOC staff will work with the consumer and family to identify needed services, provide the appropriate referrals, and assist the consumer and family in securing those services through the utilization of available generic and private resources.
Guidelines
A. Criteria
The individual needs of the consumer shall be determined by the Multidisciplinary or Planning Team. The following criteria are to be met or considered by the Multidisciplinary or Planning Team which is to include either the RCOC nurse consultant, RCOC physician or RCOC psychologist when authorizing service requests. RCOC staff will discuss with the consumer and/or family any concerns or identify other options and schedule a meeting if requested by the consumer and/or family, if RCOC staff are not able to authorize the requested service given regulations, best practice or difference of opinion. Exceptions may be made on a case-by-case basis.
1. All generic and private resources are to be explored and utilized. This includes
CCS, Medi-Cal/CAL-OPTIMA, public school, insurance and other available resources. For services provided under the Early Start program, use of the family’s insurance is voluntary if the family would incur a cost by using their insurance, i.e., co-pay, deductible, life time cap.
2. Denials from generic or private resources shall be documented in the consumer’s
file. With the exception of CCS referrals, funding may be approved on a time-limited basis if the denial process is expected to take an inordinate time, or there is a health and safety issue.
3. For children over the age of 36 months, the provision of therapy services should be addressed by the local school district.
4. For adults no longer eligible for a school program, therapy services should be funded by Medi-Cal/CAl-OPTIMA.
5. The consumer shall be assessed by a qualified professional, and agreement by the Multidisciplinary/Planning Team and RCOC staff that services are needed.
6. The need for therapy is related to the developmental disability.
7. The condition is the result of recent deterioration or injury.
8. An individualized or family service plan has been developed with appropriate goals, objectives and timelines in which the service is to be provided.
B. Levels of Service
RCOC staff may review the recommendations of the Multidisciplinary/Planning Team to ensure that Purchase of Service Guidelines are met. The following service options may be funded by RCOC. If RCOC staff are unable to authorize the level of service requested by the consumer and/or family, based on RCOC’s criteria, or best practice, then RCOC staff will discuss with the consumer and/or family other options. Exceptions may be made on a case-by-case basis.
1. Physical or Occupational Therapy
a. Evaluation for Children and Adults
• PT/OT evaluations for children may be provided if a fine or gross motor delay has been identified. For adults, evaluations may be provided if there is a marked deterioration in the consumer’s motor skills, there is a need for adaptive equipment or therapy may be warranted as part of rehabilitation after surgery or hospitalization. The primary medical doctor needs to request the evaluation. Two hours may be authorized for evaluations done at a PT/OT office and three hours if the evaluation is to be done in the home if generic and private resources are not available.
• The evaluation is to determine the need for the service and the report should include baseline developmental levels in both gross and fine motor skills and other specific information as requested.
• Recommendation should include specific objectives and goals.
b. Ongoing Therapy for Early Start Children
• Once the evaluation is completed, the Multidisciplinary/Planning Team, which includes input from RCOC specialists, will review the report and, if agreed upon, services may be provided.
• Frequency of individual therapy may be up to two times per week and will depend on the child’s diagnosis, level of involvement or other services in progress.
• If reports indicate that the child’s delays are found to be more global, RCOC staff may recommend that a comprehensive program be considered and initiated. The service coordinator would discuss this recommendation with the parents, reach a consensus and obtain consent of the parents before initiating any change.
• If children are enrolled in a comprehensive program, they would normally not be considered candidates for individual PT/OT funding through RCOC. An exception may occur when a specific medical or behavioral problem impacts the child’s fine or gross motor skills resulting in a significant delay, compared to overall functioning. In such a case, therapy may be considered in addition to the comprehensive program for a limited time, usually not more than four months.
• When a report indicates that a child’s goals have been met or they can ambulate safely and can stoop/recover objects, physical therapy and/or occupational therapy is phased out. The service coordinator will inform the parents of the report’s findings and the recommended phase out period, which would normally be 30 days. If the family is not in agreement with the proposed change, they will be provided with local meeting and due process information in writing.
c. Ongoing Therapy for Children over 3 Years of Age and Adults
• Therapy is usually not funded by RCOC for consumers over the age of three, as there are usually other generic (CAL-OPTIMA, CCS, education) or private resources (insurance) which can be used.
If there are no other funding sources, the evaluation will be reviewed by RCOC staff for recommendations and need for further service.
d. In-Home Therapy for CCS Eligible Children
Children with the medical indications listed below and who are eligible for CCS Medical Therapy Unit may receive in-home PT/OT on a time-limited basis through the RCOC.
Medically Fragile
• Have had hospitalizations for illness an average of every two months until 18 months.
• Requires suctioning of respiratory secretions at least once every two hours.
• Has had a tracheotomy for less than six months. (A child with a stable tracheotomy may not be eligible for in-home therapy services.)
• Has had gastrostomy feedings for less than three months and other health problems.
• Requires IV fluids/medications and is under one year of age.
• Is ventilator dependent.
Immunologically Compromised
• Children who have had frequent hospitalizations during the first year of life.
• Children with diagnosis of a specific immune deficiency condition.
• Children who are under six months of age with other medical problems.
Medical Equipment
• Includes children who aren’t able to use portable oxygen, portable suction machines, or who are unable to travel to appointments (i.e., physician’s office, etc.)
Over One Year of Age
• Children over one year of age will not receive in-home therapy services when the child is eligible for California Children’s Services therapy services.
For All Children Unable to Use Center-Based CCS Therapy
• Before RCOC considers funding for CCS eligible children, a letter from CCS is needed documenting that the child meets their criteria for in-home therapy. RCOC funds therapy based on recommendations from CCS therapist and it is time-limited, usually 3-6 months. CCS will need to reassess the child in order for RCOC to continue funding the service after the initial 3-6 months period. CAL-OPTIMA/EPSTD may also be accessed by CCS.
2. Speech Therapy
a. Evaluation, Early Start
• When a child’s major delay is in speech, based on developmental screening, RCOC may fund for an additional evaluation to determine programming needs.
• The report should include the child’s level of functioning in cognitive, expressive and receptive language. It should include goals and objectives for the next 6 months, method of parent education and how goals are going to be met.
b. Evaluations for Consumers over the Age of Three
• Evaluations for children who are eligible for a school program can be requested through the school as part of the IEP.
• Evaluations for adults can be requested from the primary physician and funded by generic resources.
c. Ongoing Therapy
• For children, presuming the delay is at least 30% below age level, speech consultation or ongoing therapy may be authorized. Individual sessions, of one or two times per week, or group, 2-3 times per week, will be considered. The Multidisciplinary Team, which shall include RCOC specialists, will review the report, consider the recommendations and authorize the level of service agreed upon.
• Children enrolled in a RCOC vendored comprehensive infant program or in a public school program are expected to receive some speech therapy or consultation through those programs. Additional speech therapy may be authorized on a time-limited basis if the child shows a significant discrepancy in speech as compared to other areas of development.
• When available reports indicate a child has attained 70% of language level for chronological age, therapy will usually be phased out over a transition period. Parents will be advised of the report’s findings and the recommended transition period by the service coordinator.
d. Ongoing Therapy, Consumer over the Age of Three
• Individual or group therapy may be provided to school age children as one of the IEP objectives.
• Therapy for adults may be funded by generic or private resources (CAL-OPTIMA, insurance).
3. Feeding Therapy
a. Evaluation
• A feeding evaluation may be provided if the child or adult has any of the following conditions:
GTT.
Oral/motor dis-coordination.
A medical condition that has inhibited a child or adult from exposure to oral feedings.
• Evaluations are authorized for two hours. The evaluations should include: assessment of feeding methods; assessment of feeding behavior; behavior problems associated with feeding; objectives and goals.
b. Ongoing Therapy
• Services for adults should be requested through Medi-Cal/CAL-OPTIMA.
• Frequency of therapy sessions for children may be up to two times per week, depending on: (1) age; (2) level of involvement; (3) diagnosis; (4) other services being received. A home program must be given to the parent or caregiver for follow through.
• If there is no current report or only minimal progress, upon completion of the initial program plan, RCOC staff and the Planning Team may confer with the therapist or authorize another therapist for a second opinion.
• If a report indicates the child’s primary problem is behaviorally oriented, RCOC staff may recommend behavior intervention to the parent. The report from the feeding specialist should indicate consistency in attendance and parents’ follow through in the home.
• Once a child has demonstrated the ability to chew and swallow textured foods, an RCOC specialist will reassess the need for ongoing therapy.
c. Supplementation
• Feeding therapy for children may be authorized in addition to other services (e.g., comprehensive program), if a specific medical problem (e.g., GTT) causes a significant delay compared to overall functioning. This would be on a time-limited basis, usually three months.
C. Period of Service/Renewal
1. Purchase of Service authorizations are usually authorized and written for a period up to six months. In exceptional situations where Regional Center funds need to be expended prior to the receipt of insurance/CAL-OPTIMA reimbursement due to health or safety reasons, then the provider of service or family shall reimburse Regional Center upon receipt of insurance reimbursement when applicable.
2. Prior to the service authorization renewal, the Multidisciplinary/Planning Team which may include RCOC specialists, will review the program progress report. The report should include developmental levels in the respective areas, which indicate progress from the initial evaluation, recommendations for a home program, goals and objectives. Parent satisfaction with the services provided will also be considered.
RESPITE CARE SERVICES (revised February 2, 2019)
Go to the separate respite care services guidelines documents accessible above
CHILD CARE SERVICES
Definition: Child Care is defined as care and supervision for a child under the age of eighteen who is living at home and is unable to care for her/himself when both parents or the single parent is employed full time outside the home; and/or a parent whom is engaged in a full or part-time educational or vocational training program that will lead to full or part-time employment. RCOC staff will provide information to families about available generic and private resources, such as In-Home Support Services (IHSS), and assist the consumer and family in securing and coordinating those services through the use of available generic resources, innovative programs, circles of support and natural supports.
Guidelines
A. Policy Statement
It is RCOC’s policy position that families should provide the same level of support for their children with developmental disabilities as they would for their children without developmental disabilities. Parents should pay the normal cost of childcare until the child reaches the age of 13. However, there may be situations and circumstances where access to child care services is impacted by the level, nature or degree of a child’s disability. Subsequently, RCOC has elected to make funds available to augment the cost of a child’s day care. The RCOC Child Care – Family Member Check List (RCOC #601) serves as the application that identifies the needs of the consumer and family. This form will be reviewed by the Multidisciplinary/ Planning Team to determine whether financial support for child care services will be authorized.
Under the Americans with Disabilities Act, a family should not be charged a higher child care rate which exceeds the prevailing/market rate for the area, solely due to the child having a disability. Reasonable accommodation needs to be made by the person or agency providing the day care. For children whose child care needs cannot be met by available family members, community, generic, or alternative resources, RCOC may only fund a portion of the cost of the child care services which exceeds the prevailing rate of providing day care services to a child without disabilities.
B. Criteria
RCOC may fund child care services if the service requested has been reviewed using the following criteria and is recommended by the Multidisciplinary/Planning Team. Exceptions may be made on a case-by-case basis.
1. Both parents work full-time or a single parent is employed full-time.
2. A parent is attending a full/part time vocational program that will lead to full or part time employment.
3. The primary caregiver is temporarily unable to provide care due to a crisis situation, (e.g., hospitalization of caregiver).
4. Generic or alternative resources are not available, e.g., CHS, IHSS, insurance.
5. Family support is not available (e.g. neighbors, friends or relatives).
6. Personal resources are not available (e.g., family income, trusts and child support).
7. Severe challenging behaviors and/or medical needs prevent the use of available generic or community resources.
8. Child needs ADL assistance that prevents the use of available generic or Community resources (e.g. not toilet trained at an appropriate age and is in need of assistance).
In addition:
1. RCOC may fund the most appropriate cost-effective program available (e.g. on-site school based after-school programs), which is consistent with the objectives of the PCP/IPP/IFSP.
2. Child care shall not be provided in lieu of a public school or other non-extended day programs.
3. Unused hours may not be carried over from week-to-week or month to month during the course of the authorized contract period.
4. Consideration should be given to unique situations involving divorce where the child’s parents have joint custody; and yet, both parents have employment schedules which conflict with their personal ability to meet their child’s need for child care.
5. Child care is not to be utilized in lieu of a parent having voluntarily removed their child from an available school program or during the provision of an in-home program.
6. For children 13-18 years of age, RCOC may fund the full cost of day child care or an after-school program.
C. Types of Services
RCOC has identified an array of services to support the inclusion of children in before-school, after-school and regular child care programs
1. Parent Vendored –Day Care – The provision of supplemental financial support to parents of eligible children. Parents find and identify a child care provider not vendored with RCOC (e.g. private childcare provider, nanny). Families are reimbursed by RCOC through monthly time card vouchers submitted to RCOC.
2. Child Day Care – Centers & Family Homes – The provision of child care in a licensed day care center, licensed day care home or after-school program site that is vendored by RCOC.
3. Assessment & Report – An assessment conducted by an RCOC vendor to identify a child’s child care needs and a child care program’s ability to serve a specific child in a licensed child care program or a non-licensed after-school program. This assessment includes a written report with recommendations and a proposed plan with specific goals/objectives to meet the child’s day care needs.
4. Consultation & Training – The provision of child specific consultation and/or training by an RCOC vendored provider to a licensed child care program or non-licensed after-school program and/or its staff.
5. Personal Assistance – The provision of an aide to support a child placed in a licensed day care site or an after-school program at a 1:1, 1:2, 1:3, or 1:4 staffing ratio. Such Personal Assistance may be provided only when a child has been assessed in a proactive manner to be in need of such assistance, or for a child who has been rejected or ejected from a child care program and had a subsequent assessment conducted to determine what resources might be applied to enable the child to return to an inclusive child care program. Personal Assistance is provided in the form of a trained aide who is to be approved for a specified period of time and is to be reviewed for continued authorization (e.g. 3 months, 6 months or 12 months). Authorization for Personal Assistance should be based upon the RCOC- funded assessment & report, and should include a plan for fading this form of support services. Personal Assistance hours will not be funded for time or activities outside of, or in addition to the licensed child care or after-school program setting.
D. Examples of Exceptions
As part of the IPP process, the Multidisciplinary/IPP Team may make exceptions to RCOC child care guidelines. Exceptions may include, but are not limited to:
1. A family whose financial resources indicate that they are living at poverty level (e.g. Public Assistance programs – TANF and Food Stamps recipients).
2. Situations that will result in maintaining a child in the family home and prevent either the CPS removal or voluntary placement of a child in out-of-home care.
3. Situations involving the need for extended summer and other periods when school is not in session may be reviewed on an individual basis. This exception does not include typical family holidays (e.g., Christmas Day).
4. Situations where parent’s employment is inconsistent and/or does not lend itself to a routine setting which would meet a child’s care needs (e.g. swing shifts requiring off hours, an unemployed parent seeking employment/job interviews).
E. Authorization of Hours
The RCOC Day Care – Family Member Checklist (RCOC #601) serves as the application that identifies the needs of the consumer and family. This form will be reviewed by the Multidisciplinary/ Planning Team to determine whether financial support for child care services will be authorized.
Recognizing that parents may have various conditions of employment (e.g., flexible work schedules), the number of hours authorized by RCOC staff will be based on the recommendations of the Multidisciplinary/Planning Team, and the information provided by the family on the RCOC Day Care – Family Member Check List.
If RCOC staff is unable to authorize the number of hours requested by the consumer’s family, based on RCOC’s criteria, or best practice, then RCOC staff will discuss with the family any other options with the family. Exceptions may be made on a case-by-case basis.
F. Period of Service/Renewal
1. Purchase of Service authorizations are normally authorized and written for a 3, 6 or 12 month period.
2. When authorization by RCOC staff is done on an exception basis, the period of service authorization may be less than 6 12 months to allow for periodic review to ensure that the circumstances which initially warranted the hours authorized continue and the hours are meeting the consumer’s and family’s needs.
3. Families are required to resubmit the RCOC Day Care – Family Member Check List at least annually or whenever there are changes in employment, school attendance, or child care provider.
4. Child care funding may be subject to a share of cost as determined by the legislative mandates of the Family Cost Participation Plan (FCPP).
5. Parent vendored child care is subject to review.
ADULT DAY PROGRAM
Definition: Day programs are defined as those programs, which assist the consumer who is no longer eligible for services from a local public education agency or other generic resources. Choices shall be provided to the consumer, which will enable her/him to approximate the pattern of everyday living available to the non-disabled population of the same age. Program options may include supported employment, adult education, day activity center, work activity center, or other programs funded by generic resources.
Guidelines
A. Criteria
The individual program needs of the consumer will be reviewed by the Planning Team to determine whether services are needed. If RCOC staff are not able to authorize the requested service given regulations, best practice or difference of opinion, then RCOC staff will discuss with the consumer and/or family any concerns or identify other options. The following criteria are to be considered by RCOC staff when authorizing the requested service. Exceptions may be made on a case-by-case basis:
1. RCOC shall not purchase or duplicate services, which are legally mandated to be provided by the Departments of Rehabilitation, Habilitation, or Education.
2. Whether, and to what degree, the consumer requires regularly structured programming.
3. Whether alternative services are available for promoting independent and productive living.
4. Where there are two or more appropriate programs which are able to meet the needs of the consumer; consumer choice, commuting time and cost effectiveness will be considered.
5. Whether the consumer is making reasonable progress toward an integrated and productive life in the community.
6. Whether the consumer’s participation in the program is providing him/her with the opportunity to maintain his/her present skill level.
7. All services should be provided in the least restrictive environment.
B. Levels of Service
When determining the amount and type of day program services which should be provided, the Planning Team shall consider the consumer’s choice and needs, as well as the use of available generic resources. If RCOC staff are unable to authorize the level of service requested by the consumer and/or family, based on RCOC’s criteria, or best practice, then RCOC staff will discuss with the consumer and/or family other options. RCOC may purchase up to five days or thirty hours per week of day program services. Supported employment is an option, which many of the following day programs now offer as part of their services. Categories of service options offered include:
1. Department of Adult Education, Community College, non-RCOC funded.
2. Department of Rehabilitation programs, non-RCOC funded.
3. Department of Habilitation programs, non-RCOC funded.
4. Activity centers, ratio – 1:8, 1:6.
5. Adult day care.
6. Adult day care – senior.
7. Adult day care, brain injured.
8. Adult development center, ratio – 1:4, 1:3.
9. Behavior management program, ratio – 1:3, 1:2, and 1:1.
10. Psychiatric day treatment program.
11. CAL-OPTIMA/Medicare-funded programs.
C. Period of Service/Renewals
1. Purchase of Service authorizations are normally authorized and written for at least 12 months or until revoked.
2. Purchase of Service authorizations for behavior management programs should be reviewed every 12 months to determine whether the consumer’s needs still warrant a lower staffing ratio.
3. Prior to the renewal of the Purchase of Service authorization, the Planning Team shall review the progress of the consumer and consumer satisfaction with the services provided.
SUPPORT SERVICES: DAY PROGRAM
Definition: Support services are defined as additional support staff who are temporarily provided to assist in maintaining the consumer in his/her existing day program. They may also provide a transitional period into a new day program. Services may focus on providing additional program staff training and supervision for the purpose of implementing a behavior intervention program by a qualified professional, and/or assisting with daily care needs, and/or medical needs.
Guidelines
A. Criteria
The needs of the consumer shall be reviewed by the Multidisciplinary/Planning Team and recommendations made. RCOC staff may authorize the funding of Support Services for a time limited period. If RCOC staff are not able to authorize the requested service based on RCOC Purchase of the Service Guidelines, best practice, or difference of professional opinion, then RCOC staff will discuss with the consumer and/or family and/or consumer’s support team any concerns or identify other options. Support Services are intended to be temporary and may be authorized for a time-limited period. Support Services may be considered under the following circumstances. Exceptions may be made on a case-by-case basis.
1. The case has been reviewed by the Multidisciplinary/Planning Team, the RCOC nurse and/or psychologist and other appropriate consultants. All appropriate resources, both generic and private, have been explored.
2. The consumer is exhibiting behavior, which may prevent continued enrollment in the current day program unless intervention is provided to stabilize the consumer, which will enable him/her to remain in the day program. The condition is temporary and improvement is expected to occur within 90 days.
3. The consumer has experienced a medical condition that necessitates increased care and supervision. The condition is temporary and improvement is expected to occur within 90 days.
4. The consumer displays a significant reduction in functioning in regards to activities of daily living requiring increased care. The condition is temporary and improvement is expected to occur within 90 days.
5. If any of the above conditions are not expected to improve within 90 days, Support Services may be authorized for a longer period of time, but no more than one year. All authorizations beyond 90 days may be approved for extensions, but only after a needs assessment and transition plan are completed, including the course of action that was taken, staff training completed, and the service outcomes. All authorizations beyond 90 days shall be reviewed by RCOC staff.
6. Support staff for children and adults, while attending a public school program, is the responsibility of the school district.
B. Levels of Service
The amount of Support Service hours and days required will be based upon the needs of the consumer as identified by the Multidisciplinary/Planning Team, which may include the participation or input of the RCOC psychologist or nurse consultant. If RCOC staff are unable to authorize the level of service requested by the consumer and/or family and/or consumer’s support team, based on RCOC criteria, best practice, or RCOC Purchase of Service Guidelines, the RCOC staff will discuss with the consumer and/or family any concerns or other options. Exceptions may be made on a case-by-case basis. In addition:
1. Funding for Support Services shall be authorized with vendors qualified to provide Support Services.
2. If the program support cannot be provided through a contracted vendor, then RCOC’s staff will meet with the program requesting the support to determine whether the program can provide the additional staff support needed if funding is provided at the allowable schedule of maximum allowances rate (SMA), or the vendor’s usual and customary rate if the SMA code does not apply to the service provided.
3. Support Services will be authorized for up to 90 days as outlined in Section A,
items 1, 2, 3 and 4.
4. Except in emergency situations, a transition plan must be developed with specific timelines indicating the course of action to be taken or anticipated, staff training needs, and anticipated service outcomes. Submission of this documentation must be submitted for review to RCOC staff within five days prior to the beginning of the authorization period.
5. For consumers who need Support Service for greater than 90 days, the service coordinator must request an extension. The extension request must include an assessment by the RCOC psychologist or nurse consultant as to need, intensity ratio and estimated duration. The request must also include the report from the program that includes the points listed in item 4 (Level of Service). The extension must be approved by RCOC staff.
C. Period of Service/Renewal
1. Purchase of Service authorizations shall be authorized and written for the recommended period of service based on the guidelines identified in Section A, Criteria.
2. Renewals shall be authorized based on the guidelines in Section B, Level of Service.
3. On an emergency basis only, Area Managers may authorize up to five days of Support Services without approval from additional RCOC staff. After this time period the authorization must be reviewed and approved by the RCOC psychologist, nurse consultant, or other designated RCOC staff.
TRANSPORTATION SERVICES
Definition: Transportation is defined as those services, which enable a consumer to be transported as independently as possible from his/her place of residence to and from the day program site. The Regional Center of Orange will work jointly with the consumer, family and service agencies to identify needed transportation services and secure available generic and private resources.
Guidelines
A. Criteria
The individual needs of the consumer will be reviewed by the Multidisciplinary/Planning Team to determine whether transportation services are needed. The following criteria are to be considered by RCOC staff when authorizing the service request. If the RCOC staff are not able to authorize the requested service given regulations, best practice or difference of opinion, then RCOC staff will discuss with the consumer and/or family any concerns or identify other options. Exceptions may be made on a case-by-case basis.
1. Whenever feasible, adults over public school age, will utilize public transportation.
2. All adults requesting transportation will be assessed for mobility training.
3. RCOC may purchase transportation services to the closest appropriate primary program, which is able to meet the consumer’s needs when the program does not have transportation component and public transportation is unavailable.
4. Transportation services may be purchased for only one primary program.
5. RCOC shall seek and use the most cost-effective transportation service available when purchasing transportation.
6. RCOC, the consumer, and family/advocate shall annually or at the time of review assess the potential of the consumer to travel independently utilizing a public transportation system. The assessment may be provided by an agency vendored in independent living skills training.
7. If a consumer is mobility trained and a bus pass is needed, a consumer may be requested to fund their own pass if resources permit.
8. RCOC will not fund for bus pass coupons if they are not used for transportation to a day program or work on a regular basis.
9. Consumer, parents and care providers are expected to provide routine transportation to medical, dental and other appointments or functions. Incidental transportation may be funded by RCOC on an exception basis in the following circumstances.
a. A consumer’s SSI-SSA funds are used to fund basic daily living expenses and the consumer’s savings/P&I do not exceed $300.
b. The consumer’s parent(s), or surrogate have a disability, which prevents them from transporting the consumer.
c. The consumer’s medical and/or physical condition requires use of specialized transportation to accommodate transporting the consumer.
d. The needed transportation puts an unusual demand upon the parent(s) surrogate and/or the person most involved in the provision of direct care to the consumer.
10. For children under the age of three, to maximize safety and quality assurance, parents and care providers are expected to transport infants to day programs. Transportation for infants may be funded through a parent voucher or bus pass when there is a documented need.
11. Vendored private transportation will be funded for a consumer who
• Has been assessed and found inappropriate for mobility training.
• Is awaiting mobility training.
• There is no appropriate or viable public transportation.
B. Levels of Service
The level of service shall be based on the needs of the consumer as determined by the Multidisciplinary/Planning Team. Frequency of service will be dependent on the needs of the consumer but would normally not exceed five days per week; exceptions may be made on a case-by-case basis. RCOC funded trips shall not exceed 90 minutes one-way. Exceptions to this time limit may occur only when the consumer and as appropriate, parents/conservators agree. If RCOC staff are unable to authorize the level of service requested by the consumer and/or family, based on RCOC’s criteria, or best practice, then RCOC staff will discuss with the consumer and/or family other options. Levels of service which may be authorized by RCOC staff are:
1. Mobility training through a vendored agency, if the consumer has the potential to travel independently.
2. Vouchered transportation.
3. OCTA ACCESS subscription or bus passes.
4. Commercially and RCOC vendored transit systems.
5. Travel Hosts program based on availability.
6. Incidental transportation may be provided on an exception basis.
C. Period of Service/Renewal
1. The Purchase of Service authorization for mobility training shall normally be authorized and written for the recommended period of service as identified in the vendor’s assessment of the consumer’s needs.
2. Bus passes, OCTA ACCESS subscription and Purchase of Service authorizations are normally authorized and written until revoked or conditions change which no longer warrant RCOC funding, e.g., consumer has adequate financial resources, or the consumer requires another method of transportation.
3. Commercially vendored transit systems authorizations are normally written until revoked or the consumer’s needs warrant a change.
4. Incidental transportation would be authorized on an exception basis with specific timelines for service delivery.
5. Authorized infant transportation will be reviewed for renewal every six months.
RESIDENTIAL SERVICES
Definition: Residential services are defined as those services, which are provided to the consumer, which enable him/her to live in a setting other than his/her family’s home. Residential options may include room and board, community care facility, health care facility, independent living or supported living. The provision of services may include personal care, protection, supervision, periodic assistance, independent living skills training and independent living support services.
Guidelines
A. Criteria
The individual needs of the consumer will be reviewed by the Multidisciplinary/Planning Team to determine which services are needed. The following criteria are to be considered by RCOC staff when authorizing the service request. If RCOC staff are not able to authorize the requested service given regulations, best practice or difference of opinion, then RCOC will discuss with the consumer and/or family any concerns or identify other options. Exceptions may be made on a case-by-case basis.
1. Services shall be provided in the least restrictive environment when a home setting is no longer available to meet the developmental, physical or emotional needs of the consumer, or the adult consumer chooses to live in a setting other than his/her family’s home.
For those consumers choosing to live independently or in supported living:
a. The consumer shall be at least eighteen years of age.
b. RCOC staff will work with the consumer and family to identify service needs and availability of training programs, natural supports, generic resources and community resources to ensure that the living arrangement chosen is consistent with the consumer’s resources and can be sustained.
c. Independent living skills training should be provided when it is determined that the consumer has a need for such training, and
• Has the level of skill at the time of enrollment, which will enable him/her to complete the independent living skills training successfully in relation to individual goals, and the ability to live independently with natural or minimal supports.
• Demonstrates an understanding of the goals and expectations of the program in relation to individual goals.
• Has the motivation to participate in and the ability to complete the program in relation to individual goals.
• Does not have any problems which require continuous monitoring which would preclude consumer placement in an unsupervised setting.
d. A consumer who lives at home with his/her family may be provided ILS
training with the expectation that the consumer will be moving into his/her own apartment within the next year. A plan of action needs to be developed with specific timelines.
e. Independent living support services may be provided if:
• The consumer has completed independent skills training and support services are needed on a maintenance basis.
• Natural support systems, i.e., friends, neighbors, family are unable to provide assistance.
• Generic resources, e.g., IHSS, have been applied for and denied.
• Support services are needed to transition a person from his/her family/parents’ home to his/her own living arrangements.
f. All RCOC consumers may be considered for supported living services.
Consumers shall not be excluded based solely on the nature or severity of
his/her disability. Exceptions may be made for health and safety concerns as determined as part of the IPP process.
B. Levels of Service
When determining the level of service, which is to be provided, the needs of the consumer shall be considered by the Multidisciplinary/Planning Team, as well as the consumer’s choice of service provider and cost effectiveness. If RCOC staff are unable to authorize the level of service requested by the consumer and/or family, based on RCOC’s criteria, or best practice, then RCOC staff will discuss with the consumer and/or family other options. Exceptions may be made on a case-by-case basis.
1. Residential options include:
a. Licensed community care facilities which provide 24-hour care and supervision; RCOC may provide supplemental funding, SSI-SSA would fund basic rate.
b. Licensed health care facilities which provide 24-hour care and supervision, e.g., ICF, ICFDDN, SNF; Medi-Cal would be expected to fund.
c. Room and board-this service would be funded through SSI-SSA or the consumer’s earnings.
d. Independent living-basic living expenses are funded through SSI-SSA or consumer’s earnings.
• RCOC will fund independent living skills training which provides training in such areas as menu planning, cooking, cleaning, shopping, budgeting, use of community resources, self advocacy training, and health and safety.
• RCOC will fund independent living support services necessary to provide temporary assistance to the consumer, e.g., locating an apartment, coping with a specific life situation or provide temporary assistance due to an emergency.
• The number of support hours authorized shall be dependent on the needs of the person. It is expected that the number of hours authorized on an ongoing basis shall not exceed 20 hours per month.
e. Supported living-RCOC will work with the adult consumer and his/her family/advocate to identify needed services and develop a plan of action. Due to the individualization of the services which may be required by the consumer, each request will be considered on a case-by-case basis, with RCOC funding dependent on the use of available generic and private resources, circle of support and natural supports in the community.
• RCOC may fund an initial assessment, which shall be completed by a vendored agency. This will include a person centered plan.
• A plan of action (program plan) shall be agreed to by the consumer, family/advocate and RCOC, which identifies what services and supports, are to be provided.
• The rate of payment to the provider and a recommended period of service shall be negotiated between the provider of service and RCOC prior to submission of the Purchase of Service authorization to RCOC staff, and shall be cost effective, per current supported living regulations.
• RCOC may purchase services, which cannot be provided by generic or private resources.
• Any modification to the program plan and the recommended rate of payment shall be agreed to by the consumer, family/advocate and RCOC.
• Use of natural, community and family supports shall be maximized.
f. Family Home – RCOC staff will work with the consumer and family to identify needed services, e.g., equipment, respite care, attendant care, etc., which may be needed to enable the consumer to remain in the family home. RCOC does not fund for actual living expenses. These expenses are to be funded by family resources, SSI, SSA, etc.
C. Period of Service/Renewal
1. The Purchase of Service authorization for residential services, which are funded by RCOC, shall normally be authorized and written for 12 months.
2. The Purchase of Service authorizations for Independent Living Skills training is normally authorized and written for 12 months.
3. The Purchase of Services authorizations for Independent Living Support Services shall be authorized and written for the time in which the support is expected to be provided. For support services, which are provided on a maintenance or ongoing basis, the period of service authorized shall be 12 months.
4. Prior to the renewal or modification of any service authorization, the Planning Team shall review the program or residence of the consumer and consumer satisfaction.
SUPPORT SERVICES: RESIDENTIAL
Definition: Support services are defined as additional support staff who are temporarily provided to assist in maintaining the consumer in his/her existing residential setting. They may also provide a transitional period into a new residential setting. Services may focus on providing additional staff training and supervision for the purposes of implementing a behavior intervention program, by a qualified professional, and/or assisting with daily care needs, and/or medical needs.
Guidelines
A. Criteria
The needs of the individual shall be reviewed by the Multidisciplinary/Planning Team and recommendations made. RCOC staff may authorize the funding of Support Services for a time limited period. If RCOC staff are not able to authorize the requested service based on RCOC Purchase of Service Guidelines, best practice, or difference of professional opinion, then RCOC staff will discuss with the consumer and/or family and/or consumer’s support team any concerns or identify other options. Support Services are intended to be temporary, and may be authorized for a maximum of 90 days. Support Services may be considered under one of the following circumstances; exceptions may be made on a case-by-case basis:
1. The case has been reviewed by the Multidisciplinary/Planning Team and the RCOC consulting psychologist or nurse consultant. The consumer is not appropriate for:
a. 5150-psychiatric hospitalization.
b. Medi-Cal funded facility.
c. Crisis bed.
All appropriate resources, which can include a medical review by the consumer’s physician and the utilization of consultants to develop a short-term intervention plan, have been used prior to the request for this service.
2. The consumer is exhibiting behavior, which may prevent continued placement in the current residential facility unless intervention is provided to stabilize the consumer, which will enable him/her to remain in the residence. The condition is temporary and is expected to improve within 90 days. Residential service providers are still required to provide staffing hours in accordance with Title 17 regulations for their vendored level. Support Services are to be used as an adjunct to this.
3. The consumer has experienced a medical condition that necessitates increased care and supervision. The condition is temporary and is expected to improve within 90 days.
4. The consumer displays a significant reduction in functioning in regards to daily living skills, requiring increase care. The condition is temporary and expected to improve within 90 days.
B. Levels of Service
The amount of Support Services hours and days required will be based on the needs of the consumer as identified by the Multidisciplinary/Planning Team which is to include participation or input by the RCOC psychologist or nurse consultant. If RCOC staff are unable to authorize the level of service requested by the consumer and/or family and/or consumer’s support team, base on RCOC criteria, best practice, or RCOC Purchase of Service Guidelines, then RCOC staff will discuss with the consumer and/or family any concerns or other options. Exceptions may be made on a case-by-case basis. In addition:
1. Funding for Support Services shall be authorized with vendors qualified to provide support services.
2. If a consumer is placed in a residential facility on an emergency basis, and support services are deemed necessary, temporary funding shall not exceed 90 days, during which time RCOC staff will develop a plan of action jointly with the consumer’s family and/or residential provider which may include alternative placements or other options.
3. Level of funding for residential support shall be based on the needs of the consumer as determined by the planning team, with the expected outcome of preventing placement to the state developmental center. RCOC staff shall take into consideration the current ARM rate authorized, the entrance criteria under which the consumer was originally accepted for residential placement, whether the current medical condition or behavior which necessitates the request for additional support is new, or existed at the time of the initial placement, and whether the change is expected to be a temporary condition. Alternative options may be considered based on the needs of the consumer. This may include a change in residence if it is determined that the needs of the consumer cannot be met in the current residential setting even with additional support, or the additional support is not effecting the change necessary for the consumer to continue living at his/her current residence.
4. Except for an emergency, a plan of action, which identifies a transition period, must be developed with specific timelines indicating the course of action to be taken or anticipated, staff training needs, and anticipated service outcomes. This documentation must be submitted for review to RCOC staff within five days prior to the beginning of the anticipated authorization period.
C. Period of Service/Renewal
1. Purchase of Service authorizations shall be authorized and written for the recommended period of service based on the guidelines identified in Section A, Criteria.
2. Renewals shall be authorized based on the guidelines in Section B, Levels of Service.
3. On an emergency basis only, Area Managers may authorize up to five days of Support Services without approval from additional RCOC staff. After this time period, the authorization must be reviewed and approved by the RCOC psychologist, nurse consultant or other designated RCOC staff.
PSYCHOLOGICAL, COUNSELING AND BEHAVIORAL SERVICES
Definition: Psychological, counseling and behavioral services are defined as those services (e.g., assessments, individual and family counseling, applied behavior analytic services and parenting classes) that are provided by qualified professionals vendored by the regional center to assist the consumer and/or family to effectively address issues related to the developmental disability of the consumer.
Guidelines
A. Criteria
RCOC may fund psychological, counseling or behavioral services if the service requested has been reviewed and recommended by the Multidisciplinary/Planning Team. Exceptions may be made on a case-by-case basis.
The following shall be considered by the RCOC staff when authorizing services:
1. The need for psychological, counseling or behavioral services is related to the developmental disability of the consumer.
2. Consumers and families requiring psychological, counseling or behavioral services are expected to utilize available generic resources (e.g., Medi-Cal/ CAL-OPTIMA, Community Mental Health, or private insurance, or trust funds)
3. There are no available generic or private resources to fund for the service, and denials have been documented.
4. RCOC will not authorize funding of any psychological, counseling or behavioral services that are considered experimental.
B. Levels of Service
The needs of the consumer shall be reviewed by the Multidisciplinary/Planning Team. If RCOC staff are not able to authorize the request for service given regulations, best practice, or difference of opinion, then RCOC staff will discuss with the consumer and/or family any concerns or identify other options. The following services may be provided; exceptions may be made on a case-by-case basis:
1. Behavioral Services.
Behavioral services follow the principles of applied behavior analysis and are designed to assist consumers in learning important social and adaptive skills in combination with educating parents or primary caregivers in the effective use of positive behavior supports. Behavioral services are individualized to the needs of the consumer.
To enhance understanding of basic principles of ABA and to increase the likelihood of success, it is recommended that parents and other caregivers attend behavior management workshops offered by RCOC or through community resources.
a. RCOC may purchase an assessment that meets RCOC’s Comprehensive Assessment Guidelines and is conducted by a qualified professional vendored by a regional center when at least one of the following criteria are met:
i. The consumer engages in behaviors that may be a barrier to his/her ability to remain in the least restrictive setting and/or may be limiting his/her ability to participate in community life; or
ii. The consumer displays behaviors that may be a barrier to his/her health or safety or the health or safety of others; or
iii. The consumer has failed to acquire developmentally-appropriate adaptive or functional skills (such as toileting, dressing, feeding) that are fundamental to the attainment of social inclusion and increased independence.
b. RCOC may purchase behavioral services following the completion of a comprehensive assessment and recommended treatment plan by a qualified professional vendored by a regional center. The intervention plan must identify goals, objectives, measurable outcomes, frequency of periodic assessment, and level of service for consumers and their primary caregivers. The plan must also indicate that the consumer would be a good candidate for behavior intervention and that the family/caregiver agrees to implement the recommendations of the intervention plan.
c. Behavioral services shall not exceed the type, scope, amount, and duration identified by the Multidisciplinary/Planning Team as necessary to achieve the consumer’s individual program plan (IPP) or individualized family service plan (IFSP) objectives.
i. Each behavioral service, following the initial assessment of the identified behavior(s), should begin following consensual agreement among the Multidisciplinary/Planning Team on the goals and objectives to be addressed.
ii. All behavioral services shall be assessed for effectiveness at the frequency described in the treatment plan, but at a minimum of every three months.
iii. Before making a determination for continuing, modifying, or terminating behavioral services, objective measures of the behaviors identified in the agreed-upon treatment plan must be available for review. Measurement of parents’/caregivers’ ability to implement treatment plans across all environments must be included to ensure the generalization of learned skills.
iv. Behavioral services end when the objectives identified in the agreed-upon treatment plan are accomplished.
v. When progress toward behavioral objectives is not being made, barriers to progress will be determined by the Multidisciplinary/ Planning Team to determine whether behavioral services should be continued, modified, or terminated.
vi. Behavioral services should emphasize the use of positive behavior supports. Behavior intervention procedures shall be reviewed and approved by the Multidisciplinary/Planning Team, which includes the participation of a RCOC Behavior Analyst or Psychologist.
vii. Restrictive procedures shall be further reviewed by the RCOC Qualified Professional, who may refer the intervention plan to the RCOC Behavior Modification Review Committee per Title 17 Regulations.
2. Counseling
Services provided shall meet the needs of the consumer and/or family. Counseling may be provided in the form of individual, family or group therapy. Normally sessions would not exceed one visit or counseling session per week, and the number of sessions necessary are dependent on the needs of the consumer and/or family and standards in the community.
3. Psychological Assessments
Assessments may be provided by qualified professionals vendored by regional center if generic or private resources are not available, and if they are necessary to provide information about the consumer’s need for psychological or counseling services or to assess the consumer’s current level of functioning.
a. For children enrolled in a public school, psychoeducational assessments are normally completed every three years by the school district and would not be duplicated by RCOC.
b. Adults would not be routinely assessed unless there is a specific concern or need. Generic resources will be utilized when available.
4. Parenting Classes
Services may be provided to consumers who are parents, as well to parents of consumers, who need information or training in parenting skills. Classes are usually a set number of sessions, or in some cases, individual training may be provided with the number of authorized hours based on the needs of the consumer or family.
C. Period of Service/Renewal
1. Purchase of Service authorizations for assessments and parenting classes shall be authorized for the time period in which the recommended service is to be provided.
2. Purchase of Service authorization for psychological, counseling or behavioral services shall be authorized and written for a time period not to exceed three months. This will allow for periodic review by the Multidisciplinary/Planning Team and additional RCOC staff, if necessary, to determine effectiveness of treatment. Renewal or modification of services will be authorized based on the needs of the consumer.
MEDICAL AND DENTAL SERVICES
Definition: Medical and dental services are defined as those services that are provided by licensed professionals to improve or maintain the consumer’s health status.
Routine or preventive medical and dental care should be provided to all consumers as part of health care maintenance. Routine medical and dental care should be provided by available community resources. Parents are primarily responsible for providing all medical and dental care services for their children as part of normal family expenses. Adult consumers are expected to provide for their own medical and dental needs through the use of county health clinics, CAL-OPTIMA/Medi-Cal providers, or private insurance.
Guidelines
A. Criteria
The individual needs of the consumer will be reviewed and determined by the Multidisciplinary/Planning Team, which is to include participation or input by the RCOC nurse consultant and/or RCOC physician. If RCOC staff are not able to authorize the requested service given regulations, best practice or difference of opinion, then RCOC staff will discuss with the consumer and/or family any concerns or identify other options. Exceptions may be made on a case-by-case basis.
RCOC may supplement or fund for medical or dental care if:
1. The need for medical or dental care is related to the developmental disability.
2. The consumer has no funding source for the required medical or dental services.
3. It has been documented that the consumer has been denied services (e.g., CAL-OPTIMA/Medicare, CCS, insurance) from other resources.
RCOC may fund for medication if:
1. RCOC has received medical records documenting the need for medication and the physician’s prescription is within one year.
2. The consumer has no funding source for the required medication.
3. It has been documented that the consumer has been denied services (e.g., CAL-OPTIMA/Medi-Cal, insurance).
4. The medication is on the Medi-Cal Formulary.
5. The medication being prescribed is related to the developmental disability.
An exception may be made if there is a copy of the doctor’s prescription in the chart and if there are medical records in the chart, which document why the medication is necessary and why drugs on the Medi-Cal Formulary have not or will not benefit the individual.
B. Levels of Service
The Multidisciplinary/Planning Team will recommend and RCOC staff may authorize the level of service required based on the needs of the consumer and recommendations of the licensed professional. If RCOC staff are not able to authorize the requested service given regulations, best practice, or difference of opinion, then RCOC staff will discuss with the consumer and/or family any concerns or identify other options.
C. Period of Service/Renewal
1. The Purchase of Service authorization shall be authorized and written for the period in which the service is expected to be provided.
2. When appropriate, insurance or CAL-OPTIMA/Medi-Cal/Medicare are to be billed first. In exceptional situations where Regional Center funds need to be expended prior to the receipt of insurance/CAL-OPTIMA/Medicare reimbursement due to health and safety reasons, then the provider of service or family shall reimburse Regional Center upon receipt of reimbursement.
3. Purchase of Service renewals must be reviewed by the Multidisciplinary/Planning Team and RCOC staff, which includes the RCOC nurse consultant and/or RCOC physician.
EQUIPMENT AND SUPPLIES
Definition: Equipment and supplies are defined as durable and nondurable medical equipment, including wheelchairs, walkers, and diapers, eating aids, etc., which are needed by the consumer. Due to their developmental disability, some consumers may require adaptive devices or equipment, which will enable them to maintain or maximize their independence. Supplies, which are nondurable, may be needed by the consumer to address a specific developmental need.
Guidelines
A. Criteria
The individual needs of the consumer are to be reviewed by the Multidisciplinary/ Planning Team, which is to include participation or input by the RCOC nurse consultant and/or RCOC physician. Available generic and private resources, which can provide or purchase the needed items, are to be fully explored and utilized. Families are expected to provide basic equipment, e.g., strollers, car seats, etc. and supplies for their children under the age of eighteen as they would for their children without developmental disabilities. If RCOC staff are not able to authorize the requested service, given regulations, best practice or difference of opinion, then RCOC staff will discuss with the consumer and/or family any concerns or identify other options.
RCOC may purchase medical or orthotic equipment and supplies for consumers in the following circumstances, exceptions may be made on a case-to-case basis:
1. If there is no other funding source or generic service available.
2. If the need for the equipment or supplies is related to the developmental disability.
3. If the equipment is prescribed by a physician and evaluated by an appropriate professional, e.g., physical therapist, as determined by RCOC staff.
4. There are limited financial resources available to the family.
5. RCOC may fund for assistive technology per Early Start Regulations in cases where the family would incur a cost if they used their private insurance or a generic resource.
B. Levels of Service
The needs of the consumer shall be reviewed by the Multidisciplinary/Planning Team, which includes input from the RCOC Nurse Consultant and/or RCOC physician. If RCOC staff are unable to authorize the level of service requested by the consumer and/or family, based on RCOC criteria, or best practice, then RCOC staff will discuss with the consumer and/or family other options. Equipment and supplies funded by RCOC shall include the following; exceptions may be made on a case-by-case basis:
1. Van Lifts
RCOC staff will consider the funding of van lifts if all the following conditions are met in addition to the criteria previously listed:
a. Need for lift is related to the consumer’s eligible condition for RCOC services.
b. Consumer is unable to bear weight and, thus, cannot transfer in and out of wheelchair.
c. Consumer is 16 years or older and/or weighs 110 pounds or more.
d. Consumer’s use of ramp is not feasible.
e. Consumer is involved in community integration. This should be addressed in an IPP objective.
2. Durable Equipment
RCOC staff will consider the funding of a wheelchair, braces, or other durable equipment if the following conditions are met in addition to the criteria previously listed:
a. A child is not CCS eligible and the family has limited financial resources.
b. If a child is CCS eligible, RCOC will review the CCS financial criteria for families who are over income to determine whether RCOC will assist on an exception basis.
c. An adult is not Medi-Cal/CAL-OPTIMA eligible and has limited financial resources.
d. RCOC may provide funding pending Medi-Cal/CAL-OPTIMA/insurance billing if a delay in obtaining the equipment would be detrimental to the consumer.
3. Formula/Nutritional Supplement
RCOC does not fund routine over-the-counter infant formula. RCOC policy requires families to carry out the same responsibilities for their family member with disabilities as they would for their family member without a developmental disability. RCOC does not routinely fund nutritional supplements for consumers. RCOC may fund formula or nutritional supplements if the previously listed criteria are met, and:
a. When a consumer requires specialized formula or nutritional supplement due to a medically documented diagnosis (i.e., FTT, malabsorbtion abnormality and/or GTT), RCOC may consider purchasing the formula if cost exceeds the amount of what it would cost to feed a person of the same age who is non-disabled and they are not eligible for another generic agency or resource. CCS will fund if the nutritional supplement is needed for an acute medical problem. Medi-Cal/CAL-OPTIMA will fund if the nutritional supplement is needed to maintain health. Cost would be based on Human Nutrition Information, Current Cost Statement-Moderate Cost Plan. Additionally, approval requires a doctor’s prescription and an IPP objective.
b. When a consumer requires nutritional supplements due to a medically documented diagnosis, RCOC may consider purchasing the supplement if PMD and vendored RCOC nutritionist have recommended the supplement.
4. Diapers
Each family shall carry out the same responsibilities for their family member with a disability as they would for their family member without a developmental disability. Many children without disabilities are not completely toilet trained until 4 or 5 years of age. RCOC will typically fund the cost of diapers at the generic prevailing rate. RCOC may consider purchasing or providing partial funding for one case of diapers under the following circumstances in addition to the criteria previously listed:
a. Consumers are over the age of three years.
b. There is a statement that the consumer is unable to be trained due to the severity of a medical/physical disability.
c. RCOC does not fund for consumers under the age of eight years who are enuretic at night only. Many children without disabilities have this condition.
d. RCOC will not fund for diapers if the reason the child is not toilet trained is due to the lack of parental follow-through and there is documentation in the consumer’s chart that the child is trainable and has been successful in another site, e.g., school. A behavior modification class will be offered to the family.
e. If the cost of supplying diapers would create a financial hardship. RCOC’s expectation is that the family will utilize generic resources.
f. Purchase of Service authorization for diapers may be considered for the consumer who has a condition associated with a lifelong inability to achieve bowel and bladder control. Examples of these conditions are: profound mental retardation, severe physical conditions with congenital abnormality of the urogenital organs, severe neuromuscular conditions with preclude toilet training or emptying of the bladder and bowel on schedule, using a urinal or other collection
C. Period of Service/Renewal
1. Purchase of Service authorizations shall be authorized and be written to cover the time period in which the equipment is to be purchased. In exceptional situations where Regional Center funds need to be expended prior to the receipt of insurance/CAL-OPTIMA/Medicare reimbursement due to health or safety reasons, then the provider of service or family shall reimburse Regional Center upon receipt of insurance reimbursement.
2. Purchase of Service authorizations for formula or nutritional supplement are to be authorized on a three-month basis and reviewed prior to renewal. Authorization renewals are to include the nurse consultant’s signature
3. Purchase of Service authorizations for diapers shall be on a six-month basis with renewals approved, based on the consumer’s needs. If there is documentation that a consumer has no potential for toilet training, the Purchase of Service authorization may be approved for a longer period of service.
SOCIAL AND RECREATIONAL SERVICES
Definition: Social and recreational activities are defined as those services which provide the person served with the opportunity to develop their socialization skills and to participate in family group activities in the home and community. Those services may be provided by Parks and Recreation, Special Olympics, church, school, circles of support, or other resources available to the person served. RCOC staff will provide persons served, families and service providers with information regarding available resources in the community.
Guidelines
A. Criteria
In making recommendations to the person served, family, or service provider regarding available resources in the community, the individual needs of the person served shall be considered by the service coordinator as part of the Planning Team process. RCOC will generally pursue generic resources for social or recreational services, as these should be provided by the family, community, generic resources, or personal funds (SSI, wages, etc.). RCOC staff may authorize social and recreational services related to the disability if the following criteria are met:
1. The need for the service is identified in the person’s Individual Program Plan and a specific outcome has been developed to address the need.
2. The individual has no socialization or recreation resources otherwise available to them.
3. Typical parental responsibility to pay for similar services for a minor child without disabilities has been considered.
4. The ability for an adult person served to pay for activities utilizing their personal funds (SSI, wages, etc.) has been exhausted.
5. The identified service is a specialized service or support, or a special adaptation of a generic service or support, and directed toward the alleviation of the individual’s developmental disability or toward the achievement and maintenance of an independent, productive, and normal life.
6. The identified service meets required Home and Community Based Services (HCBS) regulations, as appropriate.
7. Exceptions will be considered on a case-by-case basis in accordance with the process set forth in the Introduction to these Purchase of Service Guidelines.
Even if all criteria above are not met, social and recreational services may be considered as part of a plan to meet a respite need if requested by the person served or family and the identified service provides an intermittent break in the care and supervision of the person served.
RCOC may also fund for necessary support to facilitate meaningful participation in social and recreational activities, in lieu of the cost of the activity itself, if the Planning Team identifies a need and it is incorporated into the Individual Program Plan.
B. Levels of Service
The type of program and frequency shall be based on the needs of the person served as determined by the Planning Team.
1. Social and recreational activities may occur once or twice weekly for 6 hours total per week, but is based on the frequency and quantity of services assessed and determined to be needed within the Planning Team process.
2. If the service being authorized is a camp, one session, up to two weeks per year, may be authorized.
C. Period of Service/Renewal
1. In accordance with the Individual Program Plan, services will be reviewed at regular intervals to monitor progress and ensure continued need.
2. Purchase of Service authorizations for social and recreational activities will generally be written for a 6 to 12-month period, as determined by the Planning Team, or for the specific timeframe the activity is offered.
3. Purchase of Service renewals for social and recreational activities will be authorized upon agreement by the Planning Team that reasonable progress toward IPP objectives has occurred and the service continues to be needed.